Disparities Still Exist Post-Healthcare Reform in Massachusetts

November 19, 2010

November 18, 2010 (Chicago, Illinois) — New data indicate that disparities still exist in the invasive treatment of cardiovascular disease in Massachusetts, despite that state's Health Care Reform Act of 2006. Increased access to health insurance through the act has not yet enhanced the likelihood of receiving certain coronary procedures for African Americans, Hispanics, women, and those who are less educated, Dr Michelle A Albert (Harvard Medical School, Boston, MA) told the American Heart Association 2010 Scientific Sessions this week.

Dr Michelle A Albert

But Albert's data yielded some anomalies that are as yet unexplained and could indicate some improvements. For example, she and her colleagues found that despite receiving fewer procedures both pre- and postreform, African Americans had lower in-hospital mortality rates than whites. More work will be needed to try to tease out the explanation for this finding, she said.

The discussant of Albert's study, Dr Kim A Williams (Detroit Medical Center, MI), said: "The question that everyone in the room is interested in is whether we can show those gains in mortality in African Americans just by changing the insurance paradigm. Is this generalizable to the rest of the US?"

Massachusetts Reform a Blueprint for Obama Care

Albert said around 50 million Americans are uninsured and that these rates differ by ethnicity: 32% of Hispanic Americans are uninsured, followed by 21% of African Americans, 17% of Asians, and 12% of whites.

In response to this problem, Massachusetts passed its healthcare reform law in 2006. "The main tenets of this law mandated all residents to have health insurance. It expanded Medicaid, provided health-insurance subsidies, required employers to offer health insurance or face fines, and extended health-insurance coverage to many uninsured residents who belonged to more vulnerable populations," she explained, adding to heartwire that President Obama's US healthcare reform act "was modeled in part on the Massachusetts reform model."

There have been substantial gains following the Massachusetts act, she said, with a narrowing in the gap in insurance coverage across all sociodemographic groups and by gender and race. The largest gain was seen among Asians, who saw a 6% increase in coverage, followed by Hispanics at around 5% and African American's at 3% to 4%, she said, noting that "there is now roughly an average of 94% coverage across the population of the state." She and her colleagues set out to see whether this improvement in insurance coverage translated into narrowed disparities in the use of coronary procedures.

They compared prereform data on 62 493 Massachusetts residents with a diagnosis of ischemic heart disease (from November 2004 to July 2006) with postreform data on 61 725 patients (December 2006 to September 2008).

The primary outcome was CABG or PCI during hospitalization; secondary outcomes were all-cause and in-hospital mortality.

Most of the procedures were performed on an emergent basis, Albert said, and the postreform data show that blacks and Hispanics were significantly less likely than whites to get procedures: 43% less and 17% less, respectively. Asians, however, were 50% more likely to get procedures than whites prereform and 80% more likely postreform, with a higher mortality than whites. "The explanation for that is tough," she said, although she noted the sample size was small in the case of Asians.

The fact that African Americans had lower in-hospital mortality even though they got fewer procedures is good news, she said, but it could be clouding something more sinister. "It could be that the sickest of black patients actually never get offered procedures, so you eliminate the individuals who die," she says, noting that more research will be required to determine the reasons behind this finding.

Issues Are Complex; Prior Free Care Could Have Diluted Effects of Reform

Albert told heartwire that the Massachusetts reform act was instituted "on the background of a fairly large 'free care pool,' which is different from Medicare and Medicaid and already existed in Massachusetts before the reform, so it could have actually diluted the effect."

Nevertheless, she acknowledges the issue is "complex. Insurance only takes you so far in terms of paying for your health costs. It's important for us to do this study on a longer-term basis. There are obviously other issues at play--as we know, for example, from [Veterans Administration] data--and those issues are multifold. It means that it's really important for hospitals to take this by the neck and say, 'Look, how does discrimination affect quality and outcome?' and develop strategies to deal with that. What drives healthcare climates? Patient actions, doctors' actions, finances, and environments, so that's what would have to be dealt with in addition to insurance."

Dr Kim A Williams

Asked by heartwire whether he thinks the experience in Massachusetts could be used to model the reform of the whole US healthcare system, Williams said: "There is no way to answer that until we answer the fundamental questions about what it is that happened on an operational level. As a cardiologist, I don't really care about bypass surgeries not going up in African Americans if the mortality improves. Something else happened, and I don't know what that was.

"Can this reform be generalized? Should it be generalized? I hear loads of different things. I hear people outside of Massachusetts say that it's ruined the economy of Massachusetts, and then I hear people within Massachusetts saying, 'No, it's a good thing.' So we have sort of mixed messages, and it's going to take some time to ferret out whether this is an experiment that really helped people or not."

I'm sort of stunned that people wouldn't want to have healthcare for everyone.

Still, he remains committed to improving insurance coverage across the US population and doesn't understand the resistance to this. "I'm sort of stunned that people wouldn't want to have healthcare for everyone. If you look at the fundamentals of cardiology, we would like to decrease the number of ACS and SCDs. To do that, you've got to get people into the system to recognize their risk factors, and so they have to have enough insurance to feel comfortable going to a primary-care physician instead of using an ER after an important event has occurred. That is where I think insurance for everyone is going to make a difference."

Australia: A Model for Universal Coverage?

In contrast to the findings in Massachusetts, new research from Australia illustrates that the universal healthcare system there, which is paid for by a 3% levy out of tax, appears to be functioning well. Dr Andrea Driscoll (Monash University, Melbourne, Australia) presented a study at the AHA meeting in which 6% of all Australian primary-care practices participated. The program assisted general practitioners to assess 10-year absolute cardiovascular risk using a modified Framingham equation in 7780 patients (five to 35 per practice) with no history of coronary artery disease, peripheral arterial disease, or stroke and then to manage them. Patients' socioeconomic status was graded according to the postal codes of the doctor's practice, and they were compared by quintiles.

Dr Andrea Driscoll

Lifestyle risk factors such as diabetes, high body-mass index, inactivity, and smoking were problematic, particularly in disadvantaged areas, said Driscoll. But the lipid profiles of patients in the disadvantaged areas were better controlled, and they had a higher proportion of patients being prescribed medication compared with those in the most affluent areas. "In this population with universal healthcare, there was minimal difference in estimated absolute cardiovascular risk, although there was a high vascular age in those treated in the most disadvantaged areas compared with those in the more affluent areas," Driscoll said.

She noted that there were some limitations. "The Framingham equation was applied even though medications were being used, and socioeconomic status was based on the doctor's clinic, not individual-level data." Also, although 9% of participants were Asian Australian, no aboriginals were represented in the study, she noted, "and we know from other research that this group has very poor outcomes."

Nevertheless, she told heartwire , "The universal-healthcare system appears to work." But there are still some problems, she says; even though they don't have to pay, it is sometimes it is difficult to get patients to see their primary-care physicians. And also medications have to be copaid, she said, which can restrict use. But she stands by the system: "If Australia were to adopt the American approach, we would have a lot of issues, and in terms of public health, there would be a lot more problems than what we currently have."

Albert has no disclosures. Williams has no disclosures relevant to this issue. Driscoll's study was sponsored by a grant from Merck, Sharpe & Dohme Australia.