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Invited Commentary

Medicaid Expansion and Trauma Care: Evidence vs Politics

Scott, John W MD, MPH

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Journal of the American College of Surgeons: January 2022 - Volume 234 - Issue 1 - p 95-96
doi: 10.1097/XCS.0000000000000001
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Medicaid expansion has been a major policy advancement in effectively reducing the ills of uninsurance in the US. To date, over 12 million working-age individuals have gained health insurance because 38 states plus the District of Columbia have elected to expand Medicaid.1 Although these impressive gains have been made since the Affordable Care Act was passed in 2010, implementation of this core function of the health reform law has been uneven. In 2012, the Supreme Court ruled that states had the option to expand Medicaid or not, which turned the policy into a political football. Despite a wealth of published evidence that shows how Medicaid expansion can improve the lives of patients,2-5 12 states have persistently opted to withhold this benefit from their low-income, working-age residents.

In this issue of JACS, the elegant and robust analysis by Metzger and colleagues6 shows a clear signal regarding the impact of Medicaid expansion: this policy helps vulnerable patients. In their study, the authors performed a rigorous evaluation of the impact of Medicaid expansion on young adult trauma patients. In their analysis of hospital discharge data comparing 5 states that expanded Medicaid vs 5 that did not, they found that Medicaid expansion was associated with tremendous gains in health insurance coverage, especially among Black patients. Medicaid expansion was also associated with increased access to critically important postdischarge rehabilitation, most notably among Black patients. Contrary to earlier studies,3,7 one of their subgroup analyses showed reduction in inpatient mortality among Black trauma patients. Although the overall mortality changes for all patients were null and mortality reduction among Black patients appears to be driven by the abnormally high pre–Affordable Care Act mortality rate in expansion states, these highly intriguing findings have important ramifications if they are corroborated by future analyses.

The findings by Metzger and colleagues add to the growing evidence base in the surgical literature supporting the tremendously effective Medicaid expansion program.3-5 Evidence from trauma patients, emergency surgical patients, surgical oncology patients, and more has demonstrated significant reductions in the uninsured rate after states chose to expand Medicaid.3-5 Coverage gains have been associated with earlier presentation for patients with emergency surgical conditions such as acute appendicitis and peripheral arterial disease as well as earlier stage presentation for patients with cancer.3-5 Improved access to rehabilitation after hospital discharge has also been shown in multiple surgical populations.3-5 In addition to better access to care, Medicaid expansion has been associated with a significantly lower risk of catastrophic spending on healthcare, especially by vulnerable trauma patients.3-5 The findings from the surgical literature align with analyses of the general population showing that patients in expansion states are more likely to report having a usual source of care and less likely to report delaying care because of an inability to pay.2,4,5

Although many critics of Medicaid expansion feared that the policy would be prohibitively costly to state budgets, the evidence to date tells a different story. Medicaid expansion has been largely budget neutral, without impacting spending on competing priorities such as education or transportation.4,5,8 Most notably, however, many states have reported net savings due to the generosity of the federal match rate and the ability to reduce spending on other programs.4,5,8

Perhaps the most resounding finding by Metzger and colleagues is the reduction of disparities between Black and White patients in health insurance coverage, inpatient outcomes, and access to postdischarge care.6 This is particularly notable because the over 2 million low-income, working-age, uninsured adults in nonexpansion states are disproportionally Black, Hispanic, and Indigenous Americans.9 As such, despite the overwhelming evidence, the individuals who are most likely to benefit from Medicaid expansion are unable to do so because of their state’s refusal to adopt the policy.

Fortunately, for the 2 million uninsured working-age adults who live in states that have not yet expanded Medicaid, there are multiple policy proposals that could allow them to gain health insurance coverage.10 First, the federal government could choose to extend the federal subsidies to health insurance marketplace plans. Second, some have proposed a federally run Medicaid program exclusive to residents living in nonexpansion states. Third, others have proposed a federal public option for anyone who wants affordable insurance, sometimes referred to as a type of “Medicare for All.” Finally, all 12 nonexpansion states are still freely able to adopt Medicaid expansion at any point and thus harness the numerous health benefits for their residents that other states have experienced after implementing this policy.

Although the findings by Metzger and colleagues6 are rightly interpreted as representing the benefits of Medicaid expansion policies on trauma patients, they also demonstrate the magnitude of the avertable burden placed on vulnerable individuals by state governments. The authors are to be commended for their thoughtful and robust analysis showing how trauma patients benefit from this key policy mechanism. Their work shines a bright light on the ramifications of state policy decisions on mitigating or propagating disparities in access to care, health outcomes, and financial risk protection for our most vulnerable patients. The data are clear: Medicaid expansion helps patients.2-7 States do not suffer financially.4,5,8 Disparities can be mitigated.4-6 Ultimately, we are left asking ourselves: how long will the 12 states who have not expanded Medicaid continue to prioritize politics over patients?

References

1. The Commonwealth Fund. Medicaid expansion. https://www.commonwealthfund.org/medicaid-expansion. Accessed September 22, 2021.
2. Allen H, Sommers BD. Medicaid expansion and health: assessing the evidence after 5 years. JAMA. 2019;322:1253–1254.
3. Scott JW, Ayanian JZ, Dimick JB. Medicaid expansion and surgical care—evaluating the evidence. JAMA Surg. 2021;156:7–8.
4. Guth M, Ammula M. Building on the evidence base: studies on the effects of Medicaid expansion, February 2020 to March 2021. Kaiser Family Foundation. 6 May 2021. https://www.kff.org/medicaid/report/building-on-the-evidence-base-studies-on-the-effects-of-medicaid-expansion-february-2020-to-march-2021/. Accessed September 22, 2021.
5. Guth M, Garfield R, Rudowitz R. The effects of medicaid expansion under the ACA: studies from January 2014 to January 2020. Kaiser Family Foundation. https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/. Accessed September 22, 2021.
6. Metzger GA, Asti L, Quinn JP, et al. Association of the affordable care act medicaid expansion with trauma outcomes and access to rehabilitation among young adults: findings overall, and by race and ethnicity, and community income level. J Am Coll Surg. 2021;233:776–793.
7. Zogg CK, Scott JW, Metcalfe D, et al. Association of medicaid expansion with access to rehabilitative care in adult trauma patients. JAMA Surg. 2019;154:402–411.
8. Cross-Call J. Medicaid expansion continues to benefit state budgets, contrary to critics’ claims. Center on Budget and Policy Priorities. https://www.cbpp.org/research/health/medicaid-expansion-continues-to-benefit-state-budgets-contrary-to-critics-claims. Accessed September 22, 2021.
9. Garfield R, Orgera K. The coverage gap: uninsured poor adults in states that do not expand Medicaid. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/. Accessed September 21, 2021.
10. Rosenbaum S, Ku L, Brantley E, et al. How the medicaid saves lives act and other federal options can ensure all Americans have access to affordable coverage. The Commonwealth Fund. https://www.commonwealthfund.org/blog/2021/how-medicaid-saves-lives-act-and-other-federal-options-can-ensure-all-americans-have. Accessed September 21, 2021.
© 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.