Changes in Hospitalizations at US Safety-Net Hospitals Following Medicaid Expansion.
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SUBMITTER: Lasser KE
PROVIDER: S-EPMC8246310 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ContextThe Affordable Care Act resulted in unprecedented reductions in the uninsured population through subsidized private insurance and an expansion of Medicaid. Early estimates from the beginning of 2014 showed that the Medicaid expansion decreased uninsured discharges and increased Medicaid discharges with no change in total discharges.ObjectiveTo provide new estimates of the effect of the ACA on discharges for specific conditions.Design, setting, and participantsWe compared outcomes between states that did and did not expand Medicaid using state-level all-capture discharge data from 2009-2014 for 42 states from the Healthcare Costs and Utilization Project's FastStats database; for a subset of states we used data through 2015. We stratified the analysis by baseline uninsured rates and used difference-in-differences and synthetic control methods to select comparison states with similar baseline characteristics that did not expand Medicaid.Main outcomeOur main outcomes were total and condition-specific hospital discharges per 1,000 population and the share of total discharges by payer. Conditions reported separately in FastStats included maternal, surgical, mental health, injury, and diabetes.ResultsThe share of uninsured discharges fell in Medicaid expansion states with below (-4.39 percentage points (p.p.), -6.04 --2.73) or above (-7.66 p.p., -9.07 --6.24) median baseline uninsured rates. The share of Medicaid discharges increased in both small (6.42 p.p. 4.22-6.62) and large (10.5 p.p., 8.48-12.5) expansion states. Total and most condition-specific discharges per 1,000 residents did not change in Medicaid expansion states with high or low baseline uninsured rates relative to non-expansion states (0.418, p = 0.225), with one exception: diabetes. Discharges for that condition per 1,000 fell in states with high baseline uninsured rates relative to non-expansion states (-0.038 95% p = 0.027).ConclusionsEarly changes in payer mix identified in the first two quarters of 2014 continued through the Medicaid expansion's first year and are distributed across all condition types studied. We found no change in total discharges between Medicaid expansion and non-expansion states, however residents of states that should have been most affected by the Medicaid expansion were less likely to be hospitalized for diabetes.
| S-EPMC5619726 | biostudies-literature
Project description:ImportanceThe extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known.ObjectiveTo assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations.Design, setting, and participantsDifference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys.ExposureTime-varying state-level adoption of Medicaid expansion.Main outcomes and measuresPrimary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits.ResultsThe sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion.Conclusion and relevanceMedicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.
| S-EPMC10900969 | biostudies-literature
Project description:ImportanceAlthough readmission rates are declining under Medicare's Hospital Readmissions Reduction Program (HRRP), concerns remain that the HRRP will harm quality at safety-net hospitals because they are penalized more often. Disparities between white and black patients might widen because more black patients receive care at safety-net hospitals. Disparities may be particularly worse for clinical conditions not targeted by the HRRP because hospitals might reallocate resources toward targeted conditions (acute myocardial infarction, pneumonia, and heart failure) at the expense of nontargeted conditions.ObjectiveTo examine disparities in readmission rates between white and black patients discharged from safety-net or non-safety-net hospitals after the HRRP began, evaluating discharges for any clinical condition and the subsets of targeted and nontargeted conditions.Design, setting, and participantsCohort study conducting quasi-experimental analyses of patient hospital discharges for any clinical condition among fee-for-service Medicare beneficiaries from 2007 to 2015 after controlling for patient and hospital characteristics. Changes in disparities were measured within safety-net and non-safety-net hospitals after the HRRP penalties were enforced and compared with prior trends. These analyses were then stratified by targeted and nontargeted conditions. Analyses were conducted from October 1, 2017, through August 31, 2018.Main outcomes and measuresTrends in 30-day readmission rates among white and black patients by quarter and differences in trends across periods.ResultsThe study sample included 58 237 056 patient discharges (black patients, 9.8%; female, 57.7%; mean age [SD] age, 78.8 [7.9] years; nontargeted conditions, 50 372 806 [86.5%]). Within safety-net hospitals, disparities in readmission rates for all clinical conditions widened between black and white patients by 0.04 percentage point per quarter in the HRRP penalty period (95% CI, 0.01 to 0.07; P = .01). This widening was driven by nontargeted conditions (0.05 percentage point per quarter [95% CI, 0.01 to 0.08]; P = .006), whereas disparities for the HRRP-targeted conditions did not change (with an increase of 0.01 percentage point per quarter [95% CI, -0.07 to 0.10]; P = .74). Within non-safety-net hospitals, racial disparities remained stable in the HRRP penalty period across all conditions, whether the conditions were HRRP-targeted or nontargeted.Conclusions and relevanceFindings from this study suggest that disparities are widening within safety-net hospitals, specifically for non-HRRP-targeted conditions. Although increases in racial disparities for nontargeted conditions were modest, they represent 6 times more discharges in our cohort than targeted conditions.
