Understanding The Relationship Between Medicaid Expansions And Hospital Closures

Joint effects of Medicaid eligibility and fees on recession-linked declines in healthcare access and health status

Whether Medicaid can function as a safety net to offset health risks created by health insurance coverage losses due to job loss is conditional on (1) the eligibility guidelines shaping the pathway for households to access the program for temporary relief, and (2) Medicaid reimbursement policies affecting the value of the program for both the newly and previously enrolled. We find states with more expansive eligibility guidelines lowered the healthcare access and health risk of coverage loss associated with rising unemployment during the 2007-2009 Great Recession. Rises in cost-related barriers to care associated with unemployment were smallest in states with expansive eligibility guidelines and higher Medicaid-to-Medicare fee ratios. Similarly, states whose Medicaid programs had expansive eligibility guidelines and higher fees saw the smallest recession-linked declines in self-reported good health. Medicaid can work to stabilize access to health care during periods of joblessness. Our findings yield important insights into the alignment of at least two Medicaid policies (i.e., eligibility and payment) shaping Medicaid's viability as a safety net.

Effects of Affordable Care Act on uninsured hospitalization: Evidence from Texas

OBJECTIVE

To examine the impact of the Affordable Care Act (ACA) health insurance exchanges (Marketplace) on the rate of uninsured discharges in Texas.

DATA SOURCE AND STUDY SETTING

Secondary discharge data from 2011 to 2019 from Texas.

STUDY DESIGN

We conducted a retrospective study estimating the effects of the ACA Marketplace using difference-in-difference regressions, with the main outcome being the uninsured discharge rate. We stratified our sample by patient's race, age, gender, urbanicity, major diagnostic categories (MDC), and emergent type of admissions.

DATA COLLECTION/EXTRACTION METHODS

We used Texas hospital discharge records for non-elderly adults collected by the state of Texas and included acute care hospitals who reported data from 2011 to 2019.

PRINCIPAL FINDINGS

The expansion of insurance through ACA Marketplaces led to reductions in the uninsured discharge rate by 9.9% (95% CI, -17.5%, -2.3%) relative to the baseline mean. The effects of the ACA were felt strongest in counties with any share of Hispanic, in counties with a larger population of Black, and other racial groups, in counties with a significant share of female and older age individuals, in counties considered to be urban, in high-volume diagnoses, and emergent type of admissions.

CONCLUSIONS

These findings indicate that the ACA facilitated a shift in hospital payor mix from uninsured to insured.

US Hospital Service Availability and New 340B Program Participation

Importance

The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended.

Objective

To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership.

Design, Setting, and Participants

Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024.

Exposures

New enrollment in 340B between 2012 and 2018.

Main Outcomes and Measures

Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services.

Results

The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05).

Conclusions and Relevance

The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

Severe housing cost burden and premature mortality from cancer

Unaffordable housing has been associated with poor health. We investigated the relationship between severe housing cost burden and premature cancer mortality (death before 65 years of age) overall and by Medicaid expansion status. County-level severe housing cost burden was measured by the percentage of households that spend 50% or more of their income on housing. States were classified on the basis of Medicaid expansion status (expanded, late-expanded, nonexpanded). Mortality-adjusted rate ratios were estimated by cancer type across severe housing cost burden quintiles. Compared with the lowest quintile of severe housing cost burden, counties in the highest quintile had a 5% greater cancer mortality rate (mortality-adjusted rate ratio = 1.05, 95% confidence interval = 1.01 to 1.08). Within each severe housing cost burden quintile, cancer mortality rates were greater in states that did not expand Medicaid, though this association was significant only in the fourth quintile (mortality-adjusted rate ratio = 1.08, 95% confidence interval = 1.03 to 1.13). Our findings demonstrate that counties with greater severe housing cost burden had higher premature cancer death rates, and rates are potentially greater in non-Medicaid-expanded states than Medicaid-expanded states.

Understanding the impacts of rural hospital closures: A scoping review

PURPOSE

Rural hospitals are closing at unprecedented rates, with hundreds more at risk of closure in the coming 2 years. Multiple federal policies are being developed and implemented without a salient understanding of the emerging literature evaluating rural hospital closures and its impacts. We conducted a scoping review to understand the impacts of rural hospital closure to inform ongoing policy debates and research.

METHODS

A comprehensive search strategy was devised by library faculty to collate publications using the PRISMA extension for scoping reviews. Two coauthors then independently performed title and abstract screening, full text review, and study extraction.

FINDINGS

We identified 5054 unique citations and assessed 236 full texts for possible inclusion in our narrative synthesis of the literature on the impacts of rural hospital closure. Twenty total original studies were included in our narrative synthesis. Key domains of adverse impacts related to rural hospital closure included emergency medical service transport, local economies, availability and utilization of emergency care and hospital services, availability of outpatient services, changes in quality of care, and workforce and community members. However, significant heterogeneity existed within these findings.

CONCLUSIONS

Given the significant heterogeneity within our findings across multiple domains of impact, we advocate for a tailored approach to mitigating the impacts of rural hospital closures for policymakers. We also discuss crucial knowledge gaps in the evidence base-especially with respect to quality measures beyond mortality. The synthesis of these findings will permit policymakers and researchers to understand, and mitigate, the harms of rural hospital closure.

Efficiency effects of public hospital closures in the context of public hospital reform: a multistep efficiency analysis

In the wake of hospital reforms introduced in 2011 in Turkey, public hospitals were grouped into associations with joint management and some shared operational and administrative functions, similar in some ways to hospital trusts in the English National Health Service. Reorganization of public hospitals effect hospital and market area characteristics and existence of hospitals. The objective of this study is to examine the effect of closure on competitive hospital performances. Using administrative data from Turkish Public Hospital Statistical Yearbooks for the years 2005 to 2007 and 2014 to 2017, we conducted a three-step efficiency analysis by incorporating data envelopment analysis (DEA) and propensity score matching techniques, followed by a difference-in-differences (DiD) regression. First, we used bootstrapped DEA to calculate the efficiency scores of hospitals that were located near hospitals that had been closed. Second, we used nearest neighbour propensity score matching to form control groups and ensure that any differences between these and the intervention groups could be attributed to being near a hospital that had closed rather than differences in hospital and market area characteristics. Lastly, we employed DiD regression analysis to explore whether being near a closed hospital had an impact on the efficiency of the surviving hospitals while considering the effect of the 2011 hospital reform policies. To shed light on a potential time lag between hospital closure and changes in efficiency, we used various periods for comparison. Our results suggest that the efficiency of public hospitals in Turkey increased in hospitals that were located near hospitals that closed in Turkey from 2011. Hospital closure improves the efficiency of competitive hospitals under hospital market reforms. Future studies may wish to examine the efficiency effects of government and private sector collaboration on competition in the hospital market.

Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion

Importance

The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known.

Objective

To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations.

Design, Setting, and Participants

Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys.

Exposure

Time-varying state-level adoption of Medicaid expansion.

Main Outcomes and Measures

Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits.

Results

The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion.

Conclusion and Relevance

Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

The trend of mortality rates following hospitals downgrading and closures due to outbreak of COVID-19 in Fars province: A comparative cohort study

Background and Aims

Hospitals are one of the most important healthcare centers for providing the patients with different medical needs. Several different factors might cause hospitals to downgrade their services or departments or close down overall. One of the most multifaceted reasons for hospital downgrading or closure is infectious disease outbreaks. In this regard, we aimed to evaluate the effects of hospital closure and downgrading due to the COVID-19 pandemic on the mortality rate of the people residing in Fars province, Iran.

Methods

We gathered mortality information, including the cause of death, age, sex, place, and time of death of all deceased cases occurring during a period of 3 years, from February 20, 2018 to March 2021 from the forensic medicine and also the Department of Biostatistics in Shiraz University of Medical Sciences.

Results

A total of 71,331 deaths have been reported since 2018 through the first quarter of 2021, with 57.9% of total mortality cases attributed to male gender. The total mortality counts ranged from 4229 to 9809 deaths per quarter, from which the minimum rate was reported in the first quarter of 2018 and the maximum in the fourth quarter of 2020. Based on the causes of death, diseases of the circulatory system were shown to be the all-time most frequent cause of death, accounting for a total of 42.8% of recorded deaths, followed by neoplasms (9.77%) and diseases of the respiratory system (9.45%).

Conclusion

Although the large number of deaths at the time of the pandemic are immediately due to COVID-19 infection, deaths due to a notable number of other causes have had a significant increase which, along with the specific trend of place and causes of death, shows that the downgrading and closure of hospitals have had a significant impact on overall population mortality.

Do hospital-based emergency Medicaid programs benefit trauma centers? A mixed-methods analysis

INTRODUCTION

Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization, which can offset patient costs of care, increase access to postdischarge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement and characterize incentives for HPE participation among hospitals and TCs. We hypothesized that there would be financial, operational, and mission-based incentives.

METHODS

We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semistructured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8).

RESULTS

Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE, 77 (21%) of which are TCs. As of early 2015, 100% of TCs had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II TCs. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue ( b = 6.74, p < 0.001) and decreased uncompensated care costs ( b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included reduction of hospital bad debt, improved patient satisfaction, and community benefit in access to care.

CONCLUSION

Hospital Presumptive Eligibility programs not only are a promising pathway for long-term insurance coverage for trauma patients but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program.

LEVEL OF EVIDENCE

Economic And Value Based Evaluations; Level II.

For better or worse: Governing healthcare organisations in times of financial distress

Due to processes of financialisation, financial parties increasingly penetrate the healthcare domain and determine under which conditions care is delivered. Their influence becomes especially visible when healthcare organisations face financial distress. By zooming-in on two of such cases, we come to know more about the considerations, motives and actions of financial parties in healthcare. In this research, we were able to examine the social dynamics between healthcare executives, banks and health insurers involved in a Dutch hospital and mental healthcare organisation on the verge of bankruptcy. Informed by interviews, document analysis and translation theory, we reconstructed the motives and strategies of executives, banks and health insurers and show how they play a crucial role in decision-making processes surrounding the survival or downfall of healthcare organisations. While parties are bound by legislation and company procedures, the outcome of financial distress can still be influenced. Much depends on how executives are perceived by financial stakeholders and how they deal with threats of destabilisation of the network. We further draw attention to the consequences of financialisation processes on the practices of healthcare organisations in financial distress.

Dynamics of Macroeconomy, Medicaid, and State Fiscal Conditions: A Role of Medicaid Expansion

Background

One of the main concerns of state governments about Medicaid expansion is the potential increase in state fiscal burden following the rise in enrollments. In previous literature, limited attention has been paid to the effect of macroeconomic changes, which are closely linked to Medicaid enrollments, in understanding the impact of Medicaid expansion on a state. To narrow the gap, this study establishes a synthetic model to represent the transmission channel from an unemployment shock to the Medicaid program and state expenditures.

Methods

The panel vector autoregression (VAR) model is adopted for the empirical analysis using annual data from 2010 to 2019 for 50 US states and D.C. The unit root and Granger causality tests are conducted to check the model's appropriateness. The estimated results are analyzed by using impulse response functions.

Results

A sudden increase in the unemployment rate will raise the number of Medicaid enrollees and the state Medicaid expenditure, but the impact on the overall state budget is not clear. States that adopt Medicaid expansion will encounter surges in enrollment and increasing Medicaid expenditure during the economic recession, while the non-expansion states will only have moderate enrollment increases. However, an increased budgetary burden per new enrollees will not be significant at its level.

Conclusion

Medicaid expansion will allow more people to benefit from the public health insurance program during an economic recession while the impact on states' fiscal burden will be moderate.

The Impact of Medicaid Expansion on Early-Stage Pancreatic Adenocarcinoma at High- Versus Low-Volume Facilities

INTRODUCTION

While Medicaid Expansion (ME) has improved healthcare access, disparities in outcomes after volume-dependent surgical care persist. We sought to characterize the impact of ME on postoperative outcomes among patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) at high-volume (HVF) versus low-volume (LVF) facilities.

METHODS

Patients who underwent resection for PDAC were identified from the National Cancer Database (NCDB; 2011-2018). HVF was defined as ≥20 resections/year. Patients were divided into pre- and post-ME cohorts, and the primary outcome was textbook oncologic outcomes (TOO). Difference-in-difference (DID) analysis was used to assess changes in TOO achievement among patients living in ME versus non-ME states.

