Medicaid Expansion Associated with Decline in ICU Stays, Early Increase in Insurance Rates

Andrew Admon, MD, MPH, University of Michigan

Andrew Admon, MD, MPH

States that expanded their Medicaid programs under the Patient Protection and Affordable Care Act (PPACA) saw an early adoption of insurance coverage among hospitalized patients and a decline in ICU utilization among patients hospitalized with ambulatory care-sensitive conditions, a new study presented at the 2018 American Thoracic Society International Conference found.

Researchers collected data on all adult (18—64 years old) acute care hospital discharges between January 2012–December 2014 in 5 states: New Jersey, North Carolina, Nebraska, Washington and Wisconsin—some of which expanded their Medicaid programs under the PPACA and some of which didn’t. The diagnoses included 18 health conditions ranging from bacterial pneumonia to congestive heart failure and uncontrolled diabetes.

“While it is first important to validate these results over time and across other states, declines in ICU admission under Medicaid expansion may mean that gains in insurance access have led to early improvements in clinical outcomes,” lead author, Andrew Admon, MD, MPH, University of Michigan, said. “This may in turn reduce rates of very costly hospitalizations and alleviate strain on intensive care units, helping to offset the financial cost of expanding insurance coverage.”

Of the 5,067,190 total admissions, (11.2%) were diagnosed with ambulatory-care sensitive conditions (ACSCs). The overall ICU admission rate for all hospitalized patients was 12.1%, while the ICU admission rate was 20.9%.

In the study, ACSCs were defined using standard Agency for Healthcare Research and Quality (AHRQ) methods, with a critical illness modification that allowed for respiratory failure or sepsis as primary diagnosis for conditions like obstructive lung disease, congestive heart failure, pneumonia and urinary tract infection.

Researchers conducted a difference-in-difference analysis that evaluated the effects of Medicaid expansion on ICU admission rates as a proportion of all hospital admissions for ACSCs. A series of sensitivity analyses were also performed to test the strength of the findings.

All models were adjusted for patient and hospital characteristics, accounting for clustering of observations by hospital.

In the Medicaid expansion states, the percentage of uninsured hospitalized patients fell from 12.7% to 4.5%, while rates of Medicaid coverage increased from 19% to 26.6%. In non-expansion states, uninsurance and Medicaid rates remained stagnant (8.8% vs. 7.5% and 25% to 24.7%, respectively).

The expansion states saw a significant decline in risk-adjusted ICU admission rates among hospitalized patients with Medicaid or no insurance in the first year after expansion (-3.7% [(-6.3 - -1, P <0.01]).

“Although most research examining the effects of complex policies no health care utilization have used hospital admissions and emergency department visits as markers of ambulatory care access and quality, this study used critical illness as an alternative measure,” Admon concluded. “Because critical illness may be less susceptible to patient and provider decision-making than other types of health care utilization, they may be better markers of disease control after a complex policy change such as insurance expansion.”

To conclude, Medicaid expansion was linked to an early increase in insurance rates among hospitalized patients, and a decline in ICU utilization rates among those hospitalized with ACSCs, however, researchers noted that further research is needed to explore this effect.

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