| S-EPMC6324411 | biostudies-literature
Project description:Importance:In the United States, nonprofit hospitals receive tax-exempt status with the expectation that they provide a high level of benefit to local communities. Prior work has shown that Medicaid expansion reduced hospital spending on uncompensated care. Objective:To measure the association of tax-exempt hospital spending with community benefit and changes in uncompensated care after Medicaid expansion. Design, Setting, and Participants:This cohort study was performed using a difference-in-differences analysis (ie, a pre-post treatment-control design) to estimate changes in reported charitable categories associated with Medicaid expansion. Data from Internal Revenue Service form 990, Schedule H, tax filings for 2253 tax-exempt hospitals in the United States from 2012 to 2016 were used. Data were analyzed from June to November 2019. Exposure:The proportion of the hospital's tax filing that spanned the period after Medicaid expansion. Main Outcomes and Measures:Hospital-reported spending on uncompensated care, unreimbursed Medicaid expenses, and other community benefit spending categories. Results:Across 2253 hospitals, mean (SD) uncompensated care costs between 2012 and 2016 were $4.20 million ($8.80 million) and unreimbursed Medicaid expenses were $7.60 million ($18.62 million). Compared with tax-exempt hospitals in states that did not expand Medicaid, those in states that did expand Medicaid reported mean reductions in their provision of uncompensated care of $1.11 million (95% CI, $0.35 million to $1.87 million; P?<?.001), representing a mean change of -2% (95% CI, -6% to 2%; P?<?.001). These reductions have been offset by mean reported increases in the provision of unreimbursed Medicaid expenses of $1.63 million (95% CI, $0.31 million to $2.94 million; P?=?.02), representing a mean increase of 2% (95% CI, 1% to 4%; P?=?.01). Tax-exempt hospitals in states that expanded Medicaid reported no statistically significant mean increase in spending on other community benefit activities. Conclusions and Relevance:In this study, large decreases in uncompensated care among tax-exempt hospitals associated with Medicaid expansion were not accompanied by increases in other reportable categories of community health benefit spending. Instead, they were accompanied by increased spending on unreimbursed Medicaid expenses.
| S-EPMC7137680 | biostudies-literature
Project description:An important function of health insurance is protecting enrollees from excessively burdensome charges for unanticipated medical events. Unexpected surgery can be financially catastrophic for uninsured people. By targeting the low-income uninsured population, Medicaid expansion had the potential to reduce the financial risks associated with these events. We used two data sources (state-level data for forty-four states and patient-level data for four states) to estimate the association of Medicaid expansion with uninsured surgical hospitalizations among nonelderly adults. Uninsured surgery cases were typically admitted through the emergency department-often for common emergency procedures-and 99 percent of them were estimated to be associated with financially catastrophic visit charges. We found that Medicaid expansion was associated with reductions in both the share (6.20 percent) and the population rate (7.85 per 10,000) of uninsured surgical discharges in expansion versus nonexpansion states. Our estimates suggest that in 2019 alone, adoption of Medicaid expansion in nonexpansion states could have prevented more than 50,000 incidences of catastrophic financial burden resulting from uninsured surgery.
| S-EPMC10077516 | biostudies-literature
Project description: Not available
| S-EPMC9270698 | biostudies-literature
Project description:ObjectiveTo estimate the effect of the first full year of the ACA Medicaid expansion on hospital provision of uncompensated care, with special attention paid to hospitals that treat a disproportionate share of low-income patients.Data sourcesData from a balanced panel of short-term, general, nonfederal, Medicare-certified hospitals were obtained from Medicare cost reports from 2011 to 2014.Study design/study settingA series of difference-in-differences analyses were performed using hospitals in nonexpansion states as the control group. The dependent variable is hospital provision of uncompensated care.Data collection/extraction methodsThe data were downloaded from the National Bureau of Economic Research website.Principal findingsThe Medicaid expansion significantly reduced hospital provision of uncompensated care in 2014. In particular, within expansion states, DSH hospitals saw reductions beyond those experienced by non-DSH hospitals.ConclusionsEvidence from this study indicates that the Medicaid expansion served to widen an already broad gap in provision of uncompensated care between hospitals in expansion and nonexpansion states. In addition, within expansion states, variation in uncompensated care between hospitals that treat a disproportionate share of low-income patients and those that do not was reduced, with the former experiencing significantly larger reductions. Lawmakers considering expanding Medicaid and those deciding appropriate levels of DSH payments should consider these findings.
