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Use of Intensive Care Services and Associated Hospital Mortality After Massachusetts Healthcare Reform*

Lyon, Sarah M. MD, MSCE1; Wunsch, Hannah MD2; Asch, David A. MD, MBA3,4; Carr, Brendan G. MD, MA, MSHP3,5,6; Kahn, Jeremy M. MD, MSc7; Cooke, Colin R. MD, MSc, MS8,9

doi: 10.1097/CCM.0000000000000044
Feature Articles

Objective: To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality.

Design: Population-based cohort study.

Setting: Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform.

Patients: All nonpregnant nonelderly adults (age 18–64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were eligible, excluding patients who were not residents of a respective state at the time of admission.

Measurements: We used a difference-in-differences approach to compare trends in ICU admissions and outcomes of in-hospital mortality and discharge destination for ICU patients.

Main Result: Healthcare reform in Massachusetts was associated with a decrease in ICU patients without insurance from 9.3% to 5.1%. There were no significant changes in adjusted ICU admission rates, mortality, or discharge destination. In a sensitivity analysis excluding a state that enacted Medicaid reform prior to the study period, our difference-in-differences analysis demonstrated a significant increase in mortality of 0.38% per year (95% CI, 0.12–0.64%) in Massachusetts, attributable to a greater per-year decrease in mortality postreform in comparison states (–0.37%; 95% CI, –0.52% to –0.21%) compared with Massachusetts (0.01%; 95% CI, –0.20% to 0.11%).

Conclusion: Massachusetts healthcare reform increased the number of ICU patients with insurance but was not associated with significant changes in ICU use or discharge destination among ICU patients. Reform was also not associated with changed in-hospital mortality for ICU patients; however, this association was dependent on the comparison states chosen in the analysis.

Supplemental Digital Content is available in the text.

1Division of Pulmonary, Allergy and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA.

2Department of Anesthesiology, Columbia University, New York, NY.

3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.

4Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA.

5Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.

6Center for Policy Research, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.

7CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

8Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI.

9Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

* See also p. 970.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Lyon received support for article research from National Institutes of Health (NIH, F32 10762329) and received grant support from the Leonard Davis Institute, University of Pennsylvania (Pilot Grant). She received support for travel from the American Thoracic Society (ATS Travel Award 2012) and is employed by the Chester County Hospital. Her institution received grant support from the NIH (AHRQ F32). Dr. Wunsch received grant support from NIH. Dr. Carr was supported by Leonard Davis Institute, University of Pennsylvania. He spends a portion of his time as a Senior Policy Analyst in the Office of the Assistant Secretary for Preparedness and Response. Dr. Kahn consulted for the U.S. Department of Veterans Affairs. He received speaking honoraria from the National Association of Long-term Acute Care hospitals and Barlow Respiratory Hospital. His institution received grant support from the U.S. Department of Health and Human Services (research grants). Dr. Cooke was supported by the University of Michigan’s Robert Wood Johnson Foundation Clinical Scholars and Health and Society Programs. He and his institution received grant support from the Agency for Healthcare Research and Quality (K08), and his institution received support from Robert Wood Johnson Foundation. The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Department of Health and Human Services or its components. Dr. Asch has disclosed that he does not have any potential conflicts of interest.

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