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Potential impact of Affordable Care Act–related insurance expansion on trauma care reimbursement

Scott, John W. MD, MPH; Neiman, Pooja U. MPA; Najjar, Peter A. MD, MBA; Tsai, Thomas C. MD, MPH; Scott, Kirstin W. MPhil, PhD; Shrime, Mark G. MD, MPH, PhD; Cutler, David M. PhD; Salim, Ali MD; Haider, Adil H. MD, MPH

Journal of Trauma and Acute Care Surgery: May 2017 - Volume 82 - Issue 5 - p 887–895
doi: 10.1097/TA.0000000000001400
AAST 2016 Plenary Paper

BACKGROUND Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect.

METHODS We abstracted nonelderly adults (ages 18–64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010—the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample–supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population.

RESULTS There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8–14.7), yielding a national margin of −7.9% (95% CI, −10.6 to −5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7–17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, −0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains.

CONCLUSION Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities.

Level of Evidence Economic analysis, level II.

From the Department of Surgery, Center for Surgery and Public Health (J.W.S., P.N., T.C.T., A.S., A.H.H.), Brigham & Women's Hospital; Program in Global Surgery and Social Change (J.W.S., M.G.S.), Harvard Medical School, Boston; John F. Kennedy School of Government (P.U.), Harvard University, Cambridge, Massachusetts; David Geffen School of Medicine at the University of California (P.U.), Los Angeles, Los Angeles, California; Harvard Business School (P.N.); Department of Health Policy and Management (T.C.T.), Harvard T.H. Chan School of Public Health; Harvard Medical School (K.W.S.); Department Of Otolaryngology & Office of Global Surgery (M.G.S.), Massachusetts Eye & Ear Infirmary, Boston; Department of Economics (D.M.C.), Harvard University; National Bureau of Economics Research (D.M.C.); and Division of Trauma, Department of Surgery (A.S., A.H.H.), Brigham & Women’s Hospital, Boston, Massachusetts.

Submitted: July 31, 2016, Revised: January 11, 2016, Accepted: January 30, 2017, Published online: March 15, 2017.

This article was presented at the 75th annual meeting of the American Association for the Surgery of Trauma, September 14–17, 2016, in Waikoloa, Hawaii.

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: John W. Scott, MD, MPH, Center for Surgery and Public Health, Brigham & Women's Hospital, 1620 Tremon Street, 4-020 Boston, MA 02120; email:

© 2017 Lippincott Williams & Wilkins, Inc.