SUPPLEMENT ARTICLE
Massachusetts Health Care Reform and Orthopaedic Trauma: Lessons Learned Mitchel B. Harris, MD, FACS
Summary: Massachusetts was the first state to implement its own version of the Affordable Care Act (ACA), when it passed the Massachusetts Health Care Reform (MHR) in 2006. Similar to the ACA, its explicit purpose was universal access to health care to all residents of Massachusetts. We believe that the influence of MHR on orthopaedic trauma in Massachusetts will have implications on trauma systems across the country, given the similarities between ACA and MHR. Therefore, in this article, we discuss our experiences as Orthopaedic trauma surgeons with regard to MHR. In this regard, we reviewed the effects of the implementation of MHR on the orthopaedic trauma services at 3 of the 4 level one trauma centers in Boston, MA. Our results demonstrate a dramatic reduction in the proportion of uncompensated care at these centers in addition to the number of uninsured patients with orthopaedic trauma injuries. Key Words: Massachusetts Health Care Reform, Affordable Care Act, orthopaedic trauma health policy (J Orthop Trauma 2014;28:S20–S22)
M
assachusetts is generally considered to be the birthplace of the Affordable Care Act (ACA) (also known as “ObamaCare”).1,2 The impetus for Massachusetts Health Care Reform (MHR) and the ACA is simple; neither the state(s) nor the federal government can afford to continue spending increasing amounts of their general budget on health care finance.3 On April 12, 2006, the Massachusetts legislature approved its landmark health care reform law: Chapter 58: “An Act Providing Access to Affordable, Quality, and Accountable Health Care (MHR).” Given the relationship between ACA and MHR (Table 1),4 it is important to investigate the influence of MHR on Orthopaedic trauma to better understand potential national implications of the ACA on trauma systems. The primary stated intent of the MHR was to decrease financial barriers to gain access to health care to all citizens of the Commonwealth. Our lawmakers concurrently postulated that by improving access to primary care physicians, there would be a substantial decrease in unwarranted and expensive Accepted for publication July 17, 2014. From the Department of Orthopedic Surgery, Harvard Orthopedic Trauma Initiative, Boston, MA. The author reports no conflict of interest. Reprints: Mitchel B. Harris, MD, FACS, Department of Orthopedic Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
S20
| www.jorthotrauma.com
emergency department (ED) visits and an increase in the initiation of preventative health care measures. These “simple” fixes would help drive down the per capita cost of health care in the state. MHR also specifically sought to initiate the first formalized step toward reimbursing hospitals and providers who care for the uninsured. As orthopaedic traumatologists, we rarely determine care pathways with insurance status in mind. This is in stark contrast to nonurgent and electively scheduled procedures where the generally accepted protocol is to request and obtain insurance approval before initiating an intervention. This standard process of evaluating insurance coverage before initiating treatment may lead to patients seeking intervention from physicians/surgeons who are specified on their insurance provider panels or even choosing other hospitals which are contracted by their insurance plans. However, for emergent care, this would rarely hold true. Thus, with the onset of MHR, it would seem that trauma services within Massachusetts should experience a significant decrease in their percentage of uninsured patients. Three of the 4 level 1 trauma centers (American College of Surgeons Committee on Trauma designation) in Boston, MA, agreed to participate in a study analyzing the effect of the MHR on the uninsured rate of the orthopaedic trauma population.5 This initiative was designed to specifically evaluate the accuracy of the publicized rate of uninsured in Massachusetts and to assess the effects of MHR on our unique orthopaedic trauma population. Each trauma center reviewed their patient demographics and insurance status from 2003 to 2010. Billing and collection revenue data from 2006 and 2007 were excluded to allow for the enrollment transition period, as the MHR act was implemented over a 12-month period (July 2006 to 2007) and the penalty did not take effect until January 2008. Only Massachusetts residents with a validated “local” address who were between the ages of 18 and 64 years were included to attempt to exclusively focus on the effects of MHR. We used the broad categories of “insured” and “uninsured” when defining our cohorts. The insured cohort included patients with commercial or private policies, liability coverage, Worker’s compensation, Medicare, and Medicaid. The uninsured cohort consisted of those patients without insurance before the MHR and those who subsequently did not abide by the MHR guidelines after its implementation. There were a rather small percentage of self-insured patients defined as those who could readily afford their health care costs without an insurance carrier. During the recorded study period, .16,000 patients with extremity and pelvic fractures were treated at the 3 urban
