Journal of General Internal Medicine

, Volume 29, Issue 9, pp 1287–1295 | Cite as

Effects of Massachusetts Health Reform on the Use of Clinical Preventive Services

  • Catherine A. OkoroEmail author
  • Satvinder S. Dhingra
  • Ralph J. Coates
  • Matthew Zack
  • Eduardo J. Simoes
Original Research



Expansion of health insurance coverage, and hence clinical preventive services (CPS), provides an opportunity for improvements in the health of adults. The degree to which expansion of health insurance coverage affects the use of CPS is unknown.


To assess whether Massachusetts health reform was associated with changes in healthcare access and use of CPS.


We used a difference-in-differences framework to examine change in healthcare access and use of CPS among working-aged adults pre-reform (2002–2005) and post-reform (2007–2010) in Massachusetts compared with change in other New England states (ONES).


Population-based, cross-sectional Behavioral Risk Factor Surveillance System surveys.


A total of 208,831 survey participants aged 18 to 64 years.


Massachusetts health reform enacted in 2006.


Four healthcare access measures outcomes and five CPS.


The proportions of adults who had health insurance coverage, a healthcare provider, no cost barrier to healthcare, an annual routine checkup, and a colorectal cancer screening increased significantly more in Massachusetts than those in the ONES. In Massachusetts, the prevalence of cervical cancer screening in pre-reform and post-reform periods was about the same; however, the ONES had a decrease of −1.6 percentage points (95 % confidence interval [CI] −2.5, −0.7; p <0.001). As a result, the prevalence of cervical cancer screening in Massachusetts was increased relative to the ONES (1.7, 95 % CI 0.2, 3.2; p = 0.02). Cholesterol screening, influenza immunization, and breast cancer screening did not improve more in Massachusetts than in the ONES.


Data are self-reported.


Health reform may increase healthcare access and improve use of CPS. However, the effects of health reform on CPS use may vary by type of service and by state.


health insurance healthcare access clinical preventive services 



We thank the BRFSS coordinators in the states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont for their participation in data collection for this analysis and the staff of CDC’s Division of Behavioral Surveillance for their valuable assistance in developing the database for analysis. The authors would also like to express their thanks to Elena A. Hawk, Ph. D., Massachusetts BRFSS coordinator, and Tara W. Strine, Ph. D. for reviewing and commenting on the final draft of this work.

Funding Source

No funding was received for this study.

Prior Presentation

This article was presented at the 46th Annual Society for Epidemiologic Research Meeting, 18–21 June 2013, in Boston, Massachusetts.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Supplementary material

11606_2014_2865_MOESM1_ESM.docx (22 kb)
ESM1 (DOCX 22 kb).


