Adam Gaffney, MD; Danny McCormick, MD; David H. Bor, MD; Anna Goldman, MD; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
Acknowledgment: The authors thank Jacob Bor for his assistance on several statistical questions.
Disclosures: Dr. Gaffney serves as a leader in Physicians for a National Health Program (PNHP), a nonprofit organization that favors coverage expansion through a single-payer program. He has not received any compensation from that group but is reimbursed for some travel on behalf of the organization. Dr. McCormick reports membership on the national board of PNHP. Dr. Woolhandler reports that she cofounded and remains an active member of PNHP. She receives no financial compensation from that organization. She served as an unpaid advisor to Bernie Sanders' 2016 presidential campaign. Dr. Himmelstein reports that he cofounded and remains an active member of PNHP. He receives no financial compensation from that organization. He served as an unpaid advisor to Bernie Sanders' 2016 presidential campaign. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2806.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Gaffney (e-mail, email@example.com). Data set: All data are publicly available for download from the National Center for Health Statistics.
Corresponding Author: Adam Gaffney, MD, 1493 Cambridge Street, Cambridge, MA 02138; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Gaffney and McCormick: Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02138.
Dr. Bor: Chief Academic Officer, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139.
Dr. Goldman: Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Kresge Room 430, Boston, MA 02115.
Drs. Woolhandler and Himmelstein: 255 West 90th Street, New York, NY 10024.
Author Contributions: Conception and design: A. Gaffney, D. McCormick, D.H. Bor, S. Woolhandler, D.U. Himmelstein.
Analysis and interpretation of the data: A. Gaffney, D. McCormick, S. Woolhandler, D.U. Himmelstein.
Drafting of the article: A. Gaffney, D.U. Himmelstein.
Critical revision of the article for important intellectual content: A. Gaffney, D. McCormick, D.H. Bor, A. Goldman, S. Woolhandler, D.U. Himmelstein.
Final approval of the article: A. Gaffney, D. McCormick, D.H. Bor, A. Goldman, S. Woolhandler, D.U. Himmelstein.
Statistical expertise: A. Gaffney, S. Woolhandler, D.U. Himmelstein.
Obtaining of funding: D.H. Bor.
Administrative, technical, or logistic support: A. Goldman.
Collection and assembly of data: D.H. Bor, A. Gaffney.
Persons with comprehensive health insurance use more hospital care than those who are uninsured or have high-deductible plans. Consequently, analysts generally assume that expanding coverage will increase society-wide use of inpatient services. However, a limited supply of beds might constrain this growth.
To determine how the implementations of Medicare and Medicaid (1966) and the Patient Protection and Affordable Care Act (ACA) (2014) affected hospital use.
Repeated cross-sectional study.
Nationally representative surveys.
Respondents to the National Health Interview Survey (1962 to 1970) and Medical Expenditure Panel Survey (2008 to 2015).
Mean hospital discharges and days were measured, both society-wide and among subgroups defined by income, age, and health status. Changes between preexpansion and postexpansion periods were analyzed using multivariable negative binomial regression.
Overall hospital discharges averaged 12.8 per 100 persons in the 3 years before implementation of Medicare and Medicaid and 12.7 per 100 persons in the 4 years after (adjusted difference, 0.2 discharges [95% CI, −0.1 to 0.4 discharges] per 100 persons; P = 0.26). Hospital days did not change in the first 2 years after implementation but increased later. Effects differed by subpopulation: Adjusted discharges increased by 2.4 (CI, 1.7 to 3.1) per 100 persons among elderly compared with nonelderly persons (P < 0.001) and also increased among those with low incomes compared with high-income populations. For younger and higher-income persons, use decreased. Similarly, after the ACA's implementation, overall hospital use did not change: Society-wide rates of discharge were 9.4 per 100 persons before the ACA and 9.0 per 100 persons after the ACA (adjusted difference, −0.6 discharges [CI, −1.3 to 0.2 discharges] per 100 persons; P = 0.133), and hospital days were also stable. Trends differed for some subgroups, and rates decreased significantly in unadjusted (but not adjusted) analyses among persons reporting good or better health status and increased nonsignificantly among those in worse health.
Data sources relied on participant recall, surveys excluded institutionalized persons, and follow-up after the ACA was limited.
Past coverage expansions were associated with little or no change in society-wide hospital use; increases in groups who gained coverage were offset by reductions among others, suggesting that bed supply limited increases in use. Reducing coverage may merely shift care toward wealthier and healthier persons. Conversely, universal coverage is unlikely to cause a surge in hospital use if growth in hospital capacity is carefully constrained.
Gaffney A, McCormick D, Bor DH, et al. The Effects on Hospital Utilization of the 1966 and 2014 Health Insurance Coverage Expansions in the United States. Ann Intern Med. 2019;171:172–180. [Epub ahead of print 23 July 2019]. doi: https://doi.org/10.7326/M18-2806
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Published: Ann Intern Med. 2019;171(3):172-180.
Published at www.annals.org on 23 July 2019
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