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
Massachusetts Health Care Reform
TABLE 1. Romneycare Versus Obamacare: Key Similarities and Differences3 Individual mandate Penalty for not buying insurance Employer mandate Penalties for employers not providing insurance Subsidized insurance
Obamacare (ACA) Yes Minimum of $695 a year Yes for companies with .50 employees $2000 per employee for companies with .50 employees Yes; for anyone earning up to 400% of poverty level
Young adults
Children stay on parents’ plan until 26
Benefit limits Retroactive rescinding of coverage Preexisting conditions
Forbidden on both annual and lifetime basis Forbidden Insurers required to cover
Preventative care
Free
Contraception Effective date
Included under free preventative care March 23, 2010, specific provisions phased in through 2020
trauma centers. After the implementation of MHR, the rate of uninsured patients treated by the 3 trauma centers’ orthopaedic services dropped from approximately 24% to 14%. This represents a 40% reduction in the risk for treating uninsured individuals at these 3 trauma centers located in Boston. Further support of the beneficial effect of the MHR was reflected in the reduction in the proportion of uncompensated care provided at these 3 centers from nearly 17% to 11.5%. Our study illustrates the relative success of the implementation of MHR. However, it also highlights some areas that need further investigation. Although the uninsurance rate dropped significantly at our 3 trauma centers, the rate of uninsured trauma patients that we identified was nearly 5-fold greater than that reported publically at the state level. One could potentially attribute this disparity to the methodology used to estimate the state’s census and the percentage of insured. Our uninsured data may also be artificially inflated because 2 of the 3 trauma centers in our study were recognized by the Health Safety Net as dominant providers of statewide free care.6 If we look at the early effects on health care reform in Massachusetts as a learning tool for implementing and modifying some of the guidelines within the ACA, there are several areas that are worth noting.
Romneycare (MHR) Yes Minimum of $1200 a year Yes for companies with $11 employees $295 per employee for companies with .11 employees Yes; for anyone earning up to 300% of poverty level. Free for anyone earning up to 150% of poverty level Children can stay on parents’ plan until age 26 or until they have not been a dependent for 2 y, whichever is sooner Not forbidden, although most MA insurers do not place limits Forbidden Insurers required to cover but can limit coverage of certain conditions to 6 mo Co-pay, but must be covered without a deductible Not mentioned April 12, 2006
implementation of MHR. These findings were particularly evident in the areas of the state most affected by MHR and were not evident in those areas predominantly covered by Medicare. These data seem to parallel the trend toward an increased volume of orthopaedic procedures noted in the 3 trauma centers after the implementation of MHR. This may represent a funneling of orthopaedic trauma cases to the trauma centers due to the perceived need for these patients to require excessive resources or be of increasing complexity, be it medical, technological, or social.
RATE OF UNINSURED
Both our orthopaedic trauma population study7 and others8–10 noted a decrease in the percentage of uninsured patients receiving medical treatment. The study by Pande et al10 goes on to further analyze this impact and notes that in 2009 the reform resulted in a 63% reduction in the odds of being uninsured in Massachusetts compared with the comparison states (Rhode Island, Vermont, New Hampshire, and Connecticut), a 49% reduction in the odds of foregoing care because of cost, and a 51% reduction in the odds of not having a personal doctor. For the advantaged group, living in Massachusetts resulted in a significant reduction only in uninsurance rates compared with the comparison states.