RESULTS

Among 33,764 patients who underwent resection of PDAC, 19.1% (n = 6461) were treated at HVF. Rates of TOO achievement were higher at HVF (HVF: 45.7% vs. LVF: 32.8%; p < 0.001). On multivariable analysis, undergoing surgery at HVF was associated with higher odds of achieving TOO (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.49-1.72) and improved overall survival (OS) [hazard ratio (HR) 0.96, 95% CI 0.92-0.99]. Compared with patients living in non-ME states, individuals living in ME states were more likely to achieve TOO on adjusted DID analysis (5.4%, p = 0.041). Although rates of TOO achievement did not improve after ME at HVF (3.7%, p = 0.574), ME contributed to markedly higher rates of TOO among patients treated at LVF (6.7%, p = 0.022).

CONCLUSIONS

Although outcomes for PDAC remain volume-dependent, ME has contributed to significant improvement in TOO achievement among patients treated at LVF. These data highlight the impact of ME on reducing disparities in surgical outcomes relative to site of care.

Medicaid expansion and racial disparity in timely multidisciplinary treatment in muscle invasive bladder cancer

BACKGROUND

Multidisciplinary cancer care (neoadjuvant chemotherapy followed by radical cystectomy or trimodality therapy) is crucial for outcome of muscle-invasive bladder cancer (MIBC), a potentially curable illness. Medicaid expansion through Affordable Care Act (ACA) increased insurance coverage especially among patients of racial minorities. This study aims to investigate the association between Medicaid expansion and racial disparity in timely treatment in MIBC.

METHODS

This quasi-experimental study analyzed Black and White individuals aged 18-64 years with stage II and III bladder cancer treated with neoadjuvant chemotherapy followed by radical cystectomy or trimodality therapy from National Cancer Database 2008-2018. Primary outcome was timely treatment started within 45 days following cancer diagnosis. Racial disparity is the percentage-point difference between Black and White patients. Patients in expansion and nonexpansion states were compared using difference-in-differences and difference-in-difference-in-differences analyses, controlling for age, sex, area-level income, clinical stage, comorbidity, metropolitan status, treatment type, and year of diagnosis.

RESULTS

The study included 4991 (92.3% White, n = 4605; 7.7% Black, n = 386) patients. Percentage of Black patients who received timely care increased following the ACA in Medicaid expansion states (54.5% pre-ACA vs 57.4% post-ACA) but decreased in nonexpansion states (69.9% pre-ACA vs 53.7% post-ACA). After adjusting covariates, Medicaid expansion was associated with a net 13.7 percentage-point reduction of Black-White patient disparity in timely receipt of MIBC treatment (95% confidence interval = 0.5% to 26.8%; P < .01).

CONCLUSIONS

Medicaid expansion was associated with statically significant reduction in racial disparity between Black and White patients in timely multidisciplinary treatment for MIBC.

Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018

Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes.

CONTEXT

The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care.

METHODS

To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models.

FINDINGS

We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital.

CONCLUSIONS

Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.

Access To Oncology Services In Rural Areas: Influence Of The 340B Drug Pricing Program

Rural-urban cancer disparities, including greater mortality rates, are partially attributable to the limited availability of oncology services in rural communities. Without these services, rural residents may experience delays in timely treatment and may be less likely to complete recommended care. The 340B Drug Pricing Program allows eligible not-for-profit and public hospitals to purchase covered outpatient drugs, including high-cost oncology drugs, at discounted prices. Using 2011-20 data, we evaluated the relationship between new enrollment in the 340B program and oncology services initiation in rural general acute care hospitals that lacked oncology services in 2011. Compared with hospitals that remained unenrolled in the 340B program through 2020, hospitals that enrolled during 2012-18 were 8.3 percentage points more likely to have added oncology services as of 2020. The newly participating hospitals that added oncology services were disproportionately located in Medicaid expansion states and in counties with lower uninsurance rates. These findings suggest that the 340B program facilitates expanded access to oncology services in some rural communities, but opportunities remain to address disparities in the most disadvantaged service areas.

Policy Recommendations for Improving Rural Cancer Services in the United States

Compared with urban residents, rural Americans have seen slower declines in cancer deaths, have lower incidence but higher death rates from cancers that can be prevented through screening, have lower screening rates, are more likely to present with later-stage cancers, and have poorer cancer outcomes and lower survival. Rural health provider shortages and lack of cancer services may explain some disparities. The literature was reviewed to identify factors contributing to rural health care capacity shortages and propose policy recommendations for improving rural cancer care. Uncompensated care, unfavorable payer mix, and low patient volume impede rural physician recruitment and retainment. Students from rural areas are more likely to practice there but are less likely to attend medical school because of lower graduation rates, grades, and Medical College Admission Test (MCAT) scores versus urban students. The cancer care infrastructure is costly and financially challenging in rural areas with high proportions of uninsured and publicly insured patients. A lack of data on oncology providers and equipment impedes coordinated efforts to address rural shortages. Graduate Medical Education funding greatly favors large, urban, tertiary care teaching hospitals over residency training in rural, critical access and community-based hospitals and clinics. Policies have the potential to transform rural health care. This includes increasing advanced practice provider postgraduate oncology training opportunities and expanding the scope of practice; improving health workforce and services data collection and aggregation; transforming graduate medical education subsidies to support rural student recruitment and rural training opportunities; and expanding federal and state financial incentives and payments to support the rural cancer infrastructure.

Quality of Care and Outcomes Among Patients Hospitalized for Heart Failure in Rural vs Urban US Hospitals: The Get With The Guidelines-Heart Failure Registry

Importance

Prior studies have suggested patients with heart failure (HF) from rural areas have worse clinical outcomes. Contemporary differences between rural and urban hospitals in quality of care and clinical outcomes for patients hospitalized for HF remain poorly understood.

Objective

To assess quality of care and clinical outcomes for US patients hospitalized for HF at rural vs urban hospitals.

