title: Massachusetts health reform and Veterans Affairs health system enrollment.
abstract: OBJECTIVE
  Veterans Health Administration (VA) operates the largest integrated health system in the nation. The Affordable Care Act (ACA) does not require any changes to VA, but the individual mandate and expanded health insurance options may change veterans' preferences for coverage. We examined the impact of healthcare reform in Massachusetts, which also included these policy changes, on veterans' enrollment in VA, private insurance, and Medicaid.
  
  
  METHODS
  Massachusetts' healthcare reform in June 2006 served as a natural experiment. Using data from the 2004-2013 Current Population Surveys, we examined enrollment in VA, private insurance, and Medicaid, comparing veterans residing in Massachusetts with veterans residing in neighboring New England states that did not undergo health reform.
  
  
  METHODS
  We estimated the probability of being enrolled in VA, private insurance, and Medicaid before and after healthcare reform, using multivariate probit models while adjusting for individual characteristics. Using a difference-in-difference approach, we compared pre-post changes in enrollment probability among Massachusetts and non-Massachusetts veterans, respectively.
  
  
  RESULTS
  Compared with other New England veterans, Massachusetts veterans decreased their enrollment in VA and private insurance by 0.2 (P = .857) and 0.9 (P = .666) percentage points, respectively, following health reform. In contrast, Medicaid enrollment increased by 2.5 percentage points (P = .038).
  
  
  CONCLUSIONS
  Healthcare reform in Massachusetts was associated with greater Medicaid enrollment, but was not significantly associated with VA and private insurance enrollment. Our results are significant for informing VA fiscal planning in the post ACA era.
authors.affiliation: Center of Innovation for Veteran-Centered and Value-Driven Care, 1100 Olive Way, Suite 1400, Seattle, WA 98101. E-mail: edwin.wong@va.gov.
authors.forename: Edwin S
authors.initials: ES
authors.lastname: Wong
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Maciejewski
authors.forename: Paul L
authors.initials: PL
authors.lastname: Herbert
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Bryson
authors.forename: Chuan-Fen
authors.initials: CF
authors.lastname: Liu
mesh_terms: D005260:Female; D018166:Health Care Reform; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D008297:Male; D008404:Massachusetts; D008484:Medicaid / Q000706:statistics & numerical data; D008875:Middle Aged; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data*; D014728:Veterans / Q000706:statistics & numerical data