M ILITARY M EDICINE, 179, 11:1288,2014

Experience of the Veterans Health Administration in Massachusetts After State Health Care Reform Stephanie H. Chan, MPH*; James F. Burgess Jr., P h D ff; Jack A. Clark, PhDf§; Michael F. Mayo-Smith, MD, MPFi*

ABSTRACT Starting in 2006, Massachusetts enacted a series of health insurance reforms that successfully led to 96.6% of its population being covered by 2011. As the rest of the nation undertakes similar reforms, it is unknown how the Veterans Health Administration (VHA), one of many important Federal health care programs, will be affected. Our state-level study approach assessed the effects of health reform on utilization of VHA services in Massachusetts from 2005 to 2011. Models were adjusted for state-level demographic and economic characteristics, including health insurance rates, unemployment rates, median household income, poverty rates, and percent of population 65 years and older. No statistically significant associative change was observed in Massachusetts relative to other states over this time period. The findings raise important questions about the continuing role of VHA in American health care as health insurance coverage is one of many factors that influence decisions on where to seek health care.

INTRODUCTION The Patient Protection and Affordable Care Act (ACA) promises to improve access to needed care for nearly all Americans by extending health care insurance coverage. Lowincome individuals and families, in particular, are expected to gain increased access through Medicaid, as expansions are accepted by each state, and through the establishment of health insurance marketplaces or exchanges.1 These changes will have unknown implications on many federal health care programs, such as the Indian Health Service, TRICARE, Federally Qualified Health Centers, and the Veterans Health Administration (VHA)—all important components of the health services landscape. VHA interacts with the rest of the U.S. health care delivery system through both its national scope and its connections to higher education and research. As the largest integrated health care system in the country, it is the only system with truly national scope as it provides both primary and specialty care along with social support services to a particular popu­ lation, military Veterans. VHA serves 8.3 million Veterans through over 1,700 sites of care each year.2 In addition, VHA is the largest provider of health care training in the United States through its graduate medical education program and affiliations with over 100 medical schools around the ^Department of Veterans Affairs, VA New England Healthcare System, 200 Springs Road, Bedford, MA 01730. tCenter for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, Boston. MA 02130. +Department of Health Policy & Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02115. §Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Road, Bedford, MA 01730. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. Government. doi: 10.7205/MILMED-D-14-00093


country.3 VHA also is dedicated as part of this tripartite mission to pushing the leading edge of medical and prosthetic research, with an annual research budget of over $500 million, pursuing research focused on the particular health care needs of Veterans.4 Under ACA, enrollment in VHA health care is considered creditable insurance coverage meeting the minimum-level requirement.1 Yet, Veterans served by VHA may have new insurance options, depending on policies enacted by the states in which they live. Given the scope of ACA and the importance of VHA and Federal health care, the potential impacts of ACA on VHA have been a subject of much interest and concern.5'6 Will Veterans continue to seek care from VHA, or go elsewhere? Will demand for services increase as Veterans need to demonstrate creditable insurance coverage? How will ACA impact VHA’s ability to maintain a viable, national health care system? ACA was modeled, in part, after a series of health insur­ ance reforms enacted in Massachusetts in 2006. Among the shared provisions, both included a mandate that its resi­ dents obtain health care insurance or pay a penalty.7,8 As others have realized, the Massachusetts experience with health care reform provides an informative case study.9 In Massachusetts, the reforms led to the expansion of health insurance coverage from 90.4% of its population in 2005 to 96.6% by 2011.10 In contrast, there was a small decrease in the national health insurance rate over the same time period from 85.4% to 84.3%, respectively.10 This study looked to VHA’s experience in Massachusetts after state-level reforms in order to shed some light on the potential impact of ACA on VHA nationwide.

