Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level

Abstract

BACKGROUND: Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income. STUDY DESIGN: Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years. RESULTS:Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD e16.5 percentage points; 95% CI, e17.1 to e15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD e0.4 percentage points; 95% CI, e0.8 to e0.1 percentage points). CONCLUSIONS: The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.

Impact of Medicaid expansion on young adult firearm and motor vehicle crash trauma patients

“…These factors included the following: patient age, sex, urban/rural residence, injury severity score (ISS), presence of a severe head or neck injury, presence of any chronic condition, presence of traumatic shock, and whether an operative procedure was performed. These factors were included in the multivariable analyses because of their established relationships with one or more of the outcomes of interest [ 26 , [34] , [35] , [36] , [37] , [38] ]. Patient residential urbanicity/rurality was evaluated using the National Center for Health Statistics' county-level scheme [ 39 ].…”

“…All analyses were stratified by mechanism of injury. Similar to our analyses in the overall young adult trauma patient population [ 26 ], in this study, we examined patient characteristics in the overall study cohort and in Medicaid expansion and nonexpansion states before and after the implementation of the ACA Medicaid expansion and open enrollment in January 2014. We summarized these characteristics using frequencies and percentages, medians and interquartile ranges, or means and standard deviations (SDs).…”

“…Among trauma patients specifically, several studies have described the effects of Medicaid expansion on insurance coverage, trauma care, and outcomes. These studies have found that Medicaid expansion resulted in a greater than 15 percentage point decrease in the uninsured rate among young adult trauma patients overall in 2014 and a continued smaller decrease in the years thereafter [ [26] , [27] , [28] , [29] ]. Medicaid expansion also significantly decreased insurance coverage disparities between non-Hispanic black and non-Hispanic white trauma patients and between patients residing in lower- versus higher-income zip codes [ 26 , 30 ].…”

“…These studies have found that Medicaid expansion resulted in a greater than 15 percentage point decrease in the uninsured rate among young adult trauma patients overall in 2014 and a continued smaller decrease in the years thereafter [ [26] , [27] , [28] , [29] ]. Medicaid expansion also significantly decreased insurance coverage disparities between non-Hispanic black and non-Hispanic white trauma patients and between patients residing in lower- versus higher-income zip codes [ 26 , 30 ]. Furthermore, Medicaid expansion increased access to rehabilitation and decreased socioeconomic disparities in access to rehabilitation [ [27] , [28] , [29] , [30] ].…”

“…Furthermore, Medicaid expansion increased access to rehabilitation and decreased socioeconomic disparities in access to rehabilitation [ [27] , [28] , [29] , [30] ]. We also found that, among all young adult trauma patients, Medicaid expansion, in its first 4 years of implementation, did not reduce in-hospital mortality or unplanned readmissions overall but did reduce the disparity in in-hospital mortality between black and white trauma patients [ 26 ].…”