ED VISITS
Smulowitz et al2 recently published their analysis of the extent to which MHR was associated with changes in ED utilization. Using a difference-in-differences identification strategy, the authors found a “small but measurable increase in ED visits” across the state associated with the Ó 2014 Lippincott Williams & Wilkins
QUALITY OF CARE If mortality rate can serve as a proxy for improved health care provision, Sommers et al11 have demonstrated an improvement indirectly by noting a significant reduction in www.jorthotrauma.com |
S21
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
Harris
all-causes mortality and deaths from causes amenable to health care subsequent to the implementation of MHR. Furthermore, they found that the reductions in mortality were largest in Massachusetts counties, with lower incomes and lower insurance coverage before reform areas likely to have had the greatest increase in access to care under reform. Mortality reductions were nearly twice as large for minorities as for white adults. However, the analysis did not imply causality.
REMAINING ISSUES When the uninsured patients were asked to provide reasons for their lack of insurance despite the implementation of the MHR, one-third reported the inability to find affordable insurance. An additional one-third reported losing their insurance coverage related to the loss of a previous job. Others within this group reported that their insurance had been canceled without notice or had lapsed because of paperwork difficulties. Finally, and to a lesser degree, were the loss of coverage on a spouse’s policy, transition between jobs, and aging out of parental coverage. Ultimately, for nearly half of the uninsured who were interviewed, although they were fully aware of the individual mandate for insurance in Massachusetts, they were unable to find insurance they could afford, compared with the penalty cost of not carrying insurance.2 Other reasons cited included language and cultural barriers, lack of understanding of the new legislation, and an accurate understanding that the fine for not abiding to the MHR was less expensive than the premium cost of the policy.
LESSONS LEARNED MHR and the ACA will undoubtedly decrease the percentage of uninsured patients requiring medical care. For orthopaedic traumatologists, it is important to recognize that your individual state’s advertised uninsurance rate may not be an accurate predictor of your payor mix. This may lead you to seek/require hospital support to be able to provide optimal and consistent care for your unique population. The uninsured patients that you are treating often fit squarely into the uncomfortable position of the working poor, that is, maintaining a job yet still not being able to afford even state or federal subsidized policies. Optimal care for these patients is essential, as they need to return to work as expeditiously as possible to continue to be financially solvent. An additional group of the uninsured patients that you may encounter will represent those that are not citizens of your state and thus do not qualify for your state’s subsidized insurance. Care received outside their state, even if perceived to be an urgent intervention will not be supported by the state of residence, and the patient will be “held responsible” for payment. Ultimately, these bills are rarely able to be financed
S22
| www.jorthotrauma.com
by the patient. This group of patients may be best served through the provision of appropriate urgent services at the time of presentation, followed by a referral to one of their state-supported institutions for definitive care (eg, irrigation and debridement and splinting or external fix placement, then referral, rather than staged definitive care at an out-of-state facility). Finally, if the transition of the profession of medicine continues toward a commoditized industry, health care providers, and in particular, those practitioners whose income are predominantly determined by procedures will have to optimally align their professional interests with those of the hospital. By identifying patient-centered outcome metrics or functional outcome goals that have value to the injured patients (Patient reported outcome measures), the providers (functional outcomes), and the hospital (length of stay, return to ED, occurrence of “never events”), programmatic support should be made available by the institution concurrent with the achievement of these metrics. When evaluating the early results of MHR and generalizing them to the fullest implementation of the ACA, it is essential to emphasize the synergy that will be required between orthopaedic trauma surgeons and their hospitals to provide universal care to those in need. REFERENCES 1. Nardin R, Sayah A, Lokko H, et al. Reasons why patients remain uninsured after Massachusetts Health Care Reform: a survey of patients at a safety-net hospital. J Gen Intern Med. 2012;27:250–256. 