Design, Setting, and Participants

This retrospective cohort study analyzed 774 419 patients hospitalized for HF across 569 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between January 1, 2014, and September 30, 2021. Postdischarge outcomes were assessed in a subset of 161 996 patients linked to Medicare claims. Data were analyzed from August 2022 to January 2023.

Main Outcomes and Measures

GWTG-HF quality measures, in-hospital mortality, length of stay, and 30-day mortality and readmission outcomes.

Results

This study included 19 832 patients (2.6%) and 754 587 patients (97.4%) hospitalized at 49 rural hospitals (8.6%) and 520 urban hospitals (91.4%), respectively. Of 774 419 included patients, 366 161 (47.3%) were female, and the median (IQR) age was 73 (62-83) years. Compared with patients at urban hospitals, patients at rural hospitals were older (median [IQR] age, 74 [64-84] years vs 73 [61-83] years; standardized difference, 10.63) and more likely to be non-Hispanic White (14 572 [73.5%] vs 498 950 [66.1%]; standardized difference, 34.47). In adjusted models, patients at rural hospitals were less likely to be prescribed cardiac resynchronization therapy (adjusted risk difference [aRD], -13.5%; adjusted odds ratio [aOR], 0.44; 95% CI, 0.22-0.92), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (aRD, -3.7%; aOR, 0.71; 95% CI, 0.53-0.96), and an angiotensin receptor-neprilysin inhibitor (aRD, -5.0%; aOR, 0.68; 95% CI, 0.47-0.98) at discharge. In-hospital mortality was similar between rural and urban hospitals (460 of 19 832 [2.3%] vs 20 529 of 754 587 [2.7%]; aOR, 0.86; 95% CI, 0.70-1.07). Patients at rural hospitals were less likely to have a length of stay of 4 or more days (aOR, 0.75; 95% CI, 0.67-0.85). Among Medicare beneficiaries, there were no significant differences between rural and urban hospitals in 30-day HF readmission (adjusted hazard ratio [aHR], 1.03; 95% CI, 0.90-1.19), all-cause readmission (aHR, 0.97; 95% CI, 0.91-1.04), and all-cause mortality (aHR, 1.05; 95% CI, 0.91-1.21).

Conclusions and Relevance

In this large contemporary cohort of US patients hospitalized for HF, care at rural hospitals was independently associated with lower use of some guideline-recommended therapies at discharge and shorter length of stay. In-hospital mortality and 30-day postdischarge outcomes were similar at rural and urban hospitals.

Understanding the role of financial capacity in the delivery of opioid use disorder treatment

Opioid treatment programs must have adequate financial capacity to sustain operations and deliver a high standard of care for individuals suffering from opioid use disorder. However, there is limited consistency in the health services literature about the concept and relationship of organizational financial capacity and key outcome measures (wait time and retention). In this study, we explored five common measures of financial capacity that can be applied to opioid treatment programs: (a) reserve ratio, (b) equity ratio, (c) markup, (d) revenue growth, and (e) earned revenue. We used these measures to compare financial capacity among 135 opioid treatment programs across four data collection points: 2011 (66 programs), 2013 (77 programs), 2015 (75 programs), and 2017 (69 programs). We examined the relationship between financial capacity and wait time and retention. Findings from the literature review show inconsistencies in the definition and application of concepts associated with financial capacity across business and social service delivery fields. The analysis shows significant differences in components of financial capacity across years. We observed an increase in average earned revenue and markup in 2017 compared to prior years. The interaction between minorities and markup was significantly associated with higher likelihood of waiting (IRR = 1.077, p < .05). Earned revenue (IRR = 0.225, p < .05) was related to shorter wait time in treatment. The interaction between minorities and equity ratio is also significantly associated with retention (IRR = 0.796, p < .05). Our study offers a baseline view of the role of financial capacity in opioid treatment and suggests a framework to determine its effect on client-centered outcomes.

Understanding the relationship between nonprofit hospital community benefit spending and system membership: An analysis of independent hospital acquisitions

The Internal Revenue Service (IRS) requires nonprofit hospitals to report community benefit spending to justify their nonprofit tax exemption. We examined whether nonprofit hospital acquisitions influence the amount and type community benefit spending. We analyzed 2011-2018 data on urban, nonprofit hospitals. The analysis dataset included 57 hospitals that were acquired and a matched control group. We estimated difference-in-differences specifications to measure the effect of acquisitions on total community benefit spending, and three subcategories - clinical, population health, and other spending types. We found that acquisitions led to decreased population health spending (-$0.32 million, p < 0.01) and other spending categories (-$1.5 million, p < 0.05), but no significant change in total or clinical spending. If the acquirer was located out-of-state, total community benefit spending declined by $2.4 million (p < 0.10). Our findings support the need for community benefit spending to be considered, along with quality, efficiency, and prices, when evaluating the welfare impact of acquisitions.

The bystander effect: Impact of rural hospital closures on the operations and financial well-being of surrounding healthcare institutions

INTRODUCTION

There is presently a rural hospital shortage in the United States with 180 closures since 2005 and hundreds of institutions in financial peril. Although the hospital closure phenomenon is well-established, less is known about the spillover impact on the operations and financial wellbeing of surrounding hospitals. This preliminary study quantified how discrete rural hospital closures impact institutions in their regional proximity, finding a significant increase in inpatient admissions and emergency department visits for these "bystander hospitals".

METHODS

Using a repository of rural hospital closures collected by the UNC Sheps Center for Health Services Research, we identified closures over the past 15 years. Criteria for inclusion were hospitals that had been fully closed between 2005-2016 and with >25-bed capacity. We then designated surrounding hospitals within a 30-mile radius of each closed hospital as "bystander hospitals." We examined the average rate-of-change for inpatient admissions and emergency department visits in surrounding hospitals both two years before and after relevant hospital closures.

RESULTS

We identified 53 hospital closures and 93 bystander hospitals meeting our criteria during the study period. With respect to geographic distribution, 66% of closures were in the Southern US, including 21% in Appalachia. Average emergency department visits increased by 3.59% two years prior to a hospital's closure; however, at two years post-closure the average rate of increase rose to 10.22% (F (4,47) = 2.77, p = 0.0375). Average bystander hospital admissions fell by 5.73% in the two years preceding the hospital closure but increased 1.17% in the two years after (F (4,46) = 3.05, p = 0.0259).

