Implications of the Patient Protection and Affordable Care Act on Insurance Coverage and Rehabilitation Use Among Young Adult Trauma Patients

Abstract

IMPORTANCE Trauma is the leading cause of death and disability among young adults, who are also among the most likely to be uninsured. Efforts to increase insurance coverage, including passage of the Patient Protection and Affordable Care Act (ACA), were intended to improve access to care and promote improvements in outcomes. However, despite reported gains in coverage, the ACA's success in promoting use of high-quality care and enacting changes in clinical end points remains unclear. OBJECTIVES To assess for observed changes in insurance coverage and rehabilitation use among young adult trauma patients associated with the ACA, including the Dependent Coverage Provision (DCP) and Medicaid expansion/open enrollment, and to consider possible insurance and rehabilitation differences between DCP-eligible vs-ineligible patients and among stratified demographic and community subgroups. DESIGN, SETTING, AND PARTICIPANTS A longitudinal assessment of DCP implementation and Medicaid expansion/open enrollment using risk-adjusted before-and-after, difference-indifference, and interrupted time-series analyses was conducted. Eleven years (January 1, 2005, to September 31, 2015) of Maryland Health Services Cost Review Commission data, representing complete patient records from all payers within the state, were used to identify all hospitalized young adult (aged 18-34 years) trauma patients in Maryland during the study period. RESULTS Of the 69 507 hospitalized patients included, 50 548 (72.7%) were male, and the mean (SD) age was 25 (5) years. Before implementation of the DCP, 1 of 4 patients was uninsured. After ACA implementation, the number fell to less than 1 of 10, with similar patterns emerging in emergency department and outpatient settings. The change was primarily driven by Medicaid expansion/open enrollment, which corresponded to a 20.1 percentage-point increase in Medicaid (95% CI, 18.9-21.3) and an 18.2 percentage-point decrease in uninsured (95% CI, −19.3 to −17.2). No changes were detected among privately insured patients. Rehabilitation use increased by 5.4 percentage points (95% CI, 4.5-6.2)-a 60% relative increase from a baseline of 9%. Mortality (−0.5; 95% CI, −0.9 to −0.1) and failure-to-rescue rates (−4.5; 95% CI, −7.4 to −1.6) also significantly declined. Stratified changes point to significant differences in the percentage of uninsured patients and rehabilitation access across the board, mitigating or even eradicating disparities in certain cases. CONCLUSIONS AND RELEVANCE For patients who are injured, young, and uninsured, Medicaid expansion/open enrollment in Maryland changed insurance coverage and altered patient outcomes in ways that the DCP alone was never intended to do. Implementation of Medicaid expansion/open enrollment transformed the landscape of trauma coverage, directly affecting the health of one of the country's most vulnerable at-risk groups.

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

“…Major morbidity was defined based on presence of 1 or more of the following complications calculated using ICD-9-CM codes: pneumonia, pulmonary embolism, renal failure, cardiovascular accident, myocardial infarction, cardiac arrest, acute respiratory distress syndrome, sepsis, and severe sepsis. Demographic covariates used in stratification included age categorized by decade into adults 19 to 25 years (also eligible for extended parental private insurance coverage as of September 2010), 13 26 to 35 years, 36 to 45 years, 46 to 55 years, and 56 to 64 years; sex (male, female); and race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic).…”

“…Month and year of admission were used to define the time period of hospitalization. Patients admitted during the 33 months following extended parental private insurance coverage 13…”

“…Interrupted time-series analysis is a quasi-experimental regression technique that uses longitudinal data to model temporal changes while accounting for preintervention trends. 13 It functions by fitting linear models to values in the preintervention and postintervention periods and assessing for the magnitude of deviation in the postintervention model's intercept from preintervention trends. Deviations from expected values provide evidence of an association between changes in study outcomes and health policy change.…”

“…Deviations from expected values provide evidence of an association between changes in study outcomes and health policy change. 13…”

“…9,11 Emerging studies on the impact of health care reform suggest that changes to insurance coverage taking place as a result of the implementation of the 2010 Patient Protection and Affordable Care Act (ACA) are changing care trajectories for adult trauma patients. [12][13][14][15][16][17][18][19][20] Passage of the ACA was intended to improve access to care through improvements in insurance coverage. While the law and its various provisions, including expansion of parental private insurance coverage to children younger than 26 years, establishment of an individual insurance mandate, formation of state health insurance exchanges, expansion of tax support for employersponsored health insurance plans, and optional state expansion of Medicaid with temporary federal funding to all citizens with an income of less than 133% of the federal poverty level are known to have increased insurance coverage and selfreported access to care on a national scale, 21 the ACA's specific effect on trauma patients remains less clear.…”