The US Supreme Court and Affirmative Action: The Negative Impact on the Physician Workforce

PURPOSE

Maintaining admissions of underrepresented students to medical schools is essential to securing a diverse health care workforce. Empirical evidence indicates that minority patients may prefer practitioners of their own race. The recent US Supreme Court decision concerning affirmative action makes this goal more difficult, but medical schools can still work within the language of the law to redouble their efforts to seat a diverse class of medical students.

METHODS

We examined the literature correlating the availability of minority physicians and the health outcomes of the patients they serve. We also examined the literature on race-conscious policies of medical schools intended to address the shortage of minority physicians considering the benefits achieved through a diverse field of health care workers. We also examined the law and the recent US Supreme Court opinion, including the application of equal protection principles, to suggest strategies to seat a diverse class of students within the scope of the law.

FINDINGS

Institutions have maintained the status quo of disparate distributions of professions by race through structural biases that also limit access to medical schools. The new US Supreme Court decision is expected to exacerbate this disparity unless medical schools engage in admissions protocols that actively solicit the character and unique abilities that each of the applicants can offer to contribute to the medical school and the health care profession.

IMPLICATIONS

The new US Supreme Court mandate is likely to create challenges for medical schools in their efforts to recruit and seat minority applicants. The mandate provides little discussion, suggesting a lack of understanding of the downstream public health consequences to patients if medical school applicants are denied the benefits of race-conscious admissions policies. Nevertheless, the language of the US Supreme Court's opinion may provide a viable path forward, at least with respect to medical schools where the need for a diverse pool of health care practitioners is particularly compelling.

Reining in Costs of Kidney Dialysis: US Supreme Court Offers Hope to End Predatory Pricing

PURPOSE

Two for-profit dialysis providers control >70% of the US kidney dialysis market. They use their excessive market power to force private insurers to pay nearly 4 times the Medicare rate, earning exorbitant profits for themselves at the expense of the health care system. Both the legislative and judicial systems have been called on to address this inequity, so far without success.

METHODS

We examined the history of this issue as set forth in official Centers for Medicare & Medicaid Services, US Department of Health and Human Services, Federal Trade Commission, and other regulatory documents as well as court filings and opinions. We analyzed the legislative efforts to address the problem and the judicial response.

FINDINGS

We found that most efforts, to date, have failed. However, a 2022 US Supreme Court decision helps illuminate a path forward, in large part by defining the limits of judicial intervention.

IMPLICATIONS

We identify a path forward that would separate the monopolistic players using a multipronged effort involving US Department of Justice, Federal Trade Commission, Office of Inspector General, and states attorneys general. We also caution that, based on our research, the providers could challenge further efforts by deciding to withdraw services in certain areas or refuse to do business with certain insurers, resulting in patients having difficulty accessing dialysis.

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

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.

Impact of Affordable Care Act Insurance Expansion on Pre-Hospital Access to Care: Changes in Adult Perforated Appendix Admission Rates after Medicaid Expansion and the Dependent Coverage Provision

BACKGROUND

The Affordable Care Act (ACA) changed the landscape of insurance coverage, allowing young adults to remain on their parents' insurance until age 26 (Dependent Coverage Provision [DCP]) and states to optionally expand Medicaid up to 133% of the federal poverty level. Although both improved insurance coverage, little is known about the ACA's impact on observed receipt of timely access to acute care. The objective of this study was to compare changes in insurance coverage and perforation rates among hospitalized adults with acute appendicitis "after vs before" Medicaid expansion and the DCP using an Agency for Healthcare Research and Quality (AHRQ)-certified metric designed to measure pre-hospital access to care.

STUDY DESIGN

We performed a quasi-experimental, difference-in-difference (DID) analysis of 2008-2015 state-level inpatient claims.

RESULTS

Adults, aged 19 to 64, in expansion states experienced an absolute 7.7 percentage point decline in uninsured (95% CI 7.5 to 7.9) after Medicaid expansion compared with nonexpansion states. This coincided with a 5.4 percentage point drop in admissions for perforated appendicitis (95% CI 5.0 to 5.8) that was most pronounced among young adults, aged 26 to 34, just age-ineligible for the DCP (DID: 11.5 percentage points). Medicaid expansion insurance changes were 4.1 times larger than those encountered under the DCP (DID: 1.9). They affected all population subgroups and significantly reduced access-related disparities in race/ethnicity and lower-income communities. Although both Medicaid expansion and the DCP were associated with significant insurance gains, those attributable to the DCP were more concentrated among more privileged patients. Despite this trend, both policies resulted in larger reductions in perforation rates for historically uninsured and underserved groups.

CONCLUSIONS

Reductions in uninsured after Medicaid expansion and the DCP were associated with significant reductions in perforated appendix admission rates. Improvements in access to acute surgical care suggest that maintained/continued insurance expansion could lead to fewer delays, better patient outcomes, and reductions in disparities among the most at-risk populations.

Physician Speech and Firearm Safety: Wollschlaeger v Governor, Florida

To provide the highest-quality medical care, physicians must be able to communicate openly with their patients and provide advice in conformance with professional standards of care. Although states have the power to regulate many aspects of medical practice, laws that interfere with speech by preventing physicians from discussing specific subjects with patients are constitutionally suspect. In 2017, the US Court of Appeals for the Eleventh Circuit struck down key provisions of a Florida law that prohibited physicians from speaking with their patients about firearm safety as a violation of the First Amendment. We discuss this case, Wollschlaeger v Governor, Florida, and the implications of the ruling. Although courts may rule that physician "gag laws," such as the one in Florida, are unconstitutional, this area of the law remains unsettled. Legislative mandates that interfere with medical practice may decrease the quality of care by substituting politics and legislative judgment for medical expertise.