2. Smulowitz PB, O’Malley J, Yang X, et al. Increased use of emergency department after health care reform in Massachusetts. Ann Emerg Med 2014;64:107–115. 3. Schoenbaum SC, Doty MM, Schoen C, et al; The Commonwealth Fund. Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care. Washington, DC: Washington, DC. Office. Available at: http://www.commonwealthfund.org/publications/ fund-reports/2007/may/mirror–mirror-on-the-wall–an-international-updateon-the-comparative-performance-of-american-health. Accessed May 2007. 4. McIsaac J. Understanding Romneycare, American Thinker. 2012. Available at: http://www.americanthinker.com/2012/09/understanding_romneycare.html. Accessed August 2014. 5. Toussaint RJ, Bergeron S, Weaver MJ, et al. The effect of Massachusetts Healthcare Reform on the uninsured rate of the orthopaedic population. J Bone Joint Surg. 2014;96:e141. 6. Massachusetts Division of Health Care Finance and Policy. Health Safety Net 2011: Qtr 2 Report. 2011. Available at: http://www.mass.gov/chia/ docs/r/pubs/11/hsn-2011-q2.pdf. Accessed August 2014. 7. Burdett G. CBS Boston. 2013. Available at: CBSlocal.com. Accessed August 2014. 8. Pande AH, Ross-Degnan D, Zaslavsky A, et al. Effects of healthcare reform on coverage access and disparities. Am J Prev Med. 2011;41:1–8. 9. Long S, Stockley K, Dahlen H. Massachusetts health reforms: uninsurance remains Los, self-reported health status improves as state prepares to tackle costs. Health Aff (Millwood). 2012;31:444–451. 10. Kolstad JT, Kowalski AE. The impact of health care reform on hospital and preventive care: evidence from Massachusetts. J Public Econ. 2012; 96:909–929. 11. Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts Health Care Reform. Ann Intern Med. 2014;160:585–593.
Ó 2014 Lippincott Williams & Wilkins
Massachusetts Health Care Reform and Orthopaedic Trauma: Lessons Learned Mitchel B. Harris, MD, FACS
Summary: Massachusetts was the first state to implement its own version of the Affordable Care Act (ACA), when it passed the Massachusetts Health Care Reform (MHR) in 2006. Similar to the ACA, its explicit purpose was universal access to health care to all residents of Massachusetts. We believe that the influence of MHR on orthopaedic trauma in Massachusetts will have implications on trauma systems across the country, given the similarities between ACA and MHR. Therefore, in this article, we discuss our experiences as Orthopaedic trauma surgeons with regard to MHR. In this regard, we reviewed the effects of the implementation of MHR on the orthopaedic trauma services at 3 of the 4 level one trauma centers in Boston, MA. Our results demonstrate a dramatic reduction in the proportion of uncompensated care at these centers in addition to the number of uninsured patients with orthopaedic trauma injuries. Key Words: Massachusetts Health Care Reform, Affordable Care Act, orthopaedic trauma health policy (J Orthop Trauma 2014;28:S20–S22)
M
assachusetts is generally considered to be the birthplace of the Affordable Care Act (ACA) (also known as “ObamaCare”).1,2 The impetus for Massachusetts Health Care Reform (MHR) and the ACA is simple; neither the state(s) nor the federal government can afford to continue spending increasing amounts of their general budget on health care finance.3 On April 12, 2006, the Massachusetts legislature approved its landmark health care reform law: Chapter 58: “An Act Providing Access to Affordable, Quality, and Accountable Health Care (MHR).” Given the relationship between ACA and MHR (Table 1),4 it is important to investigate the influence of MHR on Orthopaedic trauma to better understand potential national implications of the ACA on trauma systems. The primary stated intent of the MHR was to decrease financial barriers to gain access to health care to all citizens of the Commonwealth. Our lawmakers concurrently postulated that by improving access to primary care physicians, there would be a substantial decrease in unwarranted and expensive Accepted for publication July 17, 2014. From the Department of Orthopedic Surgery, Harvard Orthopedic Trauma Initiative, Boston, MA. The author reports no conflict of interest. Reprints: Mitchel B. Harris, MD, FACS, Department of Orthopedic Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
S20
| www.jorthotrauma.com