METHODS We conducted a longitudinal, state-level analysis of VHA utilization to evaluate the effects of Massachusetts’ 2006 Health Care Reform law on utilization of VHA services in

MILITARY MEDICINE, Vol. 179, November 2014

Experience ofVHA in Massachusetts After State Health Care Reform the state, relative to the other 49 states and the District of Columbia. We analyzed data for a 7-year period: 2 years (2005-2006) before the Massachusetts health care reform, 1 year (2007) of implementation—completed in July 2007, and 4 years (2008-2011) after implementation. The unit of analysis was the state. Ordinary least squares regression analysis was used to estimate the associative changes in intercept and slope for key determinants between years. These methods are simple and straightforward to assess asso­ ciations at the aggregate level over this period, the level at which national budget policy is made. We chose VHA user rates as the main outcome, defined as the number of users divided by the Veteran population in each state. Users are individuals who have received care from VHA at least once in a calendar year, as documented in VHA medical records." The utilization data were available from the VHA Support Service Center. Secondary analyses included comparing trends between Massachusetts and National VHA user rates, and examining the increase in VHA user rate by state. To control for the influences of demographic and eco­ nomic characteristics in each state that may affect VHA uti­ lization independently, covariates were derived from U.S. Census Bureau’s publicly available databases, including rates by calendar year for percent of population insured,10 unem­ ployment rate,12 median household income,13 poverty rate,14 and percent of population 65 years and older.15 Population health insurance information was obtained from the Annual Social and Economic Supplement to the Current Population Survey. Respondents in that survey indicated whether they were “covered by a health insurance plan,” including Medi­ care, Medicaid, TRICARE, military health care, Indian Health Service, VHA, and/or private insurance, similar to the definition of coverage in the ACA requirements. This research was approved for exemption from the Insti­ tutional Review Boards of both the Edith Nourse Rogers Memorial VA Hospital and the VA Boston Healthcare System. RESULTS From 2005 to 2011, the VHA user rate in Massachusetts increased from 17.4% to 23.6% (Fig. 1). The national VHA user rate increased by nearly the same amount, from 20.8% in 2005 to 26.5% in 2011. Although VHA utilization in Massachusetts remained below the national average over this period, the parallel increases in user rates were not signifi­ cantly different (p = 0.598). Compared to states that did not implement reforms in 2006-2007, no statistically significant change in the VHA user rate for Massachusetts was observed after controlling for demographic and economic characteristics (-0.35%, 95% Cl: -6.38% to 5.68%, p - 0.964). Additionally, no statistically significant relationship was observed between the VHA user rate and the population health insurance rate in unadjusted ( p = 0.560) and adjusted {p = 0.746) models (Fig. 2).

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■ Massachusetts

■ National

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VHA user trends over time from 2005 to 2011.

VHA user rates increased for every state from 2005 to 2011, and similar increases were seen when adjusting for variation in demographic and economic characteristics between states, including unemployment rate, median house­ hold income, poverty rate, and percent of population 65 years and older (Fig. 3). The increase in the VHA user rate in Massachusetts was toward the middle of the national distri­ bution, ranked 17th out of 50 states over this time period. DISCUSSION Policy discussions in the health care community have turned to Massachusetts for hints of the future as the ACA is imple­ mented.916 Our analyses show that the health care reform in Massachusetts, implemented in 2006-2007, had no signifi­ cant associative effect on VHA utilization in the state, despite an increase in health insurance coverage to 96.6% of the population. If Massachusetts’ experience is both a valid and representative comparison, then our findings suggest that the impact of ACA on VHA utilization will be minimal. Because ACA is largely focused on insurance coverage, which does not appear to be strongly associated with VHA utilization, the net impact of ACA on VHA may be neutral. This suggests that, although there are concerns that VHA could either be overwhelmed by an influx of patients or experience a decrease in patient population, VHA will remain a viable institution as part of the national health care system. There are many drivers that influence Veterans’ decisions to use VHA services, and these have been researched in many individual-level research studies. This aggregate approach suggests it is possible that as the ACA allows Veterans to choose other care providers than they currently do as new options are made available that the ACA may simultaneously encourage Veterans to enroll for VHA care as a mechanism for meeting creditable coverage. In the early 1990s, approximately 60% of Veterans who received VHA services throughout the United States were without insurance (other than that provided by VHA) and used VHA as a “safety net.”17 By 2011, this percentage


