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ACA Medicaid Expansion Not Enough to Curb Preventable Lupus Hospitalizations
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Although Medicaid expansion through the Affordable Care Act has increased insurance coverage, it has failed to address other barriers to care, including low income and rural residence, that increase the risk for preventable hospitalizations for lupus, according to data published in Arthritis Care & Research.
“This study serves as a spotlight on national health care policy and its effect on access to care and hospitalization charges,” Elizabeth A. Brown, PhD, MPA, of the Medical University of South Carolina, told Healio Rheumatology. “Health policies are embedded in our everyday lives, but do we understand the impact policies have on our ability to access care? This study aimed to do just that — evaluate Medicaid expansion under the Affordable Care Act and highlight the effect the policy had on people living with lupus. The study highlights the fact that there are still issues with access to care even after Medicaid expansion.”
To analyze the ACA’s impact on preventable lupus hospitalizations, particularly before and after Medicaid expansion, Brown and colleagues conducted a retrospective, quasiexperimental study of data from eight states. These included four states that expanded Medicaid through the ACA on Jan. 1, 2014 — Arizona, Kentucky, New Jersey and New York — and four states that did not — Florida, Georgia, South Carolina and Wisconsin. Data inclusion criteria included all payers, patients aged 20 to 64 years and all lupus hospitalizations.
Using an Interrupted Time Series research design, which compares trends over time and analyzes differences before and after certain outcome measures, the researchers drew data from the Healthcare Cost and Utilization Project State Inpatient Databases. Lupus hospitalizations, with a principal diagnosis of predetermined ambulatory care sensitive conditions, were used as the primary unit of analysis. Access to care, measured by preventable hospitalizations, was the primary outcome variable.
In their analysis, Brown and colleagues examined eight quarterly pre-expansion time periods from Jan. 1, 2012, through Dec. 31, 2013, as well as seven post-expansion periods from Jan. 1, 2014, through Sept. 30, 2015. The remaining admissions from October through December 2015 were not included due to the transition from ICD-9 to ICD-10 codes.
According to the researchers, there were 204,150 lupus hospitalizations across all eight states during studied time periods. Of those hospitalizations, 53.5% occurred in states that did not expand Medicaid. In their unadjusted analysis, the Brown and colleagues found that Medicaid expansion states demonstrated significantly lower odds of having preventable lupus hospitalizations (OR = 0.958; 95% CI, 0.932-0.985).
However, after the researchers adjusted for several covariates, Medicaid expansion states were found to demonstrate increased odds of preventable lupus hospitalizations (OR = 1.302; 95% CI, 1.119-1.515). The adjusted analysis also showed that patients with increased age, no health insurance, rural residence, low income or public insurance — either through Medicare or Medicaid — demonstrated significantly higher odds of having a preventable hospitalization due to lupus.
“Our findings can inform clinical practice and assist health care organizations to improve access for their patients,” Brown said. “Health care providers and organizations capture data on individual determinants of health such as behaviors, biology and genetics. However, they should also capture and examine how social determinants of health, like socioeconomic status, social support, transportation and housing conditions, might affect patient outcomes.”
“For example, do providers know if patients can afford the prescription medicines that they are recommending?” she added. “Do the providers know if their patients have social support that can help them with their chronic illnesses? Do providers know if their patients live in medically underserved areas or food deserts? Do providers know if their patient has reliable transportation to health care appointments? – by Jason Laday
Disclosure: The researchers report funding from the NIH.
Perspective
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Vickie L. Sayles, MHA, BSN, CRNI, RN-BC
The Affordable Care Act was enacted to address health inequalities for Americans who lacked health insurance. Expansion of Medicaid services was expected to provide low-income individuals access to health care and improve health outcomes for this population. While Medicaid expansion did provide health insurance for many in need, it did not address other barriers to care this group faces.
Unfortunately, with the shortage of rheumatology providers across the United States, access to care for patients with rheumatic conditions continues to be an issue. Many patients utilize emergency services as opposed to office visits with their rheumatologist due of lack of transportation, child care for visits, language barriers and medication affordability. Additionally, not all health care providers accept Medicaid payments due to such low reimbursement for services. Going to the emergency room is more convenient and affordable for this vulnerable population.
These systemic disparities negatively affect care of patients with rheumatic diseases. Many patients are unable to afford to take time off work, pay for child care or travel long distances to office visits. This leads to lack of medication adherence and lab monitoring, essential chronic disease treatment, and further serious comorbidities with this population.
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