Socioeconomic, racial and ethnic segregation persists in U.S. safety net hospitals

Photo: Marko Geber/Getty Images

Data has historically shown that the majority of patients insured through Medicaid, as well as the uninsured, seek inpatient hospital care and services at safety net hospitals. The Affordable Care Act expanded Medicaid to increase access to public insurance options for low-income individuals and families, as well as improve access to specialty medical care services. 

Results of a new study led by researchers at Boston Medical Center show, however, that this expansion did not lead patients receiving care at safety net hospitals to transfer their care to non-safety-net hospitals.

Published in JAMA Network Open, the national data review showed that discharges from safety net hospitals were higher among Black and Hispanic patients living in higher-poverty Zip codes compared to those for white patients in states that expanded Medicaid.

WHAT'S THE IMPACT?

While it was initially thought that Medicaid expansion would lead a proportion of racial/ethnic minority patients to transfer their care to non-safety net hospitals, in which specialty care services are often more accessible, this simply wasn't the case based on the data.

Discharge data from 11 states that expanded Medicaid – New York, Pennsylvania, New Jersey, Kentucky, Illinois, Iowa, Arizona. Colorado, Arizona, California and Oregon – and six that did not expand Medicaid – Texas, Wisconsin, Florida, Georgia, North Carolina and Virginia – between 2017 and 2021 were included in this study. 

The data set included nearly 83% of the Hispanic population in the U.S. Hospitals in the top quartile of the number of discharges among Medicaid and/or uninsured patients in 2012 were identified as safety net hospitals. The data were grouped by age (26-64 years and over 65 years, with older individuals serving as a comparison group), Zip code-poverty level, and race/ethnicity.

During the study period, the 17 states had a total of 18,289,417 Medicaid-covered and uninsured patient discharges. Slightly more than 59% of the discharges were in states with expanded Medicaid and 40.6% in non-expansion states. 

Among patients between 26-64 years old in expansion states, discharges at safety net hospitals were higher among Black and Hispanic patients (38.5% and 39.2%, respectively) compared to white patients (22.6%), and these discharges occurred among patients from Zip codes with higher poverty levels. 

The data did not show any systematic changes in safety net hospitalizations among Medicaid-insured or uninsured patients in either expansion or non-expansion states, as well as among all subgroups by race/ethnicity and Zip code-level poverty.

This could indicate that some Medicaid patients are satisfied with their care, and benefit from many of the services available at safety net hospitals, including case management and medical interpretation. But authors stressed that more study is needed to determine if underlying structural racism plays a role in patient decisions.

THE LARGER TREND

The Affordable Care Act expanded Medicaid coverage for most adults in the U.S. with incomes up to 138% of the federal poverty level, and many states opted to do so starting in 2014. This led to increased enrollment in Medicaid, with most new enrollees reporting that they had previously been uninsured.

Medicaid expansion has been linked to a number of health and economic benefits over the past few years, and a pair of studies published in 2018 the journal Health Affairs provided evidence that expanding the federal program has positive effects on both volume and care quality, particularly in more rural areas.

The findings were published soon after the Virginia legislature voted to expand Medicaid, joining 32 states and Washington D.C. in accepting federal dollars to do so under the Affordable Care Act.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com