CONCLUSION

These findings predict a daunting future for rural healthcare. While previous literature has described the acute effects hospital closures have on communities, this study suggests a significant spillover effect on hospitals within the geographic region and a cyclical process at play in the rural healthcare sector. In the absence of significant public health assistance in regions affected by closures, poor health outcomes, including "diseases of despair," are likely to continue proliferating, disproportionately affecting the most vulnerable. In the COVID-19 era, it will be especially necessary to focus on hospital closures given increased risk of maintaining solvency due to delayed and deferred care atop already tight margins.

A Model of True CHOICES: Learnings from a Comprehensive Sexual and Reproductive Health Clinic in Tennessee that Provides Abortions and Opened the City's First Birth Center

CHOICES

Memphis Center for Reproductive Health staff is passionate about ensuring that everyone has access to the full continuum of comprehensive reproductive health care (including abortion, gender-affirming care, miscarriage management, and community birth) regardless of race, gender identity, sexual orientation, HIV status, economic status, or religious beliefs. Memphis, Tennessee, has a history of limited community birth options (birthing outside of hospital walls). In 2017, when home birth services were added to CHOICES and plans for opening Memphis' first freestanding birth center were being imagined, it was intentional to create a model in which midwifery care could be accessible for patients who may be eligible for state-funded health care services, those considered at higher health risk than traditional low-risk midwifery patients, or both. In fact, individuals and their families with limited out-of-pocket funds and those historically marginalized would purposely receive holistic, individualized care based on their unique health care needs and personal desires, driven by a reproductive justice framework. In this article, we outline the success and challenges of addressing the reproductive health needs of marginalized communities, including the benefits of a nonprofit business model, operationalizing reproductive justice concepts, and the reclamation of Black midwifery. We also discuss the challenges of caring for Black birthing people and providing abortion and gender-affirming care in a politically hostile environment. Although individuals have complex needs, at its core, CHOICES believes that every person must be seen as whole human beings and that each can be cared for by a midwife. The CHOICES approach is informed by evidence-based information, clinical judgment, and an intentional partnership with and investment in a people who have historically been and are presently pushed to the margins, neglected, and blamed for poor health outcomes and demise. Striving to adapt the CHOICES model of care in other parts of the country is important now more than ever following the Supreme Court decision to overturn Roe v. Wade.

Disparities in Spatial Access to Emergency Surgical Services in the US

Importance

Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics.

Objective

To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods.

Design, Setting, and Participants

A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022.

Main Outcomes and Measures

Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3).

Results

In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities.

Conclusions and Relevance

In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.

Providing Orthopaedic Care to Vulnerably Underserved Patients: AOA Critical Issues

Implementation of the Affordable Care Act has increased the number of Americans with health insurance. However, a substantial portion of the population is still considered underserved, including those who are uninsured, underinsured, and those who are enrolled in Medicaid. The patients frequently face substantial access-to-care issues. Many underlying social determinants of health impact this vulnerable, underserved population, and surgeons must understand the nuances of caring for the underserved. There are numerous opportunities to engage with this population, and providing care to the indigent can be rewarding for both the vulnerably underserved patient and their surgeon.

The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity

IMPORTANCE

Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending.

OBJECTIVE

To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity.

EVIDENCE REVIEW

Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included.

FINDINGS

Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity.

CONCLUSIONS AND RELEVANCE

Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Impact of Medicaid Expansion Under the Affordable Care Act on Receipt of Surgery for Breast Cancer

To determine whether Medicaid expansion under the 2010 Affordable Care Act affected rates of breast cancer surgery.

System- and Individual-Level Barriers to Accessing Medical Care Services Across the Rural-Urban Spectrum, Washington State

Background:

Residents of rural areas face barriers beyond geography and distance when accessing medical care services. The purpose of this study was to characterize medical care access barriers across several commonly used classifications of rurality.

Methods:

Washington State household residents completed a mixed-mode (paper/online) health care access survey between June 2018 and December 2019 administered to a stratified random sample of ZIP codes classified as urban, suburban, large rural, and small rural (4-tier scheme). For analyses, rurality was also classified into 2-tier schemes (rural/urban) based on ZIP code and county. Respondents reported availability of medical care services and system- and individual-level barriers to accessing services. Logistic regression models estimated the odds of reporting system- or individual-level barriers in accessing medical care services across rurality (4- and 2-tier schemes), adjusting for respondent characteristics, and weighted to account for survey design.

Results:

About 617 households completed the survey (25.7% response rate). Compared to urban residents (across all 3 schemes), more rural residents reported traveling to a distant city or town for medical care (P < .001). Rurality was significantly associated with increased odds of facing system-level barriers. Respondents from small rural areas had greater odds access barriers for primary care (OR 7.31, 95% CI 1.84-29.09) and having no primary care provider (OR 11.37, 95% CI 3.03-42.75) compared to urban respondents. Individual-level barriers were not associated with rurality.

Conclusions:

To improve healthcare access across the rural-urban spectrum, policymakers must consider system-level barriers facing rural populations.

Rural Hospital Closures: Effects on Utilization and Medical Spending Among Commercially Insured Individuals

BACKGROUND

Access to health care continues to be a challenge, especially in remote areas. Since 2013, 70 rural hospitals have closed in the United States further exacerbating barriers to health care access in rural areas.

OBJECTIVE

The objective of this study is to identify the impact of rural hospital closures on total medical spending and utilization among the commercially insured rural population.

RESEARCH DESIGN

We use a pre-post study design with a comparison group. Individual-level Texas commercial claims data in 2014-2019 were linked to the Centers for Medicare & Medicaid Services (CMS) Provider of Services Current Files, Area Health Resource File, and Census American Community Survey. We performed an event study to test for pre-trends.

SUBJECTS

Analysis sample included commercially insured individuals 19-64 years of age residing in Texas.

MEASURES

Total medical spending and counts of health care encounters.

RESULTS

Individuals residing in rural Texas areas affected by a hospital closure experienced decreases in outpatient and emergency department (ED) utilization and no statistically significant changes in total medical spending relative to the unaffected individuals. Outpatient and ED utilization decreased by 0.133 (<0.1) and 0.015 (7<0.05) visits, respectively. Heterogeneity analysis showed that individuals residing in urban Texas experienced increases in total medical spending by $12.2 per month (<0.01) as well as individual spending subcategories.

