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We expanded this definition to include patients whose insurance was identified as “self pay,” “indigent,” and “hospital responsibility,” because caring for the uninsured is a key mission of safety net hospitals. We calculated the percentage of patients in each hospital who fell into these coverage groups throughout the study period (in both the pre reform and post reform periods), and defined safety net hospitals as those hospitals in the highest quarter.Definition of pre reform and post reform periodsImplementation of Massachusetts health reform began on 1 July 2006 with expansion of Medicaid to cover previously “enrollment capped” low income populations, culminating in a penalty enforced mandate of individual insurance coverage effective 1 January 2008.22 New York embarked on incremental health reform in 2000, expanding Medicaid eligibility and making private coverage more affordable for uninsured workers on a low income.19 New Jersey passed legislation in 2008 to create an individual mandate for children.34 Neither state’s efforts achieved near universal levels of coverage, and neither included the creation of an insurance exchange or an individual mandate for adult coverage. We examined 30 day readmissions in Massachusetts and in the comparison states (New Jersey and New York) for 21 months (1 January 2008 to 30 September 2009) after this mandate (post reform period) and contrasted it with data for the 21 months (1 September 2004 to 30 June 2006) preceding reform (pre reform period), excluding the transition period (1 July 2006 to 31 December 2007).