emergency department (ED) visits and an increase in the initiation of preventative health care measures. These “simple” fixes would help drive down the per capita cost of health care in the state. MHR also specifically sought to initiate the first formalized step toward reimbursing hospitals and providers who care for the uninsured. As orthopaedic traumatologists, we rarely determine care pathways with insurance status in mind. This is in stark contrast to nonurgent and electively scheduled procedures where the generally accepted protocol is to request and obtain insurance approval before initiating an intervention. This standard process of evaluating insurance coverage before initiating treatment may lead to patients seeking intervention from physicians/surgeons who are specified on their insurance provider panels or even choosing other hospitals which are contracted by their insurance plans. However, for emergent care, this would rarely hold true. Thus, with the onset of MHR, it would seem that trauma services within Massachusetts should experience a significant decrease in their percentage of uninsured patients. Three of the 4 level 1 trauma centers (American College of Surgeons Committee on Trauma designation) in Boston, MA, agreed to participate in a study analyzing the effect of the MHR on the uninsured rate of the orthopaedic trauma population.5 This initiative was designed to specifically evaluate the accuracy of the publicized rate of uninsured in Massachusetts and to assess the effects of MHR on our unique orthopaedic trauma population. Each trauma center reviewed their patient demographics and insurance status from 2003 to 2010. Billing and collection revenue data from 2006 and 2007 were excluded to allow for the enrollment transition period, as the MHR act was implemented over a 12-month period (July 2006 to 2007) and the penalty did not take effect until January 2008. Only Massachusetts residents with a validated “local” address who were between the ages of 18 and 64 years were included to attempt to exclusively focus on the effects of MHR. We used the broad categories of “insured” and “uninsured” when defining our cohorts. The insured cohort included patients with commercial or private policies, liability coverage, Worker’s compensation, Medicare, and Medicaid. The uninsured cohort consisted of those patients without insurance before the MHR and those who subsequently did not abide by the MHR guidelines after its implementation. There were a rather small percentage of self-insured patients defined as those who could readily afford their health care costs without an insurance carrier. During the recorded study period, .16,000 patients with extremity and pelvic fractures were treated at the 3 urban
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
Massachusetts Health Care Reform
TABLE 1. Romneycare Versus Obamacare: Key Similarities and Differences3 Individual mandate Penalty for not buying insurance Employer mandate Penalties for employers not providing insurance Subsidized insurance
Obamacare (ACA) Yes Minimum of $695 a year Yes for companies with .50 employees $2000 per employee for companies with .50 employees Yes; for anyone earning up to 400% of poverty level
Young adults
Children stay on parents’ plan until 26
Benefit limits Retroactive rescinding of coverage Preexisting conditions
Forbidden on both annual and lifetime basis Forbidden Insurers required to cover
Preventative care
Free
Contraception Effective date
Included under free preventative care March 23, 2010, specific provisions phased in through 2020
trauma centers. After the implementation of MHR, the rate of uninsured patients treated by the 3 trauma centers’ orthopaedic services dropped from approximately 24% to 14%. This represents a 40% reduction in the risk for treating uninsured individuals at these 3 trauma centers located in Boston. Further support of the beneficial effect of the MHR was reflected in the reduction in the proportion of uncompensated care provided at these 3 centers from nearly 17% to 11.5%. Our study illustrates the relative success of the implementation of MHR. However, it also highlights some areas that need further investigation. Although the uninsurance rate dropped significantly at our 3 trauma centers, the rate of uninsured trauma patients that we identified was nearly 5-fold greater than that reported publically at the state level. One could potentially attribute this disparity to the methodology used to estimate the state’s census and the percentage of insured. Our uninsured data may also be artificially inflated because 2 of the 3 trauma centers in our study were recognized by the Health Safety Net as dominant providers of statewide free care.6 If we look at the early effects on health care reform in Massachusetts as a learning tool for implementing and modifying some of the guidelines within the ACA, there are several areas that are worth noting.
