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. 2018 Oct;53(5):3617-3639.
doi: 10.1111/1475-6773.12812. Epub 2018 Jan 21.

Early Impact of the Affordable Care Act Coverage Expansion on Safety-Net Hospital Inpatient Payer Mix and Market Shares

Vivian Y Wu  1 , Kathryn R Fingar  2   3 , H Joanna Jiang  4 , Raynard Washington  5 , Andrew W Mulcahy  6 , Eli Cutler  7 , Gary Pickens  3
Affiliations

Early Impact of the Affordable Care Act Coverage Expansion on Safety-Net Hospital Inpatient Payer Mix and Market Shares

Vivian Y Wu et al. Health Serv Res. 2018 Oct.

Abstract

Objective: To examine the impact of the Affordable Care Act's coverage expansion on safety-net hospitals (SNHs).

Study setting: Nine Medicaid expansion states.

Study design: Differences-in-differences (DID) models compare payer-specific pre-post changes in inpatient stays of adults aged 19-64 years at SNHs and non-SNHs.

Data collection methods: 2013-2014 Healthcare Cost and Utilization Project State Inpatient Databases.

Principal findings: On average per quarter postexpansion, SNHs and non-SNHs experienced similar relative decreases in uninsured stays (DID = -2.2 percent, p = .916). Non-SNHs experienced a greater percentage increase in Medicaid stays than did SNHs (DID = 13.8 percent, p = .041). For SNHs, the average decrease in uninsured stays (-146) was similar to the increase in Medicaid stays (153); privately insured stays were stable. For non-SNHs, the decrease in uninsured (-63) plus privately insured (-33) stays was similar to the increase in Medicaid stays (105). SNHs and non-SNHs experienced a similar absolute increase in Medicaid, uninsured, and privately insured stays combined (DID = -16, p = .162).

Conclusions: Postexpansion, non-SNHs experienced a greater percentage increase in Medicaid stays than did SNHs, which may reflect patients choosing non-SNHs over SNHs or a crowd-out of private insurance. More research is needed to understand these trends.

Keywords: Community hospitals; Medicaid expansion; medically uninsured; safety-net hospitals; state health policies; utilization.

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Figures

Figure 1
Figure 1
(a) Changes in Inpatient Volume among Adults Aged 19–64 Years for SNHs and Non‐SNHs, 2013–2014. (b) Changes in Market Share of Inpatient Stays among Adults Aged 19–64 Years for SNHs and Non‐SNHs by Payer, 2013–2014. [Color figure can be viewed at http://www.wileyonlinelibrary.com/]

  1. Notes. Data came from the 2013–2014 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for nine states: AZ, CA, CO, IA, KY, MI, MN, NJ, and NY. Dashed line signifies the projected trend extrapolated from average quarterly percent changes during the preperiod. Q1‐13, first quarter, 2013; Q2‐13, second quarter, 2013; Q3‐13, third quarter, 2013; Q4‐13, fourth quarter, 2013; Q1‐14, first quarter, 2014; Q2‐14, second quarter, 2014; Q3‐14, third quarter, 2014; Q4‐14, fourth quarter, 2014; SNH, safety‐net hospital.

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