CONCLUSIONS

Rural hospital closures led to significant decreases in outpatient and ED utilization while having no effect on health care spending. Close attention must be paid to rural hospital closures to ensure equitable health care access, especially for underserved populations.

Association Between Medicaid Expansion And Closure Of Hospital-Based Obstetric Services

Access to obstetric services has declined steadily during the past decade, driven by the closure of hospital-based obstetric units and of entire hospitals. A fundamental challenge to maintaining obstetric services is that they are frequently unprofitable for hospitals to operate, threatening hospital viability. Medicaid expansion has emerged as a possible remedy for obstetric service closure because it reduces uncompensated care and improves hospital finances. Using national hospital data from the period 2010-18, we assessed the relationship between Medicaid expansion and obstetric service closure in rural and urban communities. We found that expansion led to a large reduction in hospital closures; however, this effect was concentrated among hospitals that did not have obstetric units. Considering closure of obstetric units, we found that rural obstetric units were less likely to close immediately after expansion, but this effect faded within two years. Overall, our findings suggest that Medicaid expansion had little effect on the closure of obstetric services. Policies supporting access to obstetric care may need to directly address the financial challenges specific to this service line.

Towards a more efficient healthcare system: Opportunities and challenges caused by hospital closures amid the COVID-19 pandemic

A substantial number of United States (U.S.) hospitals have closed in recent years. The trend of closures has accelerated during the COVID-19 pandemic, as hospitals have experienced financial hardship from reduced patient volume and elective surgery cases, as well as the thin financial margins for treating patients with COVID-19. This trend of hospital closures is concerning for patients, healthcare providers, and policymakers. In this current opinion piece, we first describe the challenges caused by hospital closures and discuss what policymakers should know based on the existing research. We then discuss unique opportunities for researchers to inform policymakers by conducting careful studies that can shed light on different implications, trade-offs, and consequences of various strategies that can be followed.

Racial disparities in health care utilization, the affordable care act and racial concordance preference

The Affordable Care Act was implemented with the aim of increasing coverage and affordable access with hopes of improving health outcomes and reducing costs. Yet, disparities persist. Coverage and affordable access alone cannot explain the health care gap between racial/ethnic minorities and white patients. Instead, the focus has turned to other factors affecting utilization rates such as the patient-provider relationship. Data from nationally represented U.S. households in 2009-2017 were used to study the association between patient-provider social distance as measured by "racial/ethnic concordance" and health care utilization rates for periods covering pre- and post-ACA. Despite the reduction in financial barriers to health access with the implementation of the ACA, the correlation between racial/ethnic concordance and utilization remains positive and significant. The results suggest that while the ACA may have improved coverage and affordability, other dimensions of access, particularly acceptability, as measured by patient-provider clinical interaction experience, remains a factor in the decision to utilize care.

The Problem Of The Color Line: Spatial Access To Hospital Services For Minoritized Racial And Ethnic Groups

Examining how spatial access to health care varies across geography is key to documenting structural inequalities in the United States. In this article and the accompanying StoryMap, our team identified ZIP Code Tabulation Areas (ZCTAs) with the largest share of minoritized racial and ethnic populations and measured distances to the nearest hospital offering emergency services, trauma care, obstetrics, outpatient surgery, intensive care, and cardiac care. In rural areas, ZCTAs with high Black or American Indian/Alaska Native representation were significantly farther from services than ZCTAs with high White representation. The opposite was true for urban ZCTAs, with high White ZCTAs being farther from most services. These patterns likely result from a combination of housing policies that restrict housing opportunities and federal health policies that are based on service provision rather than community need. The findings also illustrate the difficulty of using a single metric-distance-to investigate access to care on a national scale.

Convergence of Service Providers and Managers' Perspectives on Strengths, Gaps, and Priorities for Rural Health System Redesign: A Whole-Systems Qualitative Study in Washington County, Maine

Introduction:

Both rural residents and state government leaders describe a need to redesign rural health care systems. Community members should be at the center of this effort.

Methods:

We conducted 46 in-depth interviews of direct service providers between September and November 2020 in Washington County, Maine. Data were analyzed using a thematic analysis approach.

Results:

Existing strengths included collaboration between government and health systems, and community-based services. Gaps included insufficient workforce, restricted scope of licensing and poor reimbursement, lack of coordination between health systems, and limited paramedicine capacity. Strategies for health system redesign included addressing maldistribution of services and resource optimization, changing federal and state legislation around insurance and scope of practice, and moving toward value-based purchasing models.

Conclusions:

Participants provided pragmatic recommendations based on their deep understanding of the community context. Lessons learned are likely to be salient in areas with similar profiles regarding rurality and poverty.

For-profit hospitals as anchor institutions in the United States: a study of organizational stability

Background

Anchor institutions, by definition, have a long-term presence within their local communities, but it is uncertain as to whether for-profit hospitals meet this definition; most research on anchor institutions to date has been limited to nonprofit organizations such as hospitals and universities. Accordingly, this study aims to determine whether for-profit hospitals are stable enough to fulfill the role of anchor institutions through a long-term presence in communities which may help to stabilize local economies.

Methods

This longitudinal study analyzes national, secondary data between 2008 and 2017 compiled from the Dartmouth Atlas of Health Care, the American Hospital Association Annual Survey, and County Health Rankings. We use descriptive statistics to calculate the number of closures and mergers of hospitals of different ownership type, as well as staffing levels. Using logistic regression, we also assessed whether for-profit hospitals had higher odds of closing and merging, controlling for both organization and community factors.

Results

We found for-profit hospitals to be less stable than their public and nonprofit hospital counterparts, experiencing disproportionately more closures and mergers over time, with a multivariable analysis indicating a statistically significant difference. Furthermore, for-profit hospitals have fewer full-time employees relative to their size than hospitals of other ownership types, as well as lower total payroll expenditures.

