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Sachs R, Duchovny N, Varcie J, White C. Among Medicare beneficiaries, Affordable Care Act coverage expansions reduced utilization of ambulatory care, particularly among duals. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae059. [PMID: 38841717 PMCID: PMC11152202 DOI: 10.1093/haschl/qxae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/22/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024]
Abstract
We leveraged local area variation in the size of the Affordable Care Act (ACA) expansions of Medicaid and nongroup coverage and measured changes in Medicare utilization and spending from 2010 through 2018 using the universe of Medicare fee-for-service claims. We found that the ACA coverage expansions led to decreases in the share of Medicare beneficiaries receiving ambulatory care and decreases in spending per beneficiary on ambulatory care. The reductions in ambulatory care were larger among beneficiaries enrolled in both Medicare and Medicaid ("duals"). Our results suggest that coverage expansions may lead to congestion and reduced access to physicians for those who are continuously insured.
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Affiliation(s)
- Rebecca Sachs
- Congressional Budget Office, Washington, DC 20515, United States
| | - Noelia Duchovny
- Congressional Budget Office, Washington, DC 20515, United States
| | - Joshua Varcie
- Congressional Budget Office, Washington, DC 20515, United States
| | - Chapin White
- Congressional Budget Office, Washington, DC 20515, United States
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Venkatesh H, Li T, Yu Q, Wu XC, Yi Y, Hsieh MC, Chu QD. Medicaid Expansion Increases Access for Rural and Impoverished Patients with Pancreatic Ductal Adenocarcinoma in Southern States. Ann Surg Oncol 2024; 31:2925-2931. [PMID: 38361092 DOI: 10.1245/s10434-024-15039-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Medicaid expansion (ME) impacted patients when assessed at a national level. However, of the 32 states in which Medicaid expansion occurred, only 3 were Southern states. Whether results apply to Southern states that share similar geopolitical perspectives remains elusive. We aimed to assess the impact of ME on pancreatic ductal adenocarcinoma (PDAC) treatment in eight Southern states in the USA. PATIENTS AND METHODS We identified uninsured or Medicaid patients (age 40-64 years) diagnosed with PDAC between 2011 and 2018 in Southern states from the North American Association of Central Cancer Registries-Cancer in North America (NAACCR-CiNA) research dataset. Medicaid-expanded states (MES; Louisiana, Kentucky, and Arkansas) were compared with non-MES (NMES; Tennessee, Alabama, Mississippi, Texas, and Oklahoma) using multivariate logistic regression. P < 0.05 was considered statistically significant. RESULTS Among 3036 patients, MES significantly increased odds of Medicaid insurance by 36%, and increased proportions of insured Black patients by 3.7%, rural patients by 3.8%, and impoverished patients by 18.4%. After adjusting for age, race, rural-urban status, poverty status, and summary stage, the odds of receiving radiation therapy decreased by 26% for each year of expansion in expanded states (P = 0.01). Last, ME did not result in a significant difference between MES and NMES in diagnosing early stage disease (P = 0.98) nor in receipt of chemotherapy or surgery (P = 0.23 and P = 0.63, respectively). CONCLUSIONS ME in Southern states increased insurance access to traditionally underserved groups. Interestingly, ME decreased the odds of receiving radiation therapy yearly and had no significant impact on receipt of chemotherapy or surgery.
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Affiliation(s)
| | - Tingting Li
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health at LSU Health Sciences Center, New Orleans, LA, USA
| | - Qingzhao Yu
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health at LSU Health Sciences Center, New Orleans, LA, USA
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health at LSU Health Sciences Center, New Orleans, LA, USA
| | - Yong Yi
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health at LSU Health Sciences Center, New Orleans, LA, USA
| | - Mei-Chin Hsieh
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health at LSU Health Sciences Center, New Orleans, LA, USA
| | - Quyen D Chu
- Division of Surgical Oncology, Howard University College of Medicine, Washington, DC, USA.
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Matta S, Chatterjee P, Venkataramani AS. Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion. JAMA 2024; 331:687-695. [PMID: 38411645 PMCID: PMC10900969 DOI: 10.1001/jama.2023.27014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Importance The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective To 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 Participants Difference-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. Exposure Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results The 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 Relevance Medicaid 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.