  1. 1.
    CCH Incorporated. Patient Protection and Affordable Care Act; Health Care and Education Reconciliation Act of 2010: text of P.L. 111–148, as signed by the President on March 23, 2010; text of P.L. 111–152, as signed by the President on March 30, 2010: JCT technical explanation of P.L. 111–148 and P.L. 111–152. 2010, Chicago, IL: CCH; 2010Google Scholar
  2. 2.
    Bernstein J, Chollet D, Peterson S. Issue brief: how does insurance coverage improve health outcomes? Mathematica Policy Research, Inc.: 2010:1–5.Google Scholar
  3. 3.
    Freeman JD, Kadiyala S, Bell JF, Martin DP. The causal effect of health insurance on utilization and outcomes in adults: a systematic review of US studies. Med Care. 2008;46:1023–32.PubMedCrossRefGoogle Scholar
  4. 4.
    Milstein B, Homer J, Briss P, Burton D, Pechacek T. Why behavioral and environmental interventions are needed to improve health at lower cost. Health Aff (Millwood). 2011;30:823–32.CrossRefGoogle Scholar
  5. 5.
    Centers for Disease Control and Prevention (CDC). Recommended adult immunization schedule—United States, 2010. MMWR Morbid Mortal Wkly Rep. 2010;59(1):1–4.Google Scholar
  6. 6.
    The 187th General Court of the Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006. An act providing access to affordable, quality, accountable health care. April 12, 2006: The 187th General Court of the Commonwealth of Massachusetts; 2006.Google Scholar
  7. 7.
    U.S. Department of Health and Human Services. How the health care law is making a difference for the people of Massachusetts. 2013; Accessed March 10, 2014.
  8. 8.
    Long SK. On the road to universal coverage: impacts of reform in massachusetts at one year. Health Aff (Millwood). 2008;27(4):w270–84.Google Scholar
  9. 9.
    Long SK, Stockley K. Sustaining health reform in a recession: an update on Massachusetts as of fall 2009. Health Aff (Millwood). 2010;29:1234–41.CrossRefGoogle Scholar
  10. 10.
    Long SK. Who gained the most under health reform in Massachusetts? Urban Institute; 2008Google Scholar
  11. 11.
    Long SK, Stockley K, Dahlen H. Massachusetts health reforms: uninsurance remains low, self-reported health status improves as state prepares to tackle costs. Health Aff (Millwood). 2012;31(2):444–51.CrossRefGoogle Scholar
  12. 12.
    Clark CR, Soukup J, Govidarejulu U, Riden HE, Tovar DA, Johnson PA. Lack of access due to costs remains a problem for some in Massachusetts despite the state’s health reforms. Health Reform. 2011;30(2):247–55.Google Scholar
  13. 13.
    Maxwell J, Cortes DE, Schneider KL, Graves A, Rosman B. Massachusetts’ health care reform increased access to care for Hispanics, but disparities remain. Health Aff (Millwood). 2011;30(8):1451–60.CrossRefGoogle Scholar
  14. 14.
    Tinsley L, Andrews B, Hawk H, Cohen B. Short-term effects of health-care coverage legislation—Massachusetts, 2008. MMWR Morb Mortal Wkly Rep. 2010;59(9):262–7.Google Scholar
  15. 15.
    Gettens J, Mitra M, Henry AD, Himmelstein J. Have working-age people with disabilities shared in the gains of Massachusetts health reform? Inquiry. 2011;48:183–96.PubMedGoogle Scholar
  16. 16.
    Long SK, Stockley K. The impacts of state health reform initiatives on adults in New York and Massachusetts. Health Serv Res. 2011;46(1 Pt 2):365–87.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Kolstad JT, Kowalski AE. The impact of health care reform on hospital and preventive care: evidence from Massachusetts. National Bureau of Economic Research; 2010Google Scholar
  18. 18.
    Long SK. Another look at the impacts of health reform in Massachusetts: evidence using new data and a stronger model. Am Econ Rev. 2009;99(2):508–11.CrossRefGoogle Scholar
  19. 19.
    Dhingra SS, Zack MM, Strine TW, Druss BG, Simoes E. Change in health insurance coverage in Massachusetts and other New England states by perceived health status: potential impact of health reform. Am J Public Health. 2013;103:e107–14.PubMedCrossRefGoogle Scholar
  20. 20.
    Pande AH, Ross-Degnan D, Zaslavsky AM, Salomon JA. Effects of healthcare reforms on coverage, access, and disparities: quasi-experimental analysis of evidence from Massachusetts. Am J Prev Med. 2011;41(1):1–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Chen C, Scheffler G, Chandra A. Massachusetts’ health care reform and emergency department utilization. N Engl J Med. 2011;365(12):e25.PubMedCrossRefGoogle Scholar
  22. 22.
    Zhu J, Brawarsky P, Lipsitz S, Huskamp H, Haas JS. Massachusetts health reform and disparities in coverage, access and health status. J Gen Intern Med. 2010;25(12):1356–62.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Mokdad AH, Stroup DF, Giles WH. Public health surveillance for behavioral risk factors in a changing environment. recommendations from the Behavioral Risk Factor Surveillance Team. MMWR Recomm Rep. 2003;52(RR-9):1–12.PubMedGoogle Scholar
