Medicaid Expansion, Uninsurance Rates, and Catastrophic Costs at the Time of Emergency Gynecologic Surgery.

Abstract

Objective: To estimate the effect of Medicaid expansion on uninsurance rates and catastrophic charges from emergency surgical management of ectopic pregnancy and ovarian torsion using difference-in-difference analysis and to evaluate for racial and ethnic disparities.

Methods: We conducted a retrospective cohort analysis using 2012-2018 State Inpatient Data and State Ambulatory Surgery and Services Databases in four states: Kentucky and Maryland (expansion) and Florida and North Carolina (nonexpansion). Patients undergoing surgical management of ovarian torsion or ectopic pregnancy were included. Logistic regression models were used controlling for year and expansion type; a difference-in-difference treatment indicator was used to evaluate changes in uninsurance rates and catastrophic spending (hospital charges more than 10% of estimated annual median income) among those uninsured. We then examined race and ethnicity for those uninsured before and after expansion by state.

Results: A total of 594,116 patients were included. Before expansion, the percent of patients uninsured was higher in nonexpansion states (6.5%) compared with expansion states (5.1%). After expansion, the percent uninsured decreased from 5.1% to 2.4% in expansion states compared with 6.5% to 5.3% in nonexpansion states. The interaction between expansion year and Medicaid expansion status was significant ( P <.001). Pre-expansion percent catastrophic charges among uninsured patients were higher in nonexpansion states compared with expansion states (96.7% vs 85.7%). After expansion, the percent catastrophic financial burden remained higher at 96.9% in nonexpansion states compared with 82.5% in expansion states. The interaction between expansion year and Medicaid expansion status was significant ( P <.001). The uninsured gap between Black or African American and White patients in expansion states after expansion was 0.5%-relatively unchanged-compared with 11.6% for Hispanic and non-Hispanic patients, an increase from 8.3% before expansion.

Conclusion: Medicaid expansion was associated with reductions in uninsured hospitalizations and catastrophic charges after gynecologic surgical emergencies and was associated with differences between Hispanic and non-Hispanic patients.