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Affiliation(s)
- Sasmira Matta
- Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Ukert B, Giannouchos TV. Association of the affordable care act with racial and ethnic disparities in uninsured emergency department utilization. BMC Health Serv Res 2023; 23:1302. [PMID: 38007468 PMCID: PMC10676572 DOI: 10.1186/s12913-023-10168-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 10/17/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Disparities in uninsured emergency department (ED) use are well documented. However, a comprehensive analysis evaluating how the Affordable Care Act (ACA) may have reduced racial and ethnic disparities is lacking. The goal was to assess the association of the ACA with racial and ethnic disparities in uninsured ED use. METHODS This study used data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for Georgia, Florida, Massachusetts, and New York from 2011 to 2017. Participants include non-elderly adults between 18 and 64 years old. Outcomes include uninsured rates of ED visits by racial and ethnic groups and stratified by medical urgency using the New York University ED algorithm. Visits were aggregated to year-quarter ED visits per 100,000 population and stratified for non-Hispanic White, non-Hispanic Black, and Hispanic non-elderly adults. Quasi-experimental difference-in-differences and triple differences regression analyses to identify the effect of the ACA and the separate effect of the Medicaid expansion were used comparing uninsured ED visits by race and ethnicity groups pre-post ACA. RESULTS The ACA was associated with a 14% reduction in the rate of uninsured ED visits per 100,000 population (from 10,258 pre-ACA to 8,877 ED visits per 100,000 population post-ACA) overall. The non-Hispanic Black compared to non-Hispanic White disparity decreased by 12.4% (-275.1 ED visits per 100,000) post-ACA. About 60% of the decline in the Black-White disparity was attributed to disproportionate declines in ED visit rates for conditions classified as not-emergent (-93.2 ED visits per 100,000), and primary care treatable/preventable (-64.1 ED visits per 100,000), while the disparity in ED visit rates for injuries and not preventable conditions also declined (-106.57 ED visits per 100,000). All reductions in disparities were driven by the Medicaid expansion. No significant decrease in Hispanic-White disparity was observed. CONCLUSIONS The ACA was associated with fewer uninsured ED visits and reduced the Black-White ED disparity, driven mostly by a reduction in less emergent ED visits after the ACA in Medicaid expansion states. Disparities between Hispanic and non-Hispanic White adults did not decline after the ACA. Despite the positive momentum of declining disparities in uninsured ED visits, disparities, especially among Black people, remain.
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Affiliation(s)
- Benjamin Ukert
- Department of Health Policy and Management, Texas A&M University, 212 Adriance Lab Road, 1266 TAMU, College Station, 77843-1266, USA.
| | - Theodoros V Giannouchos
- Department of Health Policy and Organization, The University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL, 35233, USA.
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Parzuchowski A, Oronce C, Guo R, Tseng CH, Fendrick AM, Mafi JN. Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012-2015. BMC Health Serv Res 2023; 23:723. [PMID: 37400793 PMCID: PMC10318663 DOI: 10.1186/s12913-023-09696-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 06/07/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND While the Affordable Care Act's Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers. METHODS Prespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012-2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance. RESULTS We identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012-2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5-31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9-5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1-7.5, p = 0.009). CONCLUSIONS Following Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.
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Affiliation(s)
- Aaron Parzuchowski
- Department of Veteran Affairs, National Clinician Scholars Program, Ann Arbor, MI, USA
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Oronce
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - A Mark Fendrick
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA.
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Gaffney A, Himmelstein DU, Dickman S, McCormick D, Cai C, Woolhandler S. Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018. J Gen Intern Med 2023; 38:434-441. [PMID: 35668239 PMCID: PMC9905461 DOI: 10.1007/s11606-022-07688-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear. OBJECTIVE To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA. DESIGN Repeated cross-sectional. SETTING National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018. PARTICIPANTS Office-based physicians. MEASURES Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration. RESULTS Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care. LIMITATION Self-reported visit length. CONCLUSION Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.