  24. 24.
    Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Operational and User’s Guide. Version 3.0. 2006; Accessed March 10, 2014.
  25. 25.
    Fahimi M, Link M, Mokdad A, Schwartz DA, Levy P. Tracking chronic disease and risk behavior prevalence as survey participation declines: statistics from the Behavioral Risk Factor Surveillance System and other national surveys. Prev Chronic Dis. 2008;5(3):A80.PubMedCentralPubMedGoogle Scholar
  26. 26.
    Li C, Balluz LS, Ford ES, Okoro CA, Zhao G, Pierannunzi C. A comparison of prevalence estimates for selected health indicators and chronic diseases or conditions from the Behavioral Risk Factor Surveillance System, the National Health Interview Survey, and the National Health and Nutrition Examination Survey, 2007–2008. Prev Med. 2012;54(6):381–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208–20.PubMedCentralPubMedGoogle Scholar
  28. 28.
    Ashenfelter O. Estimating the effect of training programs on earnings. Review of Economics and Statistics. 1978;60(1):47–57.CrossRefGoogle Scholar
  29. 29.
    Ashenfelter O, Card D. Using the Longitudinal Structure of Earnings to estimate the effect of training programs. Review of Economics and Statistics. 1985;67(4):648–60.CrossRefGoogle Scholar
  30. 30.
    Wooldridge JM. Econometric analysis of cross section and panel data. 2nd ed. MIT Press; 2007.Google Scholar
  31. 31.
    SAS Institute Inc. SAS for Windows. Version 9.2 (TS2M0). SAS Institute; 2008.Google Scholar
  32. 32.
    Research Triangle Institute. SUDAAN User’s Manual. Research Triangle Institute; 2008.Google Scholar
  33. 33.
    Centers for Disease Control and Prevention (CDC). Vital signs: colorectal cancer screening, incidence, and mortality—United States, 2002--2010. MMWR Morb Mortal Wkly Rep. 2011;60(26):884–9.Google Scholar
  34. 34.
    Centers for Disease Control and Prevention (CDC). Vital signs: breast cancer screening among women aged 50–74 years—United States, 2008. MMWR Morb Mortal Wkly Rep. 2010;59(26):813–6.Google Scholar
  35. 35.
    Swan J, Breen N, Graubard BI, et al. Data and trends in cancer screening in the United States: results from the 2005 National Health Interview Survey. Cancer. 2010;116(20):4872–81.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Coates RJ, Ogden L, Monroe JA, Buehler J, Yoon PW, Collins JL. Conclusions and future directions for periodic reporting on the use of selected adult clinical preventive services—United States. MMWR Morbid Mortal Wkly Rep. 2012;61(Suppl):73–9.Google Scholar
  37. 37.
    Shenson D, Adams M, Bolen J, Anderson L. Routine checkups don’t ensure that seniors get preventive services. J Fam Pract. 2011;60(1):E1–10.Google Scholar
  38. 38.
    Guide to Community Preventive Services. The community guide: what works to promote health. 2012; Accessed March 10, 2014.
  39. 39.
    Rodriguez SR, Osborne D, Jacobellis J. Health plan implementation of U.S. Preventive Services Task Force A and B recommendations—Colorado, 2010. MMWR Morb Mortal Wkly Rep. 2011;60(39):1348–50.Google Scholar
  40. 40.
    Malhotra K, Heiman HJ. Public health policy is political. Am J Public Health. 2012;102 (7):el; author reply el-2. doi: 10.2105/AJPH.2012.300801
  41. 41.
    Liao Y, Bang D, Cosgrove S, et al. Surveillance of health status in minority communities—Racial and Ethnic Approaches to Community Health Across the U.S. (REACH U.S.) Risk Factor Survey, United States, 2009. MMWR Surveill Summ. 2011;60(6):1–44.PubMedGoogle Scholar
  42. 42.
    Goldberg DS. Against the very idea of the politicization of public health policy. Am J Public Health. 2012;102(1):44–9.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System. BRFSS. 2012; Accessed March 10, 2014.
  44. 44.
    Simon TR, Mercy JA, Barker L. Can we talk? Importance of random-digit-dial surveys for injury prevention research. Am J Prev Med. 2006;31(5):406–10.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Catherine A. Okoro
    • 1
    Email author
  • Satvinder S. Dhingra
    • 2
  • Ralph J. Coates
    • 1
  • Matthew Zack
    • 3
  • Eduardo J. Simoes
    • 4
  1. 1.Centers for Disease Control and Prevention, Division of Behavioral Surveillance, Office of Surveillance, Epidemiology, and Laboratory ServicesPublic Health Surveillance and Informatics Program OfficeAtlantaUSA
  2. 2.Northrop Grumman, and the Centers for Disease Control and Prevention, Office of Surveillance, Epidemiology, and Laboratory ServicesPublic Health Surveillance and Informatics Program OfficeAtlantaUSA
  3. 3.Centers for Disease Control and Prevention, Office of Noncommunicable Diseases, Injury and Environmental HealthNational Center for Chronic Disease Prevention and Health PromotionAtlantaUSA
  4. 4.Department of Health Management and InformaticsUniversity of Missouri School of MedicineColumbiaUSA

Personalised recommendations