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The impact of patient protection and Affordable Care Act on trauma care

A step in the right direction

Joseph, Bellal MD; Haider, Ansab A. MD; Azim, Asad MD; Kulvatunyou, Narong MD; Tang, Andrew MD; O'Keeffe, Terence MD; Latifi, Rifat MD; Green, Donald J. MD; Friese, Randall S. MD; Rhee, Peter MD, MPH

Journal of Trauma and Acute Care Surgery: September 2016 - Volume 81 - Issue 3 - p 427–434
doi: 10.1097/TA.0000000000001082
AAST 2015 Plenary Papers
EAST Journal Club

INTRODUCTION The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement.

METHODS We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months).

RESULTS A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).

On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66).

CONCLUSION The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion.

LEVEL OF EVIDENCE Economic and value-based evaluation, level III.

From the Division of Trauma, and Acute Care Surgery; Department of Surgery (B.J., A.A.H., A.A., N.K., A.T., TO'K., R.L., D.J.G., R.S.F., P.R.), University of Arizona Medical Center, Tucson, Arizona.

Submitted: September 14, 2015, Revised: January 4, 2016, Accepted: January 5, 2016, Published online: June 28, 2016.

This study was presented at the 74th annual meeting of the American Association for the Surgery of Trauma, September 9–12, 2015, in Las Vegas, Nevada.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Bellal Joseph, MD, Division of Division of Trauma, and Acute Care Surgery; Department of Surgery, University of Arizona Medical Center; email:

© 2016 Lippincott Williams & Wilkins, Inc.