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Affiliation(s)
- Adam Gaffney
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
| | - David U. Himmelstein
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
- Hunter College, City University of New York, New York, NY USA
- Public Citizen Health Research Group, Washington, DC USA
| | | | - Danny McCormick
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
| | | | - Steffie Woolhandler
- Harvard Medical School, Boston, MA USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA USA
- Hunter College, City University of New York, New York, NY USA
- Public Citizen Health Research Group, Washington, DC USA
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Brunt CS. How Do Primary Care Providers Respond to Reimbursement Cuts? Evidence From the Termination of the Primary Care Incentive Program. Med Care Res Rev 2022; 80:303-317. [PMID: 36523254 DOI: 10.1177/10775587221139516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The Primary Care Incentive Payment Program (PCIP) provided a 10% bonus payment for Evaluation and Management (E&M) visits for eligible primary care providers (PCPs) from 2011 to 2015. Using a 2012 to 2017 sample of continuously eligible PCPs (the treatment group) and ineligible specialists with historically similar provision of billed services (the control group), this study is the first to examine how PCPs responded to the program’s termination. Using inverse probability of treatment weighted difference-in-differences models that control for inter-temporal changes in provider-specific beneficiary characteristics, individual provider fixed effects, and zip code by year fixed effects, it finds that providers responded to the removal of the 10% bonus payments by increasing their billing of bonus payment eligible E&M relative value units (RVUs) by 3.7%. This response is consistent with supplier-induced demand and suggests a 46% offsetting response consistent with actuarial assumptions by the Centers for Medicare & Medicaid Services when assessing reimbursement reductions.
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McInerney M, McCormack G, Mellor JM, Sabik LM. Association of Medicaid Expansion With Medicaid Enrollment and Health Care Use Among Older Adults With Low Income and Chronic Condition Limitations. JAMA HEALTH FORUM 2022; 3:e221373. [PMID: 35977244 PMCID: PMC9166222 DOI: 10.1001/jamahealthforum.2022.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/14/2022] [Indexed: 12/02/2022] Open
Abstract
Question Was the expansion of Medicaid to working-age adults under the Patient Protection and Affordable Care Act (ACA) associated with changes in Medicaid enrollment and health care use among older adults with low income and chronic condition limitations? Findings In this cross-sectional study of 7153 US adults 65 years or older with low income, ACA Medicaid expansion was associated with significant increases in the likelihood of Medicaid enrollment and outpatient health care use among those with chronic condition limitations. No associations were found between ACA Medicaid expansion and Medicaid enrollment and health care use among those without such limitations. Meaning In this study, expansion of Medicaid to working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were enrolled in Medicare. Importance Medicaid is an important source of supplemental coverage for older Medicare beneficiaries with low income. Research has shown that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with increased Medicaid coverage for previously eligible older adults with low income, but there has been little research on whether their health care use increased or whether such changes differed by beneficiaries’ health status. Objective To assess whether the ACA Medicaid expansion to working-age adults was associated with increased Medicaid enrollment and health care use among older adults with low income with and without chronic condition limitations. Design, Setting, and Participants This cross-sectional study used data from the National Health Interview Survey from 2010 to 2017 for adults 65 years or older with low income (≤100% of the federal poverty level). Data were analyzed from November 2020 to March 2022. Exposure Residence in a state with Medicaid expansion for working-age adults. Main Outcomes and Measures The main outcomes were Medicaid coverage and health care use, measured by physician office visits and inpatient hospital care. Survey weights were used in calculating descriptive statistics and regression estimates. In multivariate analysis, difference-in-differences models were used to compare changes in outcomes over time between respondents in Medicaid expansion states and respondents in nonexpansion states. Results Of 21 859 adults included in the study, 7153 had chronic condition limitations (4983 [70.1%] female; mean [SD] age, 76.0 [0.1] years) and 14 706 did not have chronic condition limitations (9609 [66.3%] female; mean [SD] age, 74.85 [0.08] years). Of those with chronic condition limitations, 2707 (36.7%) were enrolled in Medicaid, 2816 (39.4%) had an office visit in the past 2 weeks, and 2152 (30.7%) used inpatient hospital care in the past year. Medicaid expansion was associated with differential increases in the likelihood of having Medicaid (4.92 percentage points; 95% CI, 0.25-9.60 percentage points; P = .04) and having an office visit in the past 2 weeks (5.31 percentage points; 95% CI, 0.10-10.51 percentage points; P = .046) compared with nonexpansion. There were no differential changes between expansion and nonexpansion states in receipt of inpatient hospital care (−0.62 percentage points; 95% CI, −5.39 to 4.14 percentage points; P = .79). Among adults without chronic condition limitations, 3159 (19.8%) were enrolled in Medicaid, and no differential changes between expansion and nonexpansion states in Medicaid enrollment (−0.24 percentage points; 95% CI, −3.06 to 2.57 percentage points; P = .86) or health care use were found. Conclusions and Relevance In this cross-sectional study, ACA Medicaid expansion for working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were dually eligible for Medicare and Medicaid.
