Health Policy Journal Club, Health Policy, Advocacy

Health Policy Journal Club: Adopt Medicaid, Expand Access

Emergency physicians should defend the ACA and advocate for Medicaid expansion

While there has been significant interest in the importance of acute care hospitals for emergency conditions, there has been comparatively little analysis of the role of insurance reform upon financial sustainability and access. The disparate adoption of Medicaid expansion under the Affordable Care Act established a real-world experiment into these issues.

Researchers analyzed the effects of Medicaid expansion in three ways. First, all short-term acute care hospitals in the United States were identified using the Centers for Medicare & Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS) data for the years 2007-2017, with identification of safety-net hospitals using CMS Supplemental Security Income files. Second, U.S. Census Bureau data was used to identify state-level populations and the population earning less than the federal poverty line by zip code. Third, the 2012 Environmental Systems Research Institute Road Atlas was used to determine which populations were within 30-minute driving distance of a hospital.

Using these methodologies, changes in the size of populations without 30-minute access to acute care hospitals were determined in the 32 states that expanded Medicaid and the 19 states that did not. In non-expansion states, there was an increase in the population without access to acute care hospitals for emergency care (difference-in-differences, 0.33%; p < .001). If non-expansion states had changes in access similar to expansion states, an estimated 421,000 more persons overall, including 48,000 low-income persons, would have retained access to emergency care.

Nonexpansion states also experienced an increase in the population without emergency access to safety-net hospitals (difference-in-differences, 1.66%; p < .001). If non-expansion behaved similarly to expansion states, an estimated 2,242,000 more persons overall, including 36,400 low-income persons, would have retained access to safety-net hospitals.

Medicaid expansion led to increased access to acute care hospitals for emergency care; patients in non-expansion states could clearly benefit from adoption. Notably, the effects of Medicaid expansion on access are more pronounced when looking at safety-net hospitals, with millions of patients in non-expansion states losing out. As physicians who frequently work with underserved patient populations receiving care from safety-net hospitals, emergency physicians should be fierce defenders of the ACA and strong advocates for Medicaid expansion.


Abstract: Wallace DJ, Donohue JM, Angus DC, et al. Association between state Medicaid expansion and emergency access to acute care hospitals in the United States. JAMA Netw Open. 2020;3(11):e2025815.

Importance: State decisions not to expand Medicaid under the Patient Protection and Affordable Care Act could reduce emergency access to acute care hospitals.

Objective: 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 CMS from 2007-2017 to U.S. Census data for all 50 U.S. 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.

Exposures: State-level Medicaid expansion

Main outcomes and measures: Population without emergency access to an acute care hospital, defined as living outside a 30-minute drive of any hospital

Results: 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-indifferences, 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.

Conclusions and relevance: 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.

PMID: 33196808


EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.