Romneycare (MHR) Yes Minimum of $1200 a year Yes for companies with $11 employees $295 per employee for companies with .11 employees Yes; for anyone earning up to 300% of poverty level. Free for anyone earning up to 150% of poverty level Children can stay on parents’ plan until age 26 or until they have not been a dependent for 2 y, whichever is sooner Not forbidden, although most MA insurers do not place limits Forbidden Insurers required to cover but can limit coverage of certain conditions to 6 mo Co-pay, but must be covered without a deductible Not mentioned April 12, 2006
implementation of MHR. These findings were particularly evident in the areas of the state most affected by MHR and were not evident in those areas predominantly covered by Medicare. These data seem to parallel the trend toward an increased volume of orthopaedic procedures noted in the 3 trauma centers after the implementation of MHR. This may represent a funneling of orthopaedic trauma cases to the trauma centers due to the perceived need for these patients to require excessive resources or be of increasing complexity, be it medical, technological, or social.
RATE OF UNINSURED
Both our orthopaedic trauma population study7 and others8–10 noted a decrease in the percentage of uninsured patients receiving medical treatment. The study by Pande et al10 goes on to further analyze this impact and notes that in 2009 the reform resulted in a 63% reduction in the odds of being uninsured in Massachusetts compared with the comparison states (Rhode Island, Vermont, New Hampshire, and Connecticut), a 49% reduction in the odds of foregoing care because of cost, and a 51% reduction in the odds of not having a personal doctor. For the advantaged group, living in Massachusetts resulted in a significant reduction only in uninsurance rates compared with the comparison states.
ED VISITS
Smulowitz et al2 recently published their analysis of the extent to which MHR was associated with changes in ED utilization. Using a difference-in-differences identification strategy, the authors found a “small but measurable increase in ED visits” across the state associated with the Ó 2014 Lippincott Williams & Wilkins
QUALITY OF CARE If mortality rate can serve as a proxy for improved health care provision, Sommers et al11 have demonstrated an improvement indirectly by noting a significant reduction in www.jorthotrauma.com |
S21
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
Harris
all-causes mortality and deaths from causes amenable to health care subsequent to the implementation of MHR. Furthermore, they found that the reductions in mortality were largest in Massachusetts counties, with lower incomes and lower insurance coverage before reform areas likely to have had the greatest increase in access to care under reform. Mortality reductions were nearly twice as large for minorities as for white adults. However, the analysis did not imply causality.
REMAINING ISSUES When the uninsured patients were asked to provide reasons for their lack of insurance despite the implementation of the MHR, one-third reported the inability to find affordable insurance. An additional one-third reported losing their insurance coverage related to the loss of a previous job. Others within this group reported that their insurance had been canceled without notice or had lapsed because of paperwork difficulties. Finally, and to a lesser degree, were the loss of coverage on a spouse’s policy, transition between jobs, and aging out of parental coverage. Ultimately, for nearly half of the uninsured who were interviewed, although they were fully aware of the individual mandate for insurance in Massachusetts, they were unable to find insurance they could afford, compared with the penalty cost of not carrying insurance.2 Other reasons cited included language and cultural barriers, lack of understanding of the new legislation, and an accurate understanding that the fine for not abiding to the MHR was less expensive than the premium cost of the policy.
