CHICAGO: Young adults who experience a traumatic injury are now more likely to have insurance coverage and access to rehabilitation if they live in a state that expanded Medicaid under the Affordable Care Act (ACA), new study findings show. Further, states that expanded Medicaid also saw greater reductions in socioeconomic and racial disparities in certain areas, including insurance coverage, access to rehabilitative care, and in-hospital mortality. Researchers from The Ohio State University and the Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, report their findings in an article published on the website of the Journal of the American College of Surgeons in advance of print.
The researchers looked at five states that did and five states that did not implement Medicaid expansion. They performed difference-in-difference analyses to evaluate the effects of the ACA Medicaid expansion in its first four years on trauma care and outcomes in young adults, overall and by race/ethnicity and zip-code level median income.
"Traumatic injury is by far the leading cause of death and disability among young adults aged 18 to 44," said Jennifer N. Cooper, PhD, principal investigator of the study, associate professor of pediatrics and epidemiology at The Ohio State University and co-director of the Center for Surgical Outcomes Research at the Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus. "Knowing that the Affordable Care Act, through its Medicaid expansion, had the greatest impact on insuring more low-income young adults—who are disproportionately young adults of color—we really wanted to better understand the impact of Medicaid expansion on this patient population and their outcomes."
About the study
The researchers included 367,066 patients in their analysis, 119,090 (32.4 percent) of whom were from ACA Medicaid expansion states. The majority of patients (73.3 percent) were male, with an average age of 30.8 years. Black patients comprised 27 percent and Hispanic patients comprised 13.6 percent of the total study population. Sociodemographic characteristics were similar between patients in the Medicaid expansion and non-expansion states that were studied.
Notably, patients from non-expansion states were more likely to reside in lower income zip codes and patients from expansion states were more likely to reside in higher income zip codes. However, both groups had similar clinical and injury characteristics.
Key findings
Dr. Cooper and colleagues found that ACA Medicaid expansion, in its first four years, increased insurance coverage and access to rehabilitation among young adult trauma patients. Specifically, the uninsured rate was 17.4 percentage points lower in 2014-2017 than in 2011-2013. "Medicaid expansion was associated with a significant increase in the proportion of young adult trauma patients covered by Medicaid, with Medicaid coverage increasing in Medicaid expansion states by 21.0 percentage points and increasing in non-expansion states by only 0.3 percentage points," authors note.
An important element of the findings is that in Medicaid expansion states, disparities in inpatient rehabilitation access and disparities in in-hospital mortality between Black and white patients were reduced. Authors note, "Based on these findings, Medicaid expansion has led to between 5 and 81 fewer in-hospital deaths per 10,000 Black young adult trauma patients and between 64 and 174 more admissions to inpatient rehabilitation facilities per 10,000 young adults who have complex injuries and who reside in low-income communities." Further, "the decrease in in-hospital mortality among Black patients in expansion states was most prominent among patients with firearm injuries," with the in-hospital mortality rate in these patients decreasing by 1.55 percentage points more in the selected Medicaid expansion than non-expansion states.
They also noted that Medicaid expansion has likely led to overall improvements and reductions in racial disparities in trauma patients' economic stability and long-term quality of life and functional outcomes, though confirming this will require further study.
Disparities still exist
Authors note that despite improvements in expansion states, racial/ethnic disparities continue to exist, both nationally and among the young adult trauma patients in the Medicaid expansion states include in the study: 21 percent of Hispanic trauma patients in the included expansion states remained uninsured in 2017, compared to 9.4 percent of Black patients and 7.1 percent of white patients. Although disparities between Black and white patients improved in certain categories, the disparity between Hispanic and white patients in insurance coverage actually increased.
To address this disparity, the authors suggest that "making Medicaid or ACA Marketplace plans available to undocumented and recent immigrants would help close the coverage gap, as would outreach to encourage and facilitate enrollment in coverage among eligible Hispanic young adults."
