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ACA Medicaid Expansion Improved Access to Care and Health Outcomes of Inpatient Rehabilitation Patients
As one of the main components in the Affordable Care Act (ACA), many states expanded Medicaid coverage to nonelderly individuals with incomes up to 138% of Federal Poverty Level (FPL). As of November, 2018, 37 states have opted to expand Medicaid eligibility, among which 30 states have made the coverage effective before Jan. 1, 2016 (remaining 2 states started during 2016, 1 in 2019, and 4 to be determined).
Research exploring the effects of Medicaid Expansion on the original goals of ACA found that the expansion was associated with increases in coverage, service use, quality of care and Medicaid spending in preventive, primary, acute and emergency care settings (e.g. Mazurenko et al. 2018). Yet, very few studies focused on inpatient rehabilitation services in the post-acute care settings, a group of more (price) elastic yet costlier services.
This study uses data from the Universal Data System of Medical Rehabilitation (UDSMR), a national rehabilitation outcomes measurement system, to investigate the effects of Medicaid Expansion on rehabilitation service utilization and functionality improvements. A difference-in-difference design is adopted to estimate the changes of major outcomes in the participating states before and after the expansion as oppose to the non-expansion states. Years of 2013 and 2016 are chosen for the pre- and post-policy comparison.
The study sample includes all non-elderly adult (18-64) Medicaid patient-episodes for initial rehabilitation services (readmission and facility transfers excluded) from more than 1,300 IRFs that subscribed to UDSMR, representing more than 80% of the total service sector. The final sample covers 11,619 / 1,270 and 2,028 patient-episodes for stroke, hip fracture and joint replacement – the three major impairment groups for inpatient rehabilitation. The major outcome variables are length of stay (LOS), improvement in functional status (measured by increase in FIM score between admission and discharge), and whether or not being able to return to community after discharge. Control variables include patient FIM score at admission, case mixed group, comorbidity tier, demographics, and facility characteristics.
Preliminary results show that the total delivered patient-episodes increased by 49.41%, 27.35% and -11.83% for the three groups in the expansion states from 2013 to 2016, while the changing rates were 1.09%, 3.15% and -34.21% for the non-expansion states during the same period. After controlling for all covariates, the average length of stay per episode was not significantly changed in the participating states after expansion. But the average improvement in FIM score at discharge were lowered by 1.63, 3.61 and 2.73 points (P<0.05, 0.05 and 0.01) due to expansion. Possibility to return to community were not significantly changed due to expansion.
Results imply that Medicaid expanded coverage and increased access to rehabilitation services. Patients’ composition, treatment intensity and the health outcomes are not compromised due to the increased volume of services being delivered.
