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Association of Medicaid Expansion Under the Affordable Care Act With Outcomes and Access to Rehabilitation in Young Adult Trauma Patients

Educational Objective To identify to what extent there is an association of Medicaid expansion with insurance coverage, in-hospital mortality, failure to rescue, access to rehabilitation, and unplanned readmissions among hospitalized young adult trauma patients.
1 Credit CME
Key Points

Question  Was Medicaid expansion under the Affordable Care Act in its first year of implementation associated with improvements in insurance coverage and outcomes among young adults hospitalized for traumatic injury?

Findings  In this study, there was an 18.2% increase in Medicaid coverage and a 15.1% decrease in lack of insurance among trauma patients hospitalized across 11 Medicaid expansion states. There were no significant changes in in-hospital mortality or unplanned readmission rates, but discharge to rehabilitation increased 1.2%, a significant difference.

Meaning  In this study of hospitalized young adult trauma patients, Medicaid expansion has improved insurance coverage and access to postinjury rehabilitation.

Abstract

Importance  Trauma is the leading cause of death and disability among young adults in the United States. Young adults are also the age group most likely to be uninsured. Implementation of Medicaid expansion through the Affordable Care Act (ACA) has increased insurance coverage, but its associations with trauma care and outcomes among young adults nationwide remain unknown. We examined whether Medicaid expansion, in its first year, was associated with changes in insurance coverage and improved outcomes in young adults hospitalized for traumatic injury.

Objective  To assess the associations of ACA Medicaid expansion with insurance coverage, in-hospital mortality, failure to rescue, access to rehabilitation, and unplanned readmissions among hospitalized young adult trauma patients across many US states.

Design, Setting, and Participants  We used the Healthcare Cost and Utilization Project State Inpatient Databases to examine changes in insurance coverage and risk adjusted outcomes among young adults (age 19 to 44 years) who were hospitalized for injuries before and after Medicaid expansion and open enrollment occurred (2012-2013 vs 2014) in 11 US states that expanded Medicaid through the ACA. We also performed difference-in-difference analyses to compare these changes between 3 expansion states and 3 non-expansion states within the same geographic region.

Results  Of the 141 187 trauma patients hospitalized across 11 Medicaid expansion states, 43 871 (31.1%) were women, and the mean (SD) age was 31.4 (7.6) years. Medicaid expansion was associated with an increase in Medicaid coverage from 16 229 individuals (16.7%) to 15 358 individuals (34.9%) (difference: 18.2% [95% CI, 16.5%-20.0%]; P < .001), a decrease in lack of insurance from 27 016 individuals (27.8%) to 5589 individuals (12.7%) (difference: −15.1% [95% CI, −16.8% to −13.5%]; P < .001), and an increase in discharge to rehabilitation from 9220 individuals (11.4%) to 4736 individuals (12.6%) (difference: 1.16% [95% CI, 0.55%-1.77%]; P < .001). We found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions. Similar results were found when 3 of these states were compared with 3 geographically and demographically similar states that had not enacted Medicaid expansion.

Conclusions and Relevance  The first year of implementation of Medicaid expansion and open enrollment across 11 selected US states was associated with significant increases in Medicaid coverage, reductions in uninsured rates, and increased access to postdischarge rehabilitation among young adults hospitalized for injury. However, this study found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions.

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Article Information

Corresponding Author: Jennifer N. Cooper, PhD, Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB Ste 3A.3, Columbus, OH 43205 (jennifer.cooper@nationwidechildrens.org).

Accepted for Publication: March 10, 2018.

Published Online: June 6, 2018. doi:10.1001/jamasurg.2018.1630

Author Contributions: Dr Cooper had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Minneci, Deans, Xiang, Cooper.

Acquisition, analysis, or interpretation of data: Akande, Minneci, Deans, Cooper.

Drafting of the manuscript: Akande, Cooper.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cooper.

Administrative, technical, or material support: Cooper.

Supervision: Cooper.

Conflict of Interest Disclosures: None reported.

Funding/Support: The Research Institute at Nationwide Children’s Hospital contributed all financial and material support for this research.

Role of the Funder/Sponsor: All of the authors of this study are employees of the funder. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the data organizations that provided the Agency for Healthcare Research and Quality with the statewide data used for these analyses: Arkansas Department of Health, Colorado Hospital Association, Florida Agency for Health Care Administration, Georgia Hospital Association, Iowa Hospital Association, Kentucky Cabinet for Health and Family Services, Maryland Health Services Cost Review Commission, Nevada Department of Health and Human Services, New Jersey Department of Health, New Mexico Department of Health, North Carolina Department of Health and Human Services, Oregon Association of Hospitals and Health Systems, Rhode Island Department of Health, Washington State Department of Health. These organizations were compensated for these contributions by the funder of this study.

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