Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
JAMA Netw Open. 2020 Nov 2;3(11):e2025815. doi: 10.1001/jamanetworkopen.2020.25815.
State decisions not to expand Medicaid under the Patient Protection and Affordable Care Act could reduce emergency access to acute care hospitals.
To determine the relationship between state Medicaid expansion and emergency access to acute care hospitals in the United States.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study linked hospital-level data from the Centers for Medicare & Medicaid Services from 2007 to 2017 to US Census data for all 50 US states and the District of Columbia. Geospatial analyses and difference-in-differences regression models were used to compare temporal changes in the size of the population without 30-minute access to acute care hospitals between 32 states that expanded Medicaid with the population without access in 19 that did not, before and after expansion. Analyses focused on the total population and those with low incomes; secondary analyses examined emergency access to safety-net hospitals.
State-level Medicaid expansion.
Population without emergency access to an acute care hospital, defined as living outside a 30-minute drive of any hospital.
States that did not expand Medicaid experienced an increase in the population without access to hospitals overall (without expansion: 6.76% to 6.79% [0.03%]; vs with expansion: 5.65% to 5.35% [-0.30%]; difference-in-differences, 0.33%; 95% CI, 0.33%-0.34%; P < .001) and for low-income persons (without expansion: 7.43% to 7.39% [-0.04%]; vs with expansion: 6.25% to 6.15% [-0.10%]; difference-in-differences, 0.06%; 95% CI, 0.05%-0.07%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 421 000 more persons overall and 48 000 more low-income persons would have retained access. States that did not expand Medicaid experienced an increase in the population without access to safety-net hospitals overall (46.91% to 47.70% [0.79%] vs 33.94% to 33.07% [-0.87%]; difference-in-differences, 1.66%; 95% CI, 1.64%-1.66%; P < .001) and for low-income persons (45.28% to 46.14% [0.86%] vs 33.00% to 32.23% [-0.77%]; difference-in-differences, 1.63%; 95% CI, 1.63%-1.67%; P < .001). If access changes in nonexpansion states were the same as expansion states, an estimated 2 242 000 more persons overall and 364 000 more low-income persons would have retained access.
States that did not expand Medicaid under the Patient Protection and Affordable Care Act were associated with worse emergency access to acute care hospitals compared with states that expanded Medicaid.
重要性：根据《患者保护与平价医疗法案》，各州决定不扩大医疗补助计划，这可能会减少获得急症急性护理医院的途径。
目的：确定美国各州医疗补助计划扩大与急诊急性护理医院获得途径之间的关系。
设计、地点和参与者：本横断面研究将来自 2007 年至 2017 年美国医疗保险和医疗补助服务中心的医院级别数据与美国所有 50 个州和哥伦比亚特区的美国人口普查数据相关联。利用地理空间分析和差分法回归模型，比较了在扩大医疗补助计划的 32 个州和没有扩大医疗补助计划的 19 个州，在扩大医疗补助计划前后，30 分钟内无法获得急症护理医院的人群规模的时间变化。分析重点关注总人口和低收入人群；次要分析考察了对安全网医院的紧急访问。
暴露因素：州级医疗补助计划扩大。
主要结果和措施：无法紧急获得急症护理医院的人群，定义为居住在任何医院 30 分钟车程以外的人群。
结果：未扩大医疗补助计划的州，总体上无法获得医院服务的人群比例有所增加（无扩大：6.76%至 6.79%[0.03%]；有扩大：5.65%至 5.35%[-0.30%]；差异为 0.33%；95%CI，0.33%-0.34%；P < .001），低收入人群的比例也是如此（无扩大：7.43%至 7.39%[-0.04%]；有扩大：6.25%至 6.15%[-0.10%]；差异为 0.06%；95%CI，0.05%-0.07%；P < .001）。如果非扩张州的访问变化与扩张州相同，那么估计将有 421000 名以上的人总体上和 48000 名以上的低收入者将保留获得服务的机会。未扩大医疗补助计划的州，总体上无法获得安全网医院服务的人群比例有所增加（46.91%至 47.70%[0.79%]，而 33.94%至 33.07%[-0.87%]；差异为 1.66%；95%CI，1.64%-1.66%；P < .001），低收入人群的比例也是如此（45.28%至 46.14%[0.86%]，而 33.00%至 32.23%[-0.77%]；差异为 1.63%；95%CI，1.63%-1.67%；P < .001）。如果非扩张州的访问变化与扩张州相同，那么估计将有 2242000 名以上的人总体上和 364000 名以上的低收入者将保留获得服务的机会。
结论：与扩大医疗补助计划的州相比，未根据《患者保护与平价医疗法案》扩大医疗补助计划的州，在获得急症急性护理医院方面的情况更差。