Conclusions

Study findings suggest that for-profit hospitals operate more efficiently in terms of expenses, but this also may translate into a lower level of economic contributions to the surrounding community through employment and purchasing initiatives. For-profit hospitals may also not have the stability required to serve as long-standing anchor institutions. Future studies should consider whether for-profit hospitals make other types of community investments to offset these deficits and whether policy changes can be employed to encourage anchor activities from local businesses such as hospitals.

Medicaid Expansion Alone Not Associated With Improved Finances, Staffing, Or Quality At Critical Access Hospitals

Critical access hospitals are important providers of care for rural and other underserved communities, but they face staffing and quality challenges while operating with low margins. Medicaid expansion has been found to improve hospital finances broadly and therefore may have permitted sustained investments in staffing and quality improvement at these vulnerable hospitals. In this difference-in-differences analysis, we found that critical access hospitals in Medicaid expansion states did not have statistically significant postexpansion increases in operating margins relative to hospitals in nonexpansion states. Nor did we see evidence of statistically significant differential improvement at critical access hospitals in expansion versus nonexpansion states on either staffing measures (physicians and registered nurses per 1,000 patient days) or quality measures (percentage-point changes in readmissions and mortality within thirty days of admission for pneumonia or heart failure). These findings suggest that critical access hospitals may need to take additional measures to bolster finances to provide continued support for the delivery of high-quality care to rural and other underserved communities.

Understanding the Implications of Medicaid Expansion for Cancer Care in the US: A Review

Importance

Insurance status has been linked to important differences in cancer treatment and outcomes in the US. With more than 15 million individuals gaining health insurance through Medicaid expansion, there is an increasing need to understand the implications of this policy within the US cancer population. This review provides an overview of the fundamental principles and nuances of Medicaid expansion, as well as the implications for cancer care.

Observations

The Patient Protection and Affordable Care Act presented states with an option to expand Medicaid coverage by broadening the eligibility criteria (eg, raising the eligible income level). During the past 10 years, Medicaid expansion has been credited with a 30% reduction in the population of uninsured individuals in the US. Such a significant change in the insurance profile could have important implications for the 1.7 million patients diagnosed with cancer each year, the oncology teams that care for them, and policy makers. However, several factors may complicate efforts to characterize the effect of Medicaid expansion on the US cancer population. Most notably, there is considerable variation among states in terms of whether Medicaid expansion took place, when expansion occurred, eligibility criteria for Medicaid, and coverage types that Medicaid provides. In addition, economic and health policy factors may be intertwined with factors associated with Medicaid expansion. Finally, variability in the manner in which cancer care has been captured and depicted in large databases could affect the interpretation of findings associated with expansion.

Conclusions and Relevance

The expansion of Medicaid was a historic public policy initiative. To fully leverage this policy to improve oncological care and to maximize learning for subsequent policies, it is critical to understand the effect of Medicaid expansion. This review aims to better prepare investigators and their audiences to fully understand the implications of this important health policy initiative.

Public Payment Rates For Hospitals And The Potential For Consolidation-Induced Cost Shifting

The theory of hospital cost shifting posits that reductions in public prices lead to higher commercial prices. The cost-shifting narrative and the empirical strategies used to evaluate it typically assume no connection between public prices and the number of hospitals operating in the market (market structure). We raise the possibility of "consolidation-induced cost shifting," which recognizes that changes in public prices for hospital care can affect market structure and, through that mechanism, affect commercial prices. We investigated the first leg of that argument: that public payment may affect hospital market structure. After controlling for many confounders, we found that hospitals with a higher share of Medicare patients had lower and more rapidly declining profits and an increased likelihood of closure or acquisition compared with hospitals that were less reliant on Medicare. This is consistent with the existence of consolidation-induced cost shifting and implies that reductions in public prices must be undertaken cautiously. Mechanisms to limit closure- or acquisition-induced increases in commercial hospital prices may be important.

Relationship between rural hospital closures and the supply of nurse practitioners and certified registered nurse anesthetists

BACKGROUND

Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care.

PURPOSE

We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce.

METHOD

Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs.

FINDINGS

Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs.

DISCUSSION

We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market.

National trends in emergency department closures, mergers, and utilization, 2005-2015

Study objectives

To describe nationwide hospital-based emergency department (ED) closures and mergers, as well as the utilization of emergency departments and inpatient beds, over time and across varying geographic areas in the United States.

Methods

Observational analysis of the American Hospital Association (AHA) Annual Survey from 2005 to 2015. Primary outcomes were hospital-based ED closure and merger. Secondary outcomes were yearly ED visits per hospital-based ED and yearly hospital admissions per hospital bed.

Results

The total number of hospital-based EDs decreased from 4,500 in 2005 to 4,460 in 2015, with 200 closures, 138 mergers, and 160 new hospital-based EDs. While yearly ED visits per hospital-based ED exhibited a 28.6% relative increase (from 25,083 to 32,248), yearly hospital admissions per hospital bed had a 3.3% relative increase (from 45.4 to 43.9) from 2005 to 2015. The number of hospital admissions and hospital beds did not change significantly in urban areas and declined in rural areas. ED visits grew more uniformly across urban and rural areas.

Conclusions

The number of hospital-based ED closures is small when accounting for mergers, but occurs as many more patients are presenting to a stable number of EDs in larger health systems, though rural areas may differentially affected. EDs were managing accelerating patient volumes alongside stagnant inpatient bed capacity.

State Politics And The Uneven Fate Of Medicaid Expansion

Under the Affordable Care Act (ACA), state governments play a central role in deciding whether millions of low-income Americans have access to Medicaid. During the early years of ACA implementation, conservative opposition stalled the expansion of eligibility for Medicaid in many Republican-controlled states, even in the face of strong fiscal incentives. Can any forces overcome this partisan divide? In this article we consider the role of several key mechanisms that have affected Medicaid expansion over the past decade, including electoral competition, ballot-box initiatives, interest-group coalitions, and entrepreneurial administrators. While each mechanism has helped place Medicaid expansion on the agenda, they have done so unevenly. In Republican-controlled states where electoral competition is weak and ballot initiatives are unavailable, Medicaid expansion remains unlikely. Even when expansion is successful at the ballot box, however, state legislatures and governors have been able to delay or reverse voter-led initiatives. Moreover, the highly salient and partisan nature of Medicaid expansion has made it difficult for interest-group coalitions and progressive administrators to play a leading role in policy change. The future of Medicaid expansion, as well as other significant portions of the ACA, will continue to depend on the character of representative democracy in the states.