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dropped to 25%.18 These changes were motivated by reforms in VHA to expand its coverage focus to the general Veteran population and their primary care needs. As its population continues to change, VHA also must continue to change its strategies for provision of the benefit made available to our Nation’s Veterans as a result of their military service. It is important to note that not all health insurance plans provide the same coverage; some households may be overinsured, whereas others are underinsured and continue to lack access to needed care.19 This has been a major policy issue in Massachusetts, and the state government’s Center for Health Information and Analysis is commissioning a series of studies to explore it further and, as the ACA is implemented nationally, comparable efforts are likely to take place across the United States.20 Similarly, the variation in the type of services covered by insurers affects the out-of-pocket expenses for the consumer. Using a binary indicator, pres­


ence or absence of any type of health insurance, may not be granular enough to address the true health care needs of the population. To better understand its patient population, VHA conducts an annual survey of Veterans enrolled for VHA services, which assesses a variety of motivations for seeking care at VHA.18 For example, VHA provides services that other health care institutions may not, including expertise in mental health and prosthetics care. Veterans may also utilize VHA because of its culture of respect for military service, low co-payments, prescription drug benefits, ready access, and high-quality care. There are limitations to our findings given the associative nature of our analytic approach. The state-level aggregation obscures changes that can be assessed better with individual person-level data. Also, the health care insurance rate in Massachusetts before its own reform was already one of the

MILITARY MEDICINE, Vol. 179, November 2014

Experience ofVHA in Massachusetts After State Health Care Reform

highest in the country and the state previously had imple­ mented restrictions on pre-existing condition clauses. It is possible that 2014 ACA implementation will have different impacts in states that currently have less than 90% of its population insured, as well as in states that currently allow substantial pre-existing condition clauses. Amendments to the Massachusetts state law have been passed in the years since initial implementation, most notably a provision in 2008 requiring the use of electronic medical records, uniform billing and coding practices, and other delivery system improvements.21'22 These amendments dem­ onstrate that the reform in Massachusetts is still a work in progress, and the results of our analyses focus more on the timing of the initial reforms than the subsequent ones. In addition to differences between Massachusetts and other state’s implementing ACA, there are differences in the Veteran environment across states. Therefore, the use of Massachusetts as a bellwether comes with additional limita­ tions. Massachusetts has experienced a 20% decrease in the number of eligible Veterans in the state between 2005 and 2011, a decrease of nearly 93,000 Veterans, whereas other states have experienced less dramatic trends and even growth in Veteran population. These population trends are related to shifts in locations as Veterans age and as newer Veterans leave military service and settle in other areas. Understanding why VHA, a government run health care system, has been sought out by Veterans to provide care in certain geographical areas may provide larger lessons for American health care. Additional research with more rigorous study methodology is needed to better explore the role of VHA in the changing health insurance landscape. Yet results from this associative study may help inform national VHA policy planning at the advent of nationwide changes in access to health insurance. The implementation of the ACA has been, and will continue to be, a national exper­ iment in health care insurance coverage. VHA’s experience in Massachusetts with state-level reform suggests that VHA, at large, will maintain an important role in American health care. Although not precluded from the shifting sands, VHA is presented with an opportunity to sharpen its role in the new landscape.

ACKNOWLEDGMENTS This material is the result of work supported with resources and the use of facilities at the VA New England Healthcare System, the Edith Nourse Rogers Memorial VA Hospital, and the VA Boston Healthcare System.