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Affiliation(s)
- Melissa McInerney
- Department of Economics, Tufts University, Medford, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Grace McCormack
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts
| | - Jennifer M. Mellor
- Department of Economics, William & Mary, Williamsburg, Virginia
- Schroeder Center for Health Policy, William & Mary, Williamsburg, Virginia
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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Giannouchos TV, Ukert B, Andrews C. Association of Medicaid Expansion With Emergency Department Visits by Medical Urgency. JAMA Netw Open 2022; 5:e2216913. [PMID: 35699958 PMCID: PMC9198732 DOI: 10.1001/jamanetworkopen.2022.16913] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Relatively little is known about the association of the Medicaid eligibility expansion under the Patient Protection and Affordable Care Act with emergency department (ED) visits categorized by medical urgency. OBJECTIVE To estimate the association between state Medicaid expansions and ED visits by the urgency of presenting conditions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the Healthcare Cost and Utilization Project State Emergency Department Databases from January 2011 to December 2017 for 2 states that expanded Medicaid in 2014 (New York and Massachusetts) and 2 states that did not (Florida and Georgia). Difference-in-differences regression models were used to estimate the changes in ED visits overall and further stratified by the urgency of the conditions using an updated version of the New York University ED algorithm between the states that expanded Medicaid and those that did not, before and after the expansion. Data were analyzed between June 7 and December 12, 2021. EXPOSURE State-level Medicaid eligibility expansion. MAIN OUTCOMES AND MEASURES Emergency department visits per 1000 population overall and stratified by medical urgency of the conditions. RESULTS In total, 80.6 million ED visits by 26.0 million individuals were analyzed. Emergency department visits were concentrated among women (59.3%), non-Hispanic Black individuals (28.3%), non-Hispanic White individuals (47.8%), and those aged 18 to 34 years (47.5%) and 35 to 44 years (20.4%). The rates of ED visits increased by a mean of 2.4 visits in nonexpansion states and decreased by a mean of 2.2 visits in expansion states after 2014, resulting in a significant regression-adjusted decrease of 4.7 visits per 1000 population (95% CI, -7.7 to -1.5; P = .003) in expansion states. Most of this decrease was associated with decreases in ED visits by conditions classified as not emergent (-1.5 visits; 95% CI, -2.4 to -0.7; P < .001), primary care treatable (-1.1 visits; 95% CI, -1.6 to -0.5; P < .001), and potentially preventable (-0.3 visits; 95% CI, -0.5 to -0.1; P = .02). No significant changes were observed for ED visits related to injuries and conditions classified as not preventable (-1.4; 95% CI, -3.1 to 0.3; P = .10), as well as for substance use and mental health disorders (0.0; 95% CI, -0.2 to 0.2; P = .94). CONCLUSIONS AND RELEVANCE The findings of this study suggest that Medicaid expansion was associated with decreases in ED visits, for which decreases in ED visits for less medically emergent ED conditions may have been a factor.
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Affiliation(s)
- Theodoros V. Giannouchos
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia
| | - Benjamin Ukert
- Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station
| | - Christina Andrews
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia
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