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Original Investigation
June 28, 2017

Association of Expanded Medicaid Coverage With Hospital Length of Stay After Injury

Author Affiliations
  • 1Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
  • 2Department of Social Work, George Washington University Hospital, Washington, DC
  • 3Department of Nursing, George Washington University Hospital, Washington, DC
JAMA Surg. Published online June 28, 2017. doi:10.1001/jamasurg.2017.1720
Key Points

Question  What was the association of the expansion of Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) with hospital length of stay after injury?

Findings  In this single-center cohort study of 2314 patients from 2 states and Washington, DC, with different levels of Medicaid expansion, expansion of Medicaid eligibility was associated with a significant reduction in length of stay after injury. Moreover, duration of hospitalization was significantly reduced in a graduated fashion in proportion to the degree that Medicaid eligibility was expanded.

Meaning  Expansion of Medicaid eligibility under the Affordable Care Act was associated with reductions in duration of hospitalization after injury; the potential cost savings should be further investigated.


Importance  The expansion of Medicaid eligibility under the Affordable Care Act is a state-level decision that affects how patients with traumatic injury (trauma patients) interact with locoregional health care systems. Washington, DC; Maryland; and Virginia represent 3 unique payer systems with liberal, moderate, and no Medicaid expansion, respectively, under the Affordable Care Act. Characterizing the association of Medicaid expansion with hospitalization after injury is vital in the disposition planning for these patients.

Objective  To determine the association between expanded Medicaid eligibility under the Affordable Care Act and duration of hospitalization after injury.

Design, Setting, and Participants  This retrospective cohort study included patients admitted from Virginia, Maryland, and Washington, DC, to a single level I trauma center. Data were collected from January 1, 2013, through March 6, 2016, in Virginia and Washington, DC, and from May 1, 2013, through March 6, 2016, in Maryland. All patients with Medicare or Medicaid coverage and all uninsured patients were included. Patients with private insurance, patients with severe head or pelvic injuries, and those who died during hospitalization were excluded.

Main Outcomes and Measures  Hospital length of stay (LOS) and whether its association with patient insurance status varied by state of residence.

Results  A total of 2314 patients (1541 men [66.6%] and 773 women [33.4%]; mean [SD] age, 52.9 [22.8] years) were enrolled in the study. The uninsured rate in the Washington, DC, cohort (190 of 1699 [11.2%]) was significantly lower compared with rates in the Virginia (141 of 296 [47.6%]) or the Maryland (106 of 319 [33.2%]) cohort (P < .001). On multivariate regression controlling for injury severity and demographic variables, the difference in LOS for Medicaid vs non-Medicaid recipients varied significantly by state. For Medicaid recipients, mean LOS in Washington, DC, was significantly shorter (2.57 days; 95% CI, 2.36-2.79 days) than in Maryland (3.51 days; 95% CI, 2.81-4.38 days; P = .02) or Virginia (3.9 days; 95% CI, 2.79-5.45 days; P = .05).

Conclusions and Relevance  Expanded Medicaid eligibility is associated with shorter hospital LOS in mildly injured Medicaid recipients.