Medicaid expansions reduced racial disparities in preventable hospital outcomes

Key takeaways

• States that expanded Medicaid coverage had reductions in disparities between non-Hispanic Black and white patients for preventable hospitalizations, which decreased 10.4% from 2011 to 2018.
• Researchers found small and statistically insignificant changes between Hispanic and white patients.

Medicaid coverage expansions under the Affordable Care Act in 2014 were significantly associated with reductions in preventable hospitalizations and ED visits among non-Hispanic Black adults, a recent study in Health Affairs found.

According to Asako S. Moriya, an economist at the Agency for Healthcare Research and Quality, and Sujoy Chakravarty, PhD, an assistant research professor at the Rutgers Center for State Health Policy, prior evidence suggests that eligibility changes to the ACA resulted in “overall improvements in access to care.”

However, “little is known about whether the improvements in health care utilization outcomes varied across racial or ethnic subgroups,” they wrote. “Further, much of the previous literature is limited to one or two years after the 2014 expansions and is not well suited to capturing effects on outcomes that may become evident only in the longer term.”

Thus, the researchers evaluated all-payer hospital discharge data from 2011 to 2018 to determine related changes in hospital outcome disparities. They collected hospitalization data from 29 states and ED visit data from 26 states.

The study consisted of 42,048 and 35,904 hospitalizations and ED visits, respectively, among patients aged 27 to 64 years, the expansion’s target group.

Before the 2014 expansions, quarterly rates for preventable hospitalizations among non-Hispanic Black patients were 2.4 times higher in expansion states and 2.7 times higher in nonexpansion states compared with white patients.

Moriya and Chakravarty found that, overall, disparities among non-Hispanic Black and white patients in expansion states decreased by 10.4% for preventable hospitalizations and 13.5% for ED visits. According to the researchers, the decrease in overall ED visits was “primarily driven by preventable ED visits, although only half of ED visits were identified as preventable.”

The decrease in preventable hospitalizations was driven by reductions in hospitalizations for hypertension, chronic obstructive pulmonary disease, asthma and cardiac diseases, Moriya and Chakravarty wrote.

They pointed out that the disparity reduction reflects three effects resulting from Medicaid expansions, which included:

• individuals transitioning from no insurance to Medicaid;
• changes in access to care among newly and previously enrolled beneficiaries; and
• changes in disparities among newly and previously enrolled beneficiaries.

When analyzed by age, there were notable differences among younger patients, an encouraging result “given the limited use of ambulatory care among younger adults, especially among those in racial or ethnic minority groups,” Moriya and Chakravarty wrote.

However, when examining expansion-related disparities between Hispanic and white patients, the researchers reported that the findings were small and not statistically significant.

“We believe that this may have been a result of lower baseline differences or persisting coverage disparities and enrollment barriers experienced by Hispanic adults,” Moriya and Chakravarty wrote.

The researchers highlighted several limitations to the study. For example, the trends in ED visits were potentially impacted by an increased demand due to the increase in coverage. In addition, “some of the expansion states continued with the Medicaid fee bump after the federal mandate ended, and our results potentially combine the effects of heterogeneous state responses in physician supply and access,” Moriya and Chakravarty wrote.

“The Medicaid expansions’ positive impact on health care equity is informative for states that may be considering an expanded Medicaid program,” they concluded.

References:

• Medicaid expansion reduced black-white disparities in preventable hospital visits. https://www.eurekalert.org/news-releases/982369. Published March 10, 2023. Accessed March 13, 2023.
• Moriya A, Chakravarty S. Health Aff. 2023;doi:10.1377/hlthaff.2022.00460.