Impact of healthcare reform on the payer mix among young adult emergency department utilizers across the United States (2005-2015)

The impact of the 2014 Medicaid expansion on the health, health care access, and financial well-being of low-income young adults

Prior to the 2014 Affordable Care Act (ACA) expansion, 37% of young adults ages 19-25 in the United States were low-income and a third lacked health insurance coverage-both the highest rates for any age group in the population. The ACA's Medicaid eligibility expansion, therefore, would have been significantly beneficial to low-income young adults. This study evaluates the effect of the ACA Medicaid expansion on the health, health care access and utilization, and financial well-being of low-income young adults ages 19-25. Using 2010-2017 National Health Interview Survey data, I estimate policy effects by applying a difference-in-differences design leveraging the variation in state implementation of the expansion policy. I show that Medicaid expansion improved health insurance coverage, health care access, and financial well-being for low-income young adults in expansion states, but had no effect on their health status and health care utilization. I also find that the policy was associated with larger gains in health coverage for racial minorities relative to their Non-Hispanic White counterparts. With the continued health policy reform debates at the state and federal levels, the empirical evidence from this study can help inform policy decisions that aim to improve health care access and utilization among disadvantaged groups.

4th Generation HIV screening in the emergency department: net profit or loss for hospitals?

ABSTRACTThe objective of this study was to determine hospital costs and revenue of universal opt-out HIV ED screening. An electronic medical record (EMR)-directed, automated ED screening program was instituted at an academic medical center in San Diego, California. A base model calculated net income in US dollars for the hospital by comparing annual testing costs with reimbursements using payor mixes and cost variables. To account for differences in payor mixes, testing costs, and reimbursement rates across hospitals in the US, we performed a probabilistic sensitivity analysis. The base model included a total of 12,513 annual 4th generation HIV tests with the following payor mix: 18% Medicare, 9% MediCal, 28% commercial and 8% self-payers, with the remainder being capitated contracts. The base model resulted in a net profit for the hospital. In the probabilistic sensitivity analysis, universal 4th generation HIV screening resulted in a net profit for the hospital in 81.9% of simulations. Universal 4th generation opt-out HIV screening in EDs resulted in a net profit to an academic hospital. Sensitivity analysis indicated that ED HIV screening results in a net-profit for the majority of simulations, with higher proportions of self-payers being the major predictor of a net loss.

The impact of Medicaid expansion on trauma-related emergency department utilization: A national evaluation of policy implications

BACKGROUND

The impact of the 2014 Affordable Care Act (ACA) upon national trauma-related emergency department (ED) utilization is unknown. We assessed ACA-related changes in ED use and payer mix, hypothesizing that post-ACA ED visits would decline and Medicaid coverage would increase disproportionately in regions of widespread policy adoption.

METHODS

We queried the National Emergency Department Sample (NEDS) for those with a primary trauma diagnosis, aged 18 to 64. Comparing pre-ACA (2012) to post-ACA (10/2014 to 09/2015), primary outcomes were change in ED visits and payer status; secondary outcomes were change in costs, discharge disposition and inpatient length of stay. Univariate and multivariate analyses were performed, including difference-in-differences analyses. We compared changes in ED trauma visits by payer in the West (91% in a Medicaid expansion state) versus the South (12%).

RESULTS

Among 21.2 million trauma-related ED visits, there was a 13.3% decrease post-ACA. Overall, there was a 7.2% decrease in uninsured ED visits (25.5% vs. 18.3%, p < 0.001) and a 6.6% increase in Medicaid coverage (17.6% vs. 24.2%, p < 0.001). Trauma patients had 40% increased odds of having Medicaid post-ACA (vs. pre-ACA: aOR 1.40, p < 0.001). Patients in the West had 31% greater odds of having Medicaid (vs. South: aOR 1.31, p < 0.001). The post-ACA increase in Medicaid was greater in the West (vs. South: aOR 1.60, p < 0.001). Post-ACA, inpatients were more likely to have Medicaid (vs. ED discharge: aOR 1.20, p < 0.001) and there was a 25% increase in inpatient discharge to rehabilitation (aOR 1.24, p < 0.001).

CONCLUSION

Post-ACA, there was a significant increase in insured trauma patients and a decrease in injury-related ED visits, possibly resulting from access to other outpatient services. Ensuring sustainability of expanded coverage will benefit injured patients and trauma systems.

LEVEL OF EVIDENCE

Economic, level III.

The Influence of the United States Health Care Environment and Reform on Academic Medical Centers

Academic medical centers (AMC) provide care for most of the underinsured populations of the United States. Their large size and the high acuity of cases make AMCs vulnerable to changes in health care policy. They also are the primary centers for health care research and education and are therefore heavily dependent on federal programs and funding. Since the passage of the Affordable Care Act, AMCs have seen a decrease in the number of patients without insurance. They have also participated in the implementation of alternative payment models, including accountable care organizations, with mixed success.