The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments

Klein, Eili Y.; Levin, Scott R.; Toerper, Matthew; Makowsky, Michael D.; Xu, Tim; Cole, Gai; Kelen, Gabor D.

doi:10.1016/j.annemergmed.2017.06.021

Cited by 47 publications

(31 citation statements)

References 25 publications

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“…Medicaid expansion under the ACA decreased the number of uninsured individuals in the low-income population, and there have been several other population health benefits, including improving access to care, use patterns, and self-reported health outcomes. 6,[28][29][30] The current study results suggested that Medicaid expansion also may have improved outcomes in patients with screening-amenable cancers. In the population of low-income, potentially Medicaid-eligible adults in Ohio (a state that was part of the first round of expansions in 2014), the odds of being diagnosed with metastatic breast, cervical, colorectal, or lung cancers decreased in the postexpansion period.…”

Section: Discussionmentioning

confidence: 97%

The effect of Medicaid expansion among adults from low‐income communities on stage at diagnosis in those with screening‐amenable cancers

Kim

Koroukian²,

Statler

et al. 2020

Cancer

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Background Several states have opted to expand Medicaid under the Patient Protection and Affordable Care Act (ACA), which offers insurance coverage to low‐income individuals up to 138% of the federal poverty level. This expansion of Medicaid to a medically vulnerable population potentially can reduce cancer outcome disparities, especially among patients with screening‐amenable cancers. The objective of the current study was to estimate the effect of Medicaid expansion on the percentage of adults from low‐income communities with screening‐amenable cancers who present with metastatic disease. Methods Using state cancer registry data linked with block group–level income data, a total of 12,760 individuals aged 30 to 64 years who were diagnosed with incident invasive breast (female), cervical, colorectal, or lung cancer from 2011 through 2016 and who were uninsured or had Medicaid insurance at the time of diagnosis were identified. This sample was probability weighted based on income to reflect potential Medicaid eligibility under the ACA's Medicaid expansion. A multivariable logistic model then was fitted to examine the independent association between the exposure (pre‐expansion [years 2011‐2013] vs postexpansion [years 2014‐2016]) and the outcome (metastatic vs nonmetastatic disease at the time of diagnosis). Results After adjusting for potential confounders, individuals who were diagnosed postexpansion were found to have 15% lower odds of having metastatic disease compared with those who were diagnosed pre‐expansion (adjusted odds ratio, 0.85; 95% confidence interval, 0.77‐0.93). As a control, a separate analysis that focused on individuals with private insurance who resided in high‐income communities found nonsignificant postexpansion (vs pre‐expansion) changes in the outcome (adjusted odds ratio, 1.02; 95% confidence interval, 0.96‐1.09). Conclusions Medicaid expansion is associated with a narrowing of a critical cancer outcome disparity in adults from low‐income communities.

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Section: Discussionmentioning

confidence: 97%

The effect of Medicaid expansion among adults from low‐income communities on stage at diagnosis in those with screening‐amenable cancers

Kim

Koroukian²,

Statler

et al. 2020

Cancer

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“…Recent studies have yielded mixed conclusions in evaluating changes in ED utilization following ACA implementation in Medicaid expansion states. [9][10][11][12][13] Several studies have shown no significant increase in ED visits, while Western Journal of Emergency Medicine Table 1. Patient characteristics at a single, suburban health system emergency department before and after the implementation of the Affordable Care Act in Illinois (N=357,764; 2011-2016).…”

Section: Discussionmentioning

confidence: 99%

Examining the Effect of the Affordable Care Act on Two Illinois Emergency Departments