LESSONS LEARNED MHR and the ACA will undoubtedly decrease the percentage of uninsured patients requiring medical care. For orthopaedic traumatologists, it is important to recognize that your individual state’s advertised uninsurance rate may not be an accurate predictor of your payor mix. This may lead you to seek/require hospital support to be able to provide optimal and consistent care for your unique population. The uninsured patients that you are treating often fit squarely into the uncomfortable position of the working poor, that is, maintaining a job yet still not being able to afford even state or federal subsidized policies. Optimal care for these patients is essential, as they need to return to work as expeditiously as possible to continue to be financially solvent. An additional group of the uninsured patients that you may encounter will represent those that are not citizens of your state and thus do not qualify for your state’s subsidized insurance. Care received outside their state, even if perceived to be an urgent intervention will not be supported by the state of residence, and the patient will be “held responsible” for payment. Ultimately, these bills are rarely able to be financed
S22
| www.jorthotrauma.com
by the patient. This group of patients may be best served through the provision of appropriate urgent services at the time of presentation, followed by a referral to one of their state-supported institutions for definitive care (eg, irrigation and debridement and splinting or external fix placement, then referral, rather than staged definitive care at an out-of-state facility). Finally, if the transition of the profession of medicine continues toward a commoditized industry, health care providers, and in particular, those practitioners whose income are predominantly determined by procedures will have to optimally align their professional interests with those of the hospital. By identifying patient-centered outcome metrics or functional outcome goals that have value to the injured patients (Patient reported outcome measures), the providers (functional outcomes), and the hospital (length of stay, return to ED, occurrence of “never events”), programmatic support should be made available by the institution concurrent with the achievement of these metrics. When evaluating the early results of MHR and generalizing them to the fullest implementation of the ACA, it is essential to emphasize the synergy that will be required between orthopaedic trauma surgeons and their hospitals to provide universal care to those in need. REFERENCES 1. Nardin R, Sayah A, Lokko H, et al. Reasons why patients remain uninsured after Massachusetts Health Care Reform: a survey of patients at a safety-net hospital. J Gen Intern Med. 2012;27:250–256. 2. Smulowitz PB, O’Malley J, Yang X, et al. Increased use of emergency department after health care reform in Massachusetts. Ann Emerg Med 2014;64:107–115. 3. Schoenbaum SC, Doty MM, Schoen C, et al; The Commonwealth Fund. Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care. Washington, DC: Washington, DC. Office. Available at: http://www.commonwealthfund.org/publications/ fund-reports/2007/may/mirror–mirror-on-the-wall–an-international-updateon-the-comparative-performance-of-american-health. Accessed May 2007. 4. McIsaac J. Understanding Romneycare, American Thinker. 2012. Available at: http://www.americanthinker.com/2012/09/understanding_romneycare.html. Accessed August 2014. 5. Toussaint RJ, Bergeron S, Weaver MJ, et al. The effect of Massachusetts Healthcare Reform on the uninsured rate of the orthopaedic population. J Bone Joint Surg. 2014;96:e141. 6. Massachusetts Division of Health Care Finance and Policy. Health Safety Net 2011: Qtr 2 Report. 2011. Available at: http://www.mass.gov/chia/ docs/r/pubs/11/hsn-2011-q2.pdf. Accessed August 2014. 7. Burdett G. CBS Boston. 2013. Available at: CBSlocal.com. Accessed August 2014. 8. Pande AH, Ross-Degnan D, Zaslavsky A, et al. Effects of healthcare reform on coverage access and disparities. Am J Prev Med. 2011;41:1–8. 9. Long S, Stockley K, Dahlen H. Massachusetts health reforms: uninsurance remains Los, self-reported health status improves as state prepares to tackle costs. Health Aff (Millwood). 2012;31:444–451. 10. Kolstad JT, Kowalski AE. The impact of health care reform on hospital and preventive care: evidence from Massachusetts. J Public Econ. 2012; 96:909–929. 11. Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts Health Care Reform. Ann Intern Med. 2014;160:585–593.
Ó 2014 Lippincott Williams & Wilkins
