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Lifting the Burden

State Medicaid Expansion Reduces Financial Risk for the Injured

Scott, John W. MD, MPH1; Shrime, Mark G. MD, MPH, Ph.D.2,3; Stewart, Barclay T. MD, MScPH, PhD1; Arbabi, Saman MD, MPH1; Bulger, Eileen M. MD1; Cuschieri, Joseph MD1; Maier, Ronald V. MD1; Robinson, Bryce R.H. MD, MS1

Journal of Trauma and Acute Care Surgery: September 12, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/TA.0000000000002493
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Background Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain due to high out-of-pocket healthcare costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington state—which extended coverage to >600,000 WA residents—was associated with a reduction in financial risk among trauma patients.

Methods We analyzed all trauma patients ages 18-64y admitted to the sole Level 1 trauma center in WA from 2012-17. We defined 2012-2013 as the pre-policy period and 2014-2017 as the post-policy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate post-subsistence income and out-of-pocket expenses for our sample; and then applied these two estimates to determine catastrophic healthcare expenditure (CHE) risk as defined by the WHO (out-of-pocket health expenses >40% of estimated household post-subsistence income).

Results 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0% and the uninsured rate decreased from 19.2% to 3.7% (p<0.001 for both). There was no significant change in private insurance coverage. ME was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and <0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p<0.01).

Conclusions State Medicaid expansion led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers.

Level of Evidence Economic analysis, level II.

1 Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington

2 Center for Global Surgery Evaluation, Massachusetts Eye and Ear, Boston, Massachusetts.

3 Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.

Corresponding Author: John W. Scott, MD MPH, Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104-2499. 617-943-7211, jscott21@uw.edu

Meetings: This work will be presented as a podium presentation at the 78th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 18-21, 2019, Dallas, TX

Relevant Conflicts of Interest and Funding: None declared

© 2019 Lippincott Williams & Wilkins, Inc.