| S-EPMC5980407 | biostudies-literature
Project description:ObjectiveThe authors examined changes in buprenorphine treatment following Medicaid expansion, including the contribution of Medicaid-financed prescriptions.MethodsBuprenorphine pharmacy claims for patients were identified in the 2012-2018 IQVIA Longitudinal Prescription Data (LRx) data set, including 79.8% of U.S. retail prescriptions in 2012, increasing to 92.0% in 2018. A cohort analysis was used to assess the mean number of patients in a yearly quarter filling one or more buprenorphine prescriptions during preexpansion (2012-2013) and postexpansion (2014-2018) periods in expansion and nonexpansion states. Interrupted time-series analysis estimated associations of Medicaid expansion period with change in Medicaid-financed treatment. Separate analyses evaluated changes in duration and dose of new treatment episodes focused on mean quarterly number of patients treated with buprenorphine and proportions of new treatment episodes ≥180 days long and with ≥16 mg/day.ResultsBetween preexpansion and postexpansion, the mean quarterly number of patients taking buprenorphine increased by 93,300 in expansion states and by 84,960 in nonexpansion states. Corresponding changes for Medicaid-financed patients were 28,760 and 4,050, respectively. The fastest growth in Medicaid-financed treatment occurred among patients ages 25-44. Among new Medicaid-financed treatment episodes, little change was found in the proportion reaching the 180-day threshold, and declines were observed in the proportion receiving ≥16 mg/day.ConclusionsThe findings are consistent with previous research indicating that Medicaid expansion has increased Medicaid-financed buprenorphine treatment. However, because of offsetting changes in other payment groups, the overall increase in expansion states was similar to the increase in nonexpansion states.
| S-EPMC9097622 | biostudies-literature
Project description:BackgroundMedicaid expansion substantially increased health insurance coverage, but its effect on the delivery of preventative health care is unclear.ObjectiveThe objective of this study was to assess the impact of Medicaid expansion on the receipt of 15 different measures of preventive care including cancer screening, cardiovascular risk reduction, diabetes care, and other primary care measures.Research designWe performed serial cross-sectional analysis of Behavioral Risk Factor Surveillance System (BRFSS) survey data from 2012 to 2017. We used a quasi-experimental design with difference-in-differences (DiD) analyses to examine changes in preventative health care delivery over 3 time periods in Medicaid expansion compared with nonexpansion states.SubjectsWe included low-income (<138% federal poverty level) nonelderly (age younger than 65 y) adults residing in 46 US states.MeasuresOur predictor was residing in a Medicaid expansion state (24 states) versus nonexpansion state (19 states). Our primary outcomes were preventative health care services, which we categorized as cancer screening (breast cancer, cervical cancer, and colorectal cancer); cardiovascular risk reduction (serum cholesterol screening in low-risk groups, serum cholesterol monitoring in high-risk groups, and aspirin use); diabetes care (serum cholesterol monitoring, hemoglobin A1c monitoring, foot examination, eye examination, and influenza vaccination, and pneumonia vaccination); and other primary care measures [influenza vaccination, alcohol use screening, and human immunodeficiency virus (HIV) screening].ResultsSurvey responses from 500,495 low-income nonelderly adults from 2012 to 2017 were included in the analysis, representing 68.2 million US adults per year. Of the 15 outcomes evaluated, we did not detect statistically significant differences in cancer screening (3 outcomes), cholesterol screening or monitoring (2 outcomes), diabetes care (6 outcomes), or alcohol use screening (1 outcome) in expansion compared with nonexpansion states. Aspirin use (DiD 8.8%, P<0.001), influenza vaccination (DiD 1.4%, P=0.016), and HIV screening (DiD 1.9%, P=0.004) increased in expansion states compared with nonexpansion states.ConclusionsMedicaid expansion was associated with an increase in aspirin use, influenza vaccination, and HIV screening in expansion states. Despite improvements in access to care, including health insurance, having a primary care doctor, and routine visits, Medicaid expansion was not associated with improvements in cancer screening, cholesterol monitoring, diabetes care, or alcohol use screening. Our findings highlight implementation challenges in delivering high-quality primary care to low-income populations.
| S-EPMC7230002 | biostudies-literature
Project description:ObjectivesTo estimate the effect of Medicaid expansion under the Affordable Care Act (ACA) on the frequency and payment source for Emergency Department (ED) visits for dental care.Study designRetrospective, quasi-experimental study.Data sources/study settingWe used the State Emergency Department Database to compare changes in ED visit rates and payment source for dental conditions among patients from 33 states. These states represent four distinct policy environments, based on whether they expanded Medicaid and whether their Medicaid programs provide dental benefits. We first assessed the number of ED dental visits before (2012) and after (2014) the ACA. Then, we used differences-in-differences regression to estimate changes in insurance for dental visits by nonelderly adults.Principal findingsOur sample contained 375 944 dental ED visits. In states that expanded Medicaid and offered dental coverage, dental ED visits decreased by 14.1 percent (from 19 443 to 16 709, for a net difference of 2734). By contrast, in the remaining three state groups, dental ED visits rose. Meanwhile, the expansion significantly increased Medicaid coverage and decreased the rate of self-pay for ED dental visits.ConclusionsMedicaid expansion, combined with adult dental coverage in Medicaid, was associated with a reduction in ED utilization for dental visits.
| S-EPMC7240762 | biostudies-literature