Association of Medicaid Expansion With Quality in Safety-Net Hospitals

IMPORTANCE

Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown.

OBJECTIVE

To compare changes in quality from 2012 to 2018 between SNHs in states that expanded Medicaid vs those in states that did not.

DESIGN, SETTING, AND PARTICIPANTS

Using a difference-in-differences analysis in a cohort study, performance on quality measures was compared between SNHs, defined as those in the highest quartile of uncompensated care in the pre-Medicaid expansion period, in expansion vs nonexpansion states, before and after the implementation of Medicaid expansion. A total of 811 SNHs were included in the analysis, with 316 in nonexpansion states and 495 in expansion states. The study was conducted from January to November 2020.

EXPOSURES

Time-varying indicators for Medicaid expansion status.

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital quality measured by patient-reported experience (Hospital Consumer Assessment of Healthcare Providers and Systems Survey), health care-associated infections (central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections following colon surgery) and patient outcomes (30-day mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia). Secondary outcomes included hospital financial measures (uncompensated care and operating margins), adoption of electronic health records, provision of safety-net services (enabling, linguistic/translation, and transportation services), or safety-net service lines (trauma, burn, obstetrics, neonatal intensive, and psychiatric care).

RESULTS

In this difference-in-differences analysis of a cohort of 811 SNHs, no differential changes in patient-reported experience, health care-associated infections, readmissions, or mortality were noted, regardless of Medicaid expansion status after the Affordable Care Act. There were modest differential increases between 2012 and 2016 in the adoption of electronic health records (mean [SD]: nonexpansion states, 99.4 [7.4] vs 99.9 [3.8]; expansion states, 94.6 [22.6] vs 100.0 [2.2]; 1.7 percentage points; P = .02) and between 2012 and 2018 in the number of inpatient psychiatric beds (mean [SD]: nonexpansion states, 24.7 [36.0] vs 23.6 [39.0]; expansion states: 29.3 [42.8] vs 31.4 [44.3]; 1.4 beds; P = .02) among SNHs in expansion states, although they were not statistically significant at a threshold adjusted for multiple comparisons. In subgroup analyses comparing SNHs with higher vs lower baseline operating margins, an isolated differential improvement was noted in heart failure readmissions among SNHs with lower baseline operating margins in expansion states (mean [SD], 22.8 [2.1]; -0.53 percentage points; P = .001).

CONCLUSIONS AND RELEVANCE

This difference-in-differences cohort study found that despite reductions in uncompensated care and improvements in operating margins, there appears to be little evidence of quality improvement among SNHs in states that expanded Medicaid compared with those in states that did not.

Trends in heart failure-related cardiovascular mortality in rural versus urban United States counties, 2011-2018: A cross-sectional study

BACKGROUND

Adults in rural counties in the United States (US) experience higher rates broadly of cardiovascular disease (CVD) compared with adults in urban counties. Mortality rates specifically due to heart failure (HF) have increased since 2011, but estimates of heterogeneity at the county-level in HF-related mortality have not been produced. The objectives of this study were 1) to quantify nationwide trends by rural-urban designation and 2) examine county-level factors associated with rural-urban differences in HF-related mortality rates.

METHODS AND FINDINGS

We queried CDC WONDER to identify HF deaths between 2011-2018 defined as CVD (I00-78) as the underlying cause of death and HF (I50) as a contributing cause of death. First, we calculated national age-adjusted mortality rates (AAMR) and examined trends stratified by rural-urban status (defined using 2013 NCHS Urban-Rural Classification Scheme), age (35-64 and 65-84 years), and race-sex subgroups per year. Second, we combined all deaths from 2011-2018 and estimated incidence rate ratios (IRR) in HF-related mortality for rural versus urban counties using multivariable negative binomial regression models with adjustment for demographic and socioeconomic characteristics, risk factor prevalence, and physician density. Between 2011-2018, 162,314 and 580,305 HF-related deaths occurred in rural and urban counties, respectively. AAMRs were consistently higher for residents in rural compared with urban counties (73.2 [95% CI: 72.2-74.2] vs. 57.2 [56.8-57.6] in 2018, respectively). The highest AAMR was observed in rural Black men (131.1 [123.3-138.9] in 2018) with greatest increases in HF-related mortality in those 35-64 years (+6.1%/year). The rural-urban IRR persisted among both younger (1.10 [1.04-1.16]) and older adults (1.04 [1.02-1.07]) after adjustment for county-level factors. Main limitations included lack of individual-level data and county dropout due to low event rates (<20).

CONCLUSIONS

Differences in county-level factors may account for a significant amount of the observed variation in HF-related mortality between rural and urban counties. Efforts to reduce the rural-urban disparity in HF-related mortality rates will likely require diverse public health and clinical interventions targeting the underlying causes of this disparity.

The Affordable Care Act: policy predictors of integrated care between Hispanic-serving and mainstream mental health organizations

Background

The Patient Protection and Affordable Care Act increased funding for integrated care to improve access to quality health care among underserved populations. There is evidence that integrated care decreases inequities in access and quality of mental health care among Hispanic clients. Increasing integrated care at Hispanic-Serving Organizations may help to eliminate mental health service disparities among Hispanic clients.

Method

Using organizational responses from the 2014 and 2016 waves of the National Mental Health Service survey, this study conducted multivariate logistic analyses to assess whether the ACA policies related to integrated care increased the provision of integrated addictions treatment and primary care at mental health Hispanic-Serving Organizations, relative to Mainstream Organizations.

Results

Findings showed that Hispanic-Serving Organizations (54.4%) were less likely to provide integrated health services than Mainstream Organizations (59.1%) after the ACA. However, federal funding to help organizations transition into integrated care services (AOR = 1.74, p = 0.01) and accepting Medicaid payments (AOR = 1.59, p = 0.01) increased the provision of integrated care services at Hispanic-Serving Organizations over time.

Conclusions

Health care policies that increase funding to adopt integrated health services at community Hispanic-Serving Organizations may help decrease inequities in mental health access for Hispanics in the United States.