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3. U.S. Department of Veterans Affairs, Office of Academic Affiliations: Medical and Dental Education Program. 2013. Available at http://www .va.gov/oaa/gme_default.asp; accessed June 10, 2013. 4. U.S. Department of Veterans Affairs: Volume II, Medical Programs & Information Technology Programs, Congressional Submission, FY 2013 Funding and FY 2014 Advance Appropriations Request. Washington, DC, Department of Veterans Affairs, 2013. Available at http://www .va.gov/budget/docs/summary/Fy2013_Volume_II-Medical_Programs_ Information_Technology.pdf: accessed June 10, 2013. 5. Kizer KW: Veterans and the Affordable Care Act. JAMA 2012; 307(8): 789-90. 6. U.S. House, Committee on Veterans’ Affairs: Examining the Implications of the Affordable Care Act on VA Healthcare, Hearing, April 24, 2013. Available at http://veterans.house.gov/hearing/examining-the-implicationsof-the-affordable-care-act-on-va-healthcare; accessed June 10, 2013. 7. Mass. Gen. Laws chapter 58 of the Acts of 2006: An Act Providing Access to Affordable, Quality, Accountable Health Care, May 4, 2006. Available at https://malegislature.gov/Laws/SessionLaws/Acts/2006/ Chapter58; accessed February 25, 2014. 8. Patel K, McDonough J. From Massachusetts to 1600 Pennsylvania avenue: aboard the health reform express. Health Affairs 2010; 29(6): 1106-11. 9. Graves JA, Swartz K. Health care reform and the dynamics of insurance coverage: lessons from Massachusetts. New Engl J Med 2012; 367(13): 1181-4. 10. U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements: HIB-4: Health Insurance Coverage Status and Type of Coverage by State—All Persons: 1999 to 2011, 2012. Available at http://www.census.gov/hhes/www/hlthins/data/historical/ files/hihistt4B.xls; accessed February 25, 2014. 11. Veteran Population Model 2007: Washington, DC: Department of Vet­ erans Affairs. Office of the Assistant Secretaiy for Policy and Planning, 2008. Available at http://www.va.gov/vetdata/veteran_population.asp; accessed June 10, 2013. 12. U.S. Census Bureau & Bureau of Labor Statistics, Current Population Survey: Employment status of the civilian noninstitutional population in states by sex, race, Hispanic or Latino ethnicity, and detailed age, 2012. Available at http://www.bls.gov/lau/tablel4fulll2.xls; accessed December 28, 2013. 13. U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements: Table H-8. Median Household Income by State: 1984 to 2011, 2012. Available at http://www.census.gov/hhes/ www/income/data/historical/household/2011/H08_2011 .xls; accessed December 28, 2013. 14. U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements. Table 21. Number of Poor and Poverty Rate, by State, 2012. Available at http://www.census.gov/hhes/www/poverty/ data/historical/hstpov21.x!s; accessed December 28, 2013. 15. U.S. Census Bureau, Current Population Survey: Age and Sex Compo­ sition in the United States: Table 1. Population, 2012. Available at http:// www.census.gov/population/age/data/files/2012/2012gender_table 1.xlsx; accessed February 25, 2014. 16. Long SK, Stockley K: Sustaining health reform in a recession: an update on Massachusetts as of Fall 2009. Health Affairs 2010; 29(6): 1234-41. 17. Wilson NJ, Kizer KW: The VA health care system: an unrecognized national safety net. Health Affairs 1997; 16(4): 200-4. 18. U.S. Department of Veterans Affairs: 2011 Survey of Veteran Enrollees’ Health and Reliance Upon VA: Washington, DC, Office of the Assistant Deputy Under Secretaiy for Health for Policy and Planning, 2012. Avail­ able at http://www.va.gov/HEALTHPOLICYPLANNING/SOE2011/ SoE2011_Report.pdf; accessed February 25, 2014. 19. Fortney JC, Burgess JF Jr, Bosworth HB, Booth BM, Kaboli PJ: A re-conceptualization of access for 21st century healthcare. J Gen Intern Med 2011; 26(Suppl 2): 639-47. 20. Center for Health Information and Analysis: Request for Responses to: The Evolving Marketplace: Exploring the Impact of Uninsurance


Experience o f VHA in Massachusetts After State Health Care Reform and Underinsurance on Consumers, Employers, and Communities in Massachusetts, 2013. Available at http://www.mass.gov/chia/gov/lawsregs/email/rfr-impact-of-uninsurance-and-underinsurance.html; accessed May 7, 2013. 21. Mass. Gen. Laws chapter 450 of the Acts of 2006: An Act Further Regu­ lating Health Care Access, January 3, 2007, 2006. Available at https://


malegislature.gov/Laws/SessionLaws/Acts/2006/Chapter450; accessed February 25, 2014. 22. Mass. Gen. Laws chapter 205 of the Acts of 2007: An Act Further Regulating Health Care Access. November 29, 2007. Available at https:// malegislature.gov/Laws/SessionLaws/Acts/2007/Chapter205; accessed February 25, 2014.

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Experience of the Veterans Health Administration in Massachusetts after state health care reform.

Starting in 2006, Massachusetts enacted a series of health insurance reforms that successfully led to 96.6% of its population being covered by 2011. A...
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