Original Investigation |

Massachusetts Health Care Reform and Reduced Racial Disparities in Minimally Invasive Surgery

Andrew P. Loehrer, MD1; Zirui Song, PhD2,3; Hugh G. Auchincloss, MD1; Matthew M. Hutter, MD, MPH1
[+] Author Affiliations
1Department of Surgery, Massachusetts General Hospital, Boston
2Francis Weld Peabody Society, Harvard Medical School, Boston, Massachusetts
3National Bureau of Economic Research, Cambridge, Massachusetts
JAMA Surg. 2013;148(12):1116-1122. doi:10.1001/jamasurg.2013.2750.
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Importance  Racial disparities in receipt of minimally invasive surgery (MIS) persist in the United States and have been shown to also be associated with a number of driving factors, including insurance status. However, little is known as to how expanding insurance coverage across a population influences disparities in surgical care.

Objective  To evaluate the impact of Massachusetts health care reform on racial disparities in MIS.

Design, Setting, and Participants  A retrospective cohort study assessed the probability of undergoing MIS vs an open operation for nonwhite patients in Massachusetts compared with 6 control states. All discharges (n = 167 560) of nonelderly white, black, or Latino patients with government insurance (Medicaid or Commonwealth Care insurance) or no insurance who underwent a procedure for acute appendicitis or acute cholecystitis at inpatient hospitals between January 1, 2001, and December 31, 2009, were assessed. Data are from the Hospital Cost and Utilization Project State Inpatient Databases.

Intervention  The 2006 Massachusetts health care reform, which expanded insurance coverage for government-subsidized, self-pay, and uninsured individuals in Massachusetts.

Main Outcomes and Measures  Adjusted probability of undergoing MIS and difference-in-difference estimates.

Results  Prior to the 2006 reform, Massachusetts nonwhite patients had a 5.21–percentage point lower probability of MIS relative to white patients (P < .001). Nonwhite patients in control states had a 1.39–percentage point lower probability of MIS (P = .007). After reform, nonwhite patients in Massachusetts had a 3.71–percentage point increase in the probability of MIS relative to concurrent trends in control states (P = .01). After 2006, measured racial disparities in MIS resolved in Massachusetts, with nonwhite patients having equal probability of MIS relative to white patients (0.06 percentage point greater; P = .96). However, nonwhite patients in control states without health care reform have a persistently lower probability of MIS relative to white patients (3.19 percentage points lower; P < .001).

Conclusions and Relevance  The 2006 Massachusetts insurance expansion was associated with an increased probability of nonwhite patients undergoing MIS and resolution of measured racial disparities in MIS.

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Figure 1.
Trend in Inpatient Appendectomy and Cholecystectomy for Uninsured and Government-Subsidized Patients

The rate of procedures indicates the number of procedures captured divided by the total population with no insurance, Medicaid, or Commonwealth Care insurance coverage (in Massachusetts). The vertical dashed line indicates the 2006 Massachusetts health care reform.

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Figure 2.
Trends in Minimally Invasive Surgery

A, Nonwhite patients. B, White patients. The vertical dashed lines indicate the 2006 Massachusetts health care reform.

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Figure 3.
Effect of Nonwhite Race/Ethnicity on the Probability of Undergoing Minimally Invasive Surgery

The percentage point difference in the probability of undergoing minimally invasive surgery (MIS) is between government-subsidized and self-pay nonwhite patients and government-subsidized and self-pay white patients, controlling for age, sex, comorbidities, hospital type, admission type, and complicated presentation.aP < .05.bP = .96.

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