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Original Investigation
January 2, 2019

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

Author Affiliations
  • 1Yale School of Medicine, New Haven, Connecticut
  • 2Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 3Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut
  • 4Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
  • 5Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
JAMA Surg. Published online January 2, 2019. doi:10.1001/jamasurg.2018.5177
Key Points

Question  To what extent have insurance coverage, outcomes, and discharge to rehabilitation changed among adult trauma patients as a result of Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act?

Findings  This difference-in-difference analysis found that adults with injuries in expansion states experienced an absolute 13.7 percentage point decline in the percentage of patients who are uninsured after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation that persisted across inpatient rehabilitation facilities, home health agencies, and skilled nursing facilities.

Meaning  By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional trauma patients in expansion states.

Abstract

Importance  Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective  To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Design, Setting, and Participants  Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states.

Interventions/Exposure  Policy implementation in January 2014.

Main Outcomes and Measures  Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation.

Results  A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity–, age-, and sex-based disparities in which patients use rehabilitation.

Conclusions and relevance  This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

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