Impact of ACA-related Insurance Expansion Policies on Mortality and Access to Post-Discharge Care for Trauma Patients: An Analysis of the National Trauma Data Bank

Background Uninsured trauma patients have worse outcomes and worse access to post-discharge care that is critically important for recovery after injury. Little is known regarding the impact of the insurance coverage expansion policies of the Affordable Care Act (ACA), most notably state-level Medicaid expansion, on trauma patients. In this study, we examine the national impact of these policies on payer-mix, inpatient mortality, and access to post-acute care for trauma patients. Methods We used the 2011-2016 National Trauma Data Bank to evaluate for changes in insurance coverage among 18-64 year-old trauma patients. Our pre-/post-expansion models defined 2011-2013 as the pre-policy period, 2015-2016 as the post-policy period, and 2014 as a washout year. To evaluate for policy-associated changes in inpatient mortality and discharge disposition among the policy-eligible sample, we leveraged multivariable linear regression techniques to adjust for year-to-year variation in patient demographics, injury characteristics, and facility traits. We then examined the relationship between the magnitude of facility-level reductions in uninsured patients and access to post-acute care following policy implementation. Results We identified 1,656,469 patients meeting inclusion criteria between 2011-2016. The pre-policy uninsured rate of 23.4% fell by 5.9 percentage-points after coverage expansion (p30% relative increase in discharge to a post-acute care facility and a similar increase in discharge with home health services (p25% reduction in the uninsured rate among nonelderly adult trauma patients. Although no immediate impact on inpatient mortality was seen, insurance coverage expansion was associated with a higher proportion of patients receiving critically important post-discharge care. Level of Evidence Level III, Epidemiological Corresponding Author: John W. Scott, MD MPH, Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104-2499, 617-943-7211, jscott21@uw.edu Meetings: This work will be presented as a podium presentation at the 77th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 26-29, 2018, San Diego, CA. Relevant Conflicts of Interest and Funding: None declared © 2018 Lippincott Williams & Wilkins, Inc.

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