Probst

Walls

Cirone

et al. 2019

WestJEM

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Introduction: The emergency department (ED) has long served as a safety net for the uninsured and those with limited access to routine healthcare. This study aimed to compare the characteristics and severity of ED visits in an Illinois academic medical center (AMC) and community hospital (CH) of a single health system before and after the implementation of the Affordable Care Act (ACA). Methods: This was a retrospective record review of 357,764 ED visits from January 1, 2011-December 31, 2016, of which 74% were at the AMC and 26% at the CH. We assessed the severity of ED visits by applying the previously validated Ballard algorithm, which classifies ED visits as non-emergent, intermediate, or emergent. Descriptive analyses were conducted to compare the characteristics of ED visits before and after the implementation of the ACA. We conducted multilevel logistic regression analysis to examine the odds of non-emergent compared to intermediate/ emergent ED visits by the ACA implementation status controlling for patient demographic characteristics, insurance status, and multiple visits per patient. Results: ED visits for patients with Medicaid or other governmental coverages increased in the post-ACA compared to pre-ACA period (Pre: 33.2 % vs Post: 38.3% at the AMC, and Pre: 29.7% vs Post: 35.1% at the CH). A statistically significant decrease in ED visits for uninsured patients was observed at the AMC and CH in the post-ACA period compared to the pre-ACA period (Pre: 12.1% vs Post: 6.4%, and Pre: 13.9% vs Post: 9.8%, respectively). Results from the regression analysis showed a significant decreased odds of non-emergent vs intermediate/emergent ED visits during the post-ACA period compared to the pre-ACA period at the AMC (odds ratio [OR] 0.68; confidence interval [CI], 0.66-0.70). However, an increased odds of non-emergent vs. intermediate/emergent ED visits was observed at the CH (OR 1.09; CI, 1.04-1.14). Conclusion: Similar to other Medicaid expansion states, ED utilization for uninsured patients decreased at both the AMC and the CH in the post-ACA period. While Medicaid visits for children < 18 years declined in the post-ACA period, it increased for ages 21 to 65 years of age. Contrary to our hypothesis, the severity of emergent ED visits increased in the post-ACA period but not at the CH.

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“…In 2008 and 2009, 19% of ED visits were potentially preventable, of which 23%–24% were made by the uninsured. Since 2009, Medicaid expansion in Maryland has resulted in lower uninsured rates (Maryland Institute for Emergency Medical Services Systems & Health Services Cost Review Commission, 2017) but essentially no change in overall ED use (Agency for Healthcare Research and Quality, 2017; Klein et al, 2017), indicating that factors other than and in addition to insurance status also affect primary care access and care-seeking behaviors. PPV rates are often used as a proxy measure for lack of access to care, but they more accurately reflect increased health risks resulting from such lack of access, such as complications from unmanaged chronic diseases.…”

Section: Discussionmentioning

confidence: 99%

Geographic Variance in Maryland’s Potentially Preventable Emergency Visits: Comparison of Explanatory Models

Rowe

2019

West J Nurs Res

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The use of emergency departments (EDs) for potentially preventable visits is costly and inefficient. In Maryland, about 20%–30% of such visits are ambulatory care sensitive and thus potentially preventable. The uninsured are often perceived to account for a disproportionate share of such visits. This analysis aimed to (a) compare and explain the geographic variance in Maryland’s potentially preventable ED visit (PPV) rates for the total and uninsured populations and (b) test the predictive value of regression models developed. Geographic hot spots of increased PPV rates were highly correlated for uninsured and total populations, but uninsured rates were more clustered in urban areas. Poisson and geographically weighted regression (GWR) models best fit the data and predicted 40%–52% and 46% of the variance in 2009 total and uninsured rates, respectively. Significant predictors of increased PPV rates were social determinants of health: lower per capita income and education levels, and higher percentage of female-headed households.

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The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments

Cited by 47 publications

References 25 publications

The effect of Medicaid expansion among adults from low‐income communities on stage at diagnosis in those with screening‐amenable cancers

The effect of Medicaid expansion among adults from low‐income communities on stage at diagnosis in those with screening‐amenable cancers

Examining the Effect of the Affordable Care Act on Two Illinois Emergency Departments

Geographic Variance in Maryland’s Potentially Preventable Emergency Visits: Comparison of Explanatory Models

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