Did Massachusetts Health Reform Increase Use of the Veterans Affairs Health Care System?

Wong ES, Maciejewski ML, Hebert PL, Batten AJ, Nelson KM, Fihn SD, Liu C. Did Massachusetts Health Reform Increase Use of the Veterans Affairs Health Care System? Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.

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Objective: The Veterans Affairs Health Care System (VA) is the largest integrated health system in the United States. Massachusetts Health Reform (MHR), implemented in June 2006, introduced a mandate requiring minimum health insurance coverage and new health insurance options available to eligible Massachusetts residents. VA enrollment satisfied the individual mandate, however, new options under MHR, such as the Medicaid expansion, may have prompted some VA enrollees to shift care from VA to non-VA sources. This study examined whether MHR was associated with changes in veterans' use of VA primary care (PC). Study Design: Using VA administrative data, we identified all veterans residing in Massachusetts and neighboring New England (NE) states (Connecticut, Maine, New Hampshire, Rhode Island and Vermont) and were enrolled in VA at any time during the period October 2004 to September 2008. We compared quarterly rates of exit from VA, defined as absence from VA data in subsequent quarters, across groups. We measured veterans' PC use as the number of PC face-to-face visits in each quarter during the study period. Using MHR implementation as a natural experiment, we applied difference-in-difference methods to compare pre-post changes in PC use among Massachusetts and other NE veterans, respectively. We modeled PC visit counts using negative binomial regression adjusting for patient demographics, comorbidity, local economic conditions, non-VA healthcare supply and patient fixed-effects. Analyses were stratified by age group (under 65 and 65+) to account for differences due to Medicare eligibility. Population Studied: 230,811 VA enrollees residing in NE during the study period (84,859 Massachusetts; 145,952 other NE). Results: Among Massachusetts veterans, the rate of exit in a quarter increased from 1.5% pre-MHR to 2.0% post-MHR. For other NE veterans, the rate of exit increased from 1.7% pre-MHR to 1.9% post-MHR. Prior to reform, mean PC visits per patient per quarter were 0.81 and 0.76 for under age 65 Massachusetts and other NE veterans, respectively. Among age 65+ veterans prior to reform, mean PC visits per patient per quarter were 0.82 and 0.75 for Massachusetts and other NE veterans, respectively. In adjusted analyses, MHR was associated with a 0.012 (p = 0.004) and 0.007 (p = 0.022) increase in quarterly PC visits for VA enrollees under age 65 and age 65+, respectively. Among veterans continuously present in VA data through all follow-up quarters, MHR was associated with a 0.032 (p < 0.001) and 0.021 (p < 0.001) increase in quarterly PC visits for under age 65 and age 65+ enrollees, respectively. Conclusion: MHR was associated with small, but statistically significant increases in PC use. For example, among under 65 veterans, an additional 12 quarterly PC visits per 1,000 VA enrollees were attributable to MHR. The positive association was concentrated among the subpopulation of VA users who remained continuously enrolled in VA following MHR. Implications for Policy or Practice: The impact of the Affordable Care Act, which includes many components present in MHR, on veterans' future utilization of VA remain unknown. Our findings suggest some veterans may choose to seek care through non-VA options. However, among veterans who remain enrolled in VA after health reform, VA may become an increasingly important source of care.