Affordable Care Act Impact in Kentucky: Increasing Access, Reducing Disparities

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.

Effect of Medicaid expansion on inflammatory bowel disease and healthcare utilization

BACKGROUND

Kentucky was among the first to adopt Medicaid expansion, resulting in reducing uninsured rates from 14.3% to 6.4%. We hypothesize that Medicaid expansion resulted in increased elective healthcare utilization and reductions in emergency treatments by patients suffering Inflammatory Bowel Disease (IBD).

METHODS

The Hospital Inpatient Discharge and Outpatient Services Database (HIDOSD) identified all encounters related to IBD from 2009 to 2020 in Kentucky. Several demographic variables were compared in pre- and post-Medicaid expansion adoption.

RESULTS

Our study analyzed 3386 pre-expansion and 24,255 post-expansion encounters for IBD patients. Results showed that hospitalization rates dropped (47.7%-8.4%), outpatient visits increased (52.3%-91.6%) and Emergency visits decreased (36.7%-11.4%). Admission following a clinical referral similarly increased with a corresponding drop in emergency room admissions. Hospital costs and lengths of stay also dropped following Medicaid expansion.

CONCLUSION

In the IBD population, Medicaid expansion improved access to preventative care, reduced hospital costs by decreasing emergency care, and increased elective care pathways.

Prevalence and Treatment for Alcohol Use Disorders Based on Kentucky Medicaid 2012-2019 Datasets

Alcohol use is the leading substance use in the United States. Persons with alcohol use disorder (AUD) face enormous health consequences and family problems. Analysis of Medicaid enrollee data is critical to understand different aspects of AUD and the treatment utilization for patients with AUD. Yearly patient-level data were constructed from the Kentucky 2012-2019 Medicaid claims data. ICD-9-CM and ICD-10-CM codes were used to identify patients with AUD and their comorbid conditions, the 11-digit National Drug Codes were used to identify medication treatments, and procedure codes were used to identify psychosocial and behavioral therapies. Logistic regression models were used to examine factors that were associated with AUD prevalence and AUD treatments. The prevalence of AUD trended up over time. Patients living in metro areas, between ages 45-54, having mental disorders, tobacco use, and with a family history of alcoholism had significantly higher rates of AUD. About 60% of patients diagnosed with AUD had major depressive disorder or anxiety. The treatment utilization for AUD also trended up from 2012 to 2019; however, it was still lower than 25% in 2019. Pharmacological treatments were used in only 2.89% of AUD cases in 2012, which increased to 8.13% in 2019. Psychosocial treatments were used in only 1.59% of AUD cases in 2012 that increased to 18.95% in 2019. The prevalence of AUD trended up over years. However, the treatment utilization for AUD was lower than 25%, even as of 2019. There is an urgent need for comprehensive, evidence-based, personalized AUD treatments.

Impact of the Affordable Care Act Medicaid Expansion on Reimbursement in Emergency General Surgery

BACKGROUND

Kentucky had one of the nation's largest increases in insurance coverage with the Affordable Care Act's (ACA) Medicaid expansion, quadrupling the proportion of Kentuckians with insurance coverage. This study compares reimbursement rates for surgical procedures performed by emergency general surgery (EGS) services at the University of Kentucky (UK) before and after Medicaid expansion in January 2014.

METHODS

This IRB-approved, single-institution study retrospectively evaluated all patients undergoing surgical treatment by our EGS team from 1/1/2011 to 12/31/2016. We queried operative records for the most frequently performed procedures by the EGS service. We reviewed patient electronic medical records and hospital financial records to identify insurance status, diagnosis codes, and expected hospital reimbursements, based on UK Hospital's procedure/payer accounting models.

RESULTS

Four thousand six hundred ninety-three patient procedures met inclusion criteria; 46.5% of these came before ACA expansion and 53.5% after expansion. The most frequent procedures performed were incision and drainage, laparoscopic appendectomy, laparoscopic cholecystectomy, and exploratory laparotomy. After ACA expansion, the proportion of patients with Medicaid nearly doubled (19.8% vs. 35.6%, p < 0.001). Concomitantly, there was a more than fivefold decrease in the uninsured patient population after expansion (23.3% vs. 4.6%, p < 0.001), and mean hospital reimbursement increased for laparoscopic appendectomy (13.7%, p < 0.001), laparoscopic cholecystectomy (50.7%, p < 0.001), and incision and drainage (70.2%, p < 0.001).

CONCLUSION

After ACA expansion, there was a sustained decrease in proportion of uninsured patients and a concomitant sustained increase in proportion of patients with access to Medicaid services in the EGS operative population, leading to increased mean hospital reimbursements and decreased patient financial burden.

Impacts of insurance expansion on health cost, health access, and health behaviors: evidence from the medicaid expansion in the US

Expansion of subsidized health insurance may result in both safer and riskier health behavior and outcomes. While having insurance lowers cost barriers to receive both usual and preventive care, the lower potential cost from adverse health events may also promote risky behavior. In this paper, I exploit expansion in the Medicaid program under the Affordable Care Act to estimate the impact of insurance expansion on health outcomes and behaviors for low-income individuals in the US. I find that expansion of coverage has significantly lowered cost and increased access, particularly among minority populations, but has had no significant impact on preventive health behaviors. At the same time, I also find no evidence of moral hazard or increase risky behavior like smoking and drinking among residents of expansion states.

Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014

BACKGROUND CONTEXT

Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients.

PURPOSE

To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA.

STUDY DESIGN

Retrospective analysis.

PATIENT SAMPLE

Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014.

OUTCOME MEASURES

Racial disparities in discharge rates before versus after ACA passage.

METHODS

Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders.

RESULTS

All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001).

CONCLUSION

Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.

Trends in Uninsured Rates Before and After Medicaid Expansion in Counties Within and Outside of the Diabetes Belt

OBJECTIVE

To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged <65 years and to determine whether the Patient Protection and Affordable Care Act (ACA), which expanded Medicaid, impacted insurance coverage in the Diabetes Belt, a region across 15 southern and eastern U.S. states in which residents have high rates of diabetes.

RESEARCH DESIGN AND METHODS

Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50-64 years, the percentage of women, Distressed Communities Index value, and rurality.

RESULTS

In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states.

CONCLUSIONS

ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt.

Changes In Health Insurance Coverage, Access To Care, And Income-Based Disparities Among US Adults, 2011-17

The Affordable Care Act increased insurance coverage and access to care, according to numerous national studies. However, the administration of President Donald Trump implemented several policies that may have affected the act's effectiveness. It is unknown what effect these changes had on access to care. We used survey data for 2011-17 from the Behavioral Risk Factor Surveillance System to assess changes access to care among nonelderly adults from before to after the change in administration in 2017. We found that the proportion of adults who were uninsured or avoided care because of cost increased by 1.2 percentage points and 1.0 percentage points, respectively, during 2017. These changes were greater among respondents who had household incomes below 138 percent of the federal poverty level, resided in states that did not expand eligibility for Medicaid, or both. At the population level, our findings imply that approximately two million additional US adults experienced these outcomes at the end of 2017, compared to the end of 2016.