Journal of General Internal Medicine

, Volume 27, Issue 11, pp 1548–1554

Access to Care After Massachusetts’ Health Care Reform: A Safety Net Hospital Patient Survey

  • Danny McCormick
  • Assaad Sayah
  • Hermione Lokko
  • Steffie Woolhandler
  • Rachel Nardin
Original Research



Massachusetts’ health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.


To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.


We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts’ second largest safety net hospital between July 25, 2009 and March 20, 2010.


Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.


Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.


Access to care improved less than access to insurance following Massachusetts’ health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.


access to care health insurance health disparities health care reform health care policy 

Supplementary material

11606_2012_2173_MOESM1_ESM.docx (16 kb)
Supplementary Table 1.Cost Sharing and Health Benefits in Massachusetts Public Health Insurance Plans in 2009–2010 (DOCX 16 kb)


  1. 1.
    Chapter 58: An Act Providing Access to Affordable, Quality, Accountable Health Care. 2006. Available at: Accessed May 18, 2012.
  2. 2.
    Current Population Survey, 2010. Table HI06. Health Insurance Coverage Status by State for All People: 2009. U.S. Census Bureau. Available at: Accessed May 18, 2012.
  3. 3.
    Long S, Stockley K. Sustaining health reform in a recession: an update on Massachusetts as of fall 2009. Health Aff. 2010;29:1234–41.CrossRefGoogle Scholar
  4. 4.
    Health insurance coverage in Massachusetts: Results from the 2008–2010 Massachusetts Health Insurance Surveys. Massachusetts Department of Health Care Financing and Policy, October, 2009. Available at: Accessed May 18, 2012.
  5. 5.
  6. 6.
    Hoffman C, Paradise J. Health insurance and access to health care in the United States. Ann N Y Acad Sci. 2008;1136:149–60.PubMedCrossRefGoogle Scholar
  7. 7.
    Weissman J, Zaslavsky A, Wolf R, Ayanian J. State Medicaid coverage and access to care for low-income adults. J Health Care Poor Underserved. 2008;19:307–19.PubMedCrossRefGoogle Scholar
  8. 8.
    Santerre R. The inequity of Medicaid reimbursement in the United States. Appl Health Econ Health Policy. 2002;1:25–32.PubMedGoogle Scholar
  9. 9.
    Bisgaier J, Rhodes K. Auditing access to specialty care for children with public insurance. N Engl J Med. 2011;364:2324–33.PubMedCrossRefGoogle Scholar
  10. 10.
    Commonwealth of Massachusetts MassHealth Provider Manual Series. Office of Health and Human Services, November 2009. Available at: Accessed May 18, 2012.
  11. 11.
  12. 12.
    The costs and adequacy of Safety net Access for the uninsured. Robert Wood Johnson Foundation, June, 2010. Available at: Accessed May 18, 2012.
  13. 13.
    Health safety net provider FAQ: Frequently asked questions about Health Safety Net (HSN) regulations, eligibility and billing. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Division of Health Care Finance and Policy, January 5, 2009. Available at: Accessed May 18, 2012.
  14. 14.
    Health Safety Net—HSN (Free Care): An Overview. MassResources, 2011. Available at: Accessed May 18, 2012.
  15. 15.
    New England Healthcare Exchange Network. Available at: Accessed May 18, 2012.
  16. 16.
    Emergency severity index, Version 4: Implementation Handbook. Agency for Healthcare Research and Quality, May 2005. Available at: Accessed May 18, 2012.
  17. 17.
    The Massachusetts health reform survey. Urban Institute, 2009. Available at: Accessed May 18, 2012.
  18. 18.
    Austvoll-Dahlgren A, Aaserud M, Vist G, et al. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database Syst Rev. 2008:CD007017.Google Scholar
  19. 19.
    Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA. 2007;298:61–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Remler DK, Greene J. Cost-sharing: a blunt instrument. Annu Rev Public Health. 2009;30:293–311.PubMedCrossRefGoogle Scholar
  21. 21.
    Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA. 2001;285:421–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Wong MD, Andersen R, Sherbourne CD, Hays RD, Shapiro MF. Effects of cost sharing on care seeking and health status: results from the Medical Outcomes Study. Am J Public Health. 2001;91:1889–94.PubMedCrossRefGoogle Scholar
  23. 23.
    Division of Health Care Finance and Policy. Health safety net 2010 annual report; December 2010. Available at: Accessed May 5, 2012.

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Danny McCormick
    • 1
    • 3
  • Assaad Sayah
    • 2
    • 3
  • Hermione Lokko
    • 3
  • Steffie Woolhandler
    • 4
  • Rachel Nardin
    • 1
    • 3
  1. 1.Department of MedicineCambridge Health AllianceCambridgeUSA
  2. 2.Department of Emergency MedicineCambridge Health AllianceCambridgeUSA
  3. 3.Harvard Medical SchoolBostonUSA
  4. 4.City University of New York School of Public HealthNew YorkUSA

Personalised recommendations