Changes in inpatient payer-mix and hospitalizations following Medicaid expansion

Evidence from all-capture hospital discharge data

Seth Freedman, Sayeh Nikpay, Aaron Carroll, Kosali Simon

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Context: The Affordable Care Act resulted in unprecedented reductions in the uninsured population through subsidized private insurance and an expansion of Medicaid. Early estimates from the beginning of 2014 showed that the Medicaid expansion decreased uninsured discharges and increased Medicaid discharges with no change in total discharges. Objective: To provide new estimates of the effect of the ACA on discharges for specific conditions. Design, setting, and participants: We compared outcomes between states that did and did not expand Medicaid using state-level all-capture discharge data from 2009–2014 for 42 states from the Healthcare Costs and Utilization Project’s FastStats database; for a subset of states we used data through 2015. We stratified the analysis by baseline uninsured rates and used difference-in-differences and synthetic control methods to select comparison states with similar baseline characteristics that did not expand Medicaid. Main outcome: Our main outcomes were total and condition-specific hospital discharges per 1,000 population and the share of total discharges by payer. Conditions reported separately in FastStats included maternal, surgical, mental health, injury, and diabetes. Results: The share of uninsured discharges fell in Medicaid expansion states with below (-4.39 percentage points (p.p.), -6.04 –-2.73) or above (-7.66 p.p., -9.07 –-6.24) median baseline uninsured rates. The share of Medicaid discharges increased in both small (6.42 p.p. 4.22–6.62) and large (10.5 p.p., 8.48–12.5) expansion states. Total and most condition-specific discharges per 1,000 residents did not change in Medicaid expansion states with high or low baseline uninsured rates relative to non-expansion states (0.418, p = 0.225), with one exception: diabetes. Discharges for that condition per 1,000 fell in states with high baseline uninsured rates relative to non-expansion states (-0.038 95% p = 0.027). Conclusions: Early changes in payer mix identified in the first two quarters of 2014 continued through the Medicaid expansion’s first year and are distributed across all condition types studied. We found no change in total discharges between Medicaid expansion and non-expansion states, however residents of states that should have been most affected by the Medicaid expansion were less likely to be hospitalized for diabetes.

Original languageEnglish (US)
Article numbere0183616
JournalPLoS One
Volume12
Issue number9
DOIs
StatePublished - Sep 1 2017

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Medicaid
diabetes
Inpatients
Hospitalization
health care costs
mental health
Medical problems
insurance
control methods
Insurance
Patient Protection and Affordable Care Act
Health
Health Care Costs
Population
Mental Health
Mothers
Databases

ASJC Scopus subject areas

  • Medicine(all)
  • Biochemistry, Genetics and Molecular Biology(all)
  • Agricultural and Biological Sciences(all)

Cite this

Changes in inpatient payer-mix and hospitalizations following Medicaid expansion : Evidence from all-capture hospital discharge data. / Freedman, Seth; Nikpay, Sayeh; Carroll, Aaron; Simon, Kosali.

In: PLoS One, Vol. 12, No. 9, e0183616, 01.09.2017.

Research output: Contribution to journalArticle

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abstract = "Context: The Affordable Care Act resulted in unprecedented reductions in the uninsured population through subsidized private insurance and an expansion of Medicaid. Early estimates from the beginning of 2014 showed that the Medicaid expansion decreased uninsured discharges and increased Medicaid discharges with no change in total discharges. Objective: To provide new estimates of the effect of the ACA on discharges for specific conditions. Design, setting, and participants: We compared outcomes between states that did and did not expand Medicaid using state-level all-capture discharge data from 2009–2014 for 42 states from the Healthcare Costs and Utilization Project’s FastStats database; for a subset of states we used data through 2015. We stratified the analysis by baseline uninsured rates and used difference-in-differences and synthetic control methods to select comparison states with similar baseline characteristics that did not expand Medicaid. Main outcome: Our main outcomes were total and condition-specific hospital discharges per 1,000 population and the share of total discharges by payer. Conditions reported separately in FastStats included maternal, surgical, mental health, injury, and diabetes. Results: The share of uninsured discharges fell in Medicaid expansion states with below (-4.39 percentage points (p.p.), -6.04 –-2.73) or above (-7.66 p.p., -9.07 –-6.24) median baseline uninsured rates. The share of Medicaid discharges increased in both small (6.42 p.p. 4.22–6.62) and large (10.5 p.p., 8.48–12.5) expansion states. Total and most condition-specific discharges per 1,000 residents did not change in Medicaid expansion states with high or low baseline uninsured rates relative to non-expansion states (0.418, p = 0.225), with one exception: diabetes. Discharges for that condition per 1,000 fell in states with high baseline uninsured rates relative to non-expansion states (-0.038 95{\%} p = 0.027). Conclusions: Early changes in payer mix identified in the first two quarters of 2014 continued through the Medicaid expansion’s first year and are distributed across all condition types studied. We found no change in total discharges between Medicaid expansion and non-expansion states, however residents of states that should have been most affected by the Medicaid expansion were less likely to be hospitalized for diabetes.",
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N2 - Context: The Affordable Care Act resulted in unprecedented reductions in the uninsured population through subsidized private insurance and an expansion of Medicaid. Early estimates from the beginning of 2014 showed that the Medicaid expansion decreased uninsured discharges and increased Medicaid discharges with no change in total discharges. Objective: To provide new estimates of the effect of the ACA on discharges for specific conditions. Design, setting, and participants: We compared outcomes between states that did and did not expand Medicaid using state-level all-capture discharge data from 2009–2014 for 42 states from the Healthcare Costs and Utilization Project’s FastStats database; for a subset of states we used data through 2015. We stratified the analysis by baseline uninsured rates and used difference-in-differences and synthetic control methods to select comparison states with similar baseline characteristics that did not expand Medicaid. Main outcome: Our main outcomes were total and condition-specific hospital discharges per 1,000 population and the share of total discharges by payer. Conditions reported separately in FastStats included maternal, surgical, mental health, injury, and diabetes. Results: The share of uninsured discharges fell in Medicaid expansion states with below (-4.39 percentage points (p.p.), -6.04 –-2.73) or above (-7.66 p.p., -9.07 –-6.24) median baseline uninsured rates. The share of Medicaid discharges increased in both small (6.42 p.p. 4.22–6.62) and large (10.5 p.p., 8.48–12.5) expansion states. Total and most condition-specific discharges per 1,000 residents did not change in Medicaid expansion states with high or low baseline uninsured rates relative to non-expansion states (0.418, p = 0.225), with one exception: diabetes. Discharges for that condition per 1,000 fell in states with high baseline uninsured rates relative to non-expansion states (-0.038 95% p = 0.027). Conclusions: Early changes in payer mix identified in the first two quarters of 2014 continued through the Medicaid expansion’s first year and are distributed across all condition types studied. We found no change in total discharges between Medicaid expansion and non-expansion states, however residents of states that should have been most affected by the Medicaid expansion were less likely to be hospitalized for diabetes.

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