Filling the need for trusted information on national health issues…

New Analysis Shows States with Medicaid Expansion Experienced Declines in Uninsured Hospital Discharges

Expanded health insurance coverage through the Affordable Care Act (ACA) is having a major impact on hospital payer mix across the country.  Similar to other reports recently released, new data examining hospital discharges in 16 states with data through the second quarter in 2014 show increases in Medicaid and declines in uninsured or self-pay discharges in states that implemented the Medicaid expansion.  These trends hold true for all hospital discharges as well as for specific services such as mental health or asthma. This information adds to a growing body of evidence indicating that coverage expansions are affecting providers and may lead to decreases in uncompensated care for the uninsured.  These 16 states include 6 states that have not implemented (Florida, Georgia, Indiana, Missouri, Virginia, and Wisconsin) and 10 states that had implemented the Medicaid expansion (Arizona, California, Colorado, Hawaii, Iowa, Kentucky, Michigan, Minnesota, New Jersey, New York) by the second quarter in 2014.

Key Findings

Prior to the ACA’s major coverage expansions, growth rates for inpatient stays in expansion and non-expansion states moved in tandem, but patterns diverged starting in 2014.  From 2010 through 2013, the number of quarterly Medicaid and uninsured discharges in both expansion and non-expansion states changed cyclically in a similar pattern (Figures 1 and 2). Beginning in 2014, expansion states show sharp increases in inpatient stays for Medicaid and sharp declines for uninsured compared to non-expansion states (Figures 1 and 2).

Figure 1: Median Quarterly Change in Inpatient Hospital Stays for Adult Hospitalizations with Medicaid as Expected Payer 2010-2014

Figure 1: Median Quarterly Change in Inpatient Hospital Stays for Adult Hospitalizations with Medicaid as Expected Payer 2010-2014

Figure 2: Median Quarterly Change in Inpatient Hospital Stays for Adult Hospitalizations for Uninsured Patients, 2010-2014

Figure 2: Median Quarterly Change in Inpatient Hospital Stays for Adult Hospitalizations for Uninsured Patients, 2010-2014

Comparing inpatient stays by payer for 2013 to 2014 shows sharp increases for Medicaid and sharp declines in uninsured for expansion states. Data show that while inpatient stays declined by 3.4% for a typical expansion state from 2013 to 2014, Medicaid inpatient stays increased by 16.3% and uninsured stays decreased by 36.9%.  A typical non-expansion state experienced a decline in inpatient stays of 4.0% with small (0.5%) increases in Medicaid stays and slight declines in uninsured inpatient stays (2.9%) (Figure 3).

Figure 3: Median Percent Change in Inpatient Hospital Stays by Payer, 2013-2014

Figure 3: Median Percent Change in Inpatient Hospital Stays by Payer, 2013-2014

Increases in Medicaid discharges and declines in uninsured discharges for expansion states were especially pronounced for mental health.  Among the states included in this analysis, adult mental health stays accounted for 5.8% of adult hospital stays in the 2nd quarter of 2014 (data not shown).  A typical expansion state experienced a decrease of 1.5% in mental health inpatient stays but saw a 36.5% increase in Medicaid mental health inpatient stays and a 44.4% decline in uninsured stays for mental health.  Non-expansion states saw overall mental health stays increase slightly (1.6% increase) with similar slight increases across payers except for private (Figure 4).

Figure 4: Median Percent Change in Inpatient Hospital Stays for Mental Health by Payer, 2013-2014

Figure 4: Median Percent Change in Inpatient Hospital Stays for Mental Health by Payer, 2013-2014

The 2013 to 2014 trends for expansion and non-expansion states are consistent across other types of inpatient stays.  Among states in this analysis, medical conditions account for about half of all stays, surgical discharges account for about 23% of all stays, and other conditions account for much smaller shares (data not shown). These shares are similar for expansion and non-expansion states. Looking at changes in stays for other types of conditions including asthma, coronary heart failure (CHF), diabetes, and surgical care reveal similar patterns for expansion states as seen for total adult hospitalizations: while discharges declined overall, Medicaid discharges increased and uninsured discharges declined (Figure 5). For non-expansion states, stays for most conditions were flat or declined, both overall and for Medicaid and uninsured discharges. The exceptions to the pattern for non-expansion states were discharges for CHF, which rose 1.6% overall and 15.3% and 4.3% for uninsured and Medicaid, respectively, and diabetes, which rose slightly for all payers as well as Medicaid (Figure 6).

Figure 5: Median Percent Change in Inpatient Hospital Stays for Expansion States by Condition and Payer, 2013-2014

Figure 5: Median Percent Change in Inpatient Hospital Stays for Expansion States by Condition and Payer, 2013-2014

Figure 6: Median Percent Change in Inpatient Hospital Stays for Non-Expansion States by Condition and Payer, 2013-2014

Figure 6: Median Percent Change in Inpatient Hospital Stays for Non-Expansion States by Condition and Payer, 2013-2014

Looking ahead, changes may converge. Data for the later quarters in 2014 (not included in this analysis) show that the percent changes from quarter to quarter were not as disparate for expansion and non-expansion states as they were for the early months in 2014. This is likely because big level changes were occurring by payer when individuals changed coverage as a result of the Medicaid expansion in expansion states. Going forward, change between expansion and non-expansion states may follow similar trends as prior to the implementation of the ACA.  In addition, it will be important to assess how these changes in discharges by payer are affecting hospitals’ financial position. While hospitals in expansion states saw large shifts in payer mix between Medicaid and uninsured, most hospital discharges are covered by other payers such as Medicare or private insurance. As states and hospitals continue to report data on changes in payer mix and financial performance, we will be able to gain a fuller picture of the full impact of the ACA on providers.

Methods

This data note uses data from the Healthcare Cost and Utilization Project (HCUP) to examine changes in discharges by payer for states that did and did not implement the ACA Medicaid expansion.  HCUP consists of family of health care databases developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). Specifically, this analysis is based on data in the State Inpatient Databases (SID).  The data is discharge-level data for all patients treated in community, non-rehabilitation hospitals in the state and is weighted to represent all discharges in the state.  While 48 states participate in the SID, this analysis examines data from 16 states with data from 2010 through the second quarter of 2014.  The 16 states include 6 states that had not implemented (Florida, Georgia, Indiana, Missouri, Virginia, and Wisconsin) and 10 states that had implemented the Medicaid expansion (Arizona, California, Colorado, Hawaii, Iowa, Kentucky, Michigan, Minnesota, New Jersey, New York) in this time period.

This data includes nearly 3 million hospital stays in the second quarter of 2014 (with 1.8 million (61%) from the expansion states and 1.2 million (39%) from the non-expansion states).  Discharges in expansion and non-expansion states were concentrated in a small number of large states. For the group of expansion states, California and New York accounted for more than half of all discharges (54%), and for the non-expansion states, Florida and Georgia accounted for 56% of the discharges for the second quarter in 2014.  (Table 1)  Because these large states have a bigger impact on the overall experience of each group of states, we used the median for the group when examining outcomes of payer mix, percent change by quarter and when measuring change from 2013 to 2014.

The dominant payers for both expansion and non-expansion states were Medicare and private insurance.  For all discharges in the second quarter of 2014, the typical expansion state had a higher percentage of Medicaid discharges compared to non-expansion states (22% versus 15%) and a lower percentage of uninsured discharges (3% versus 9%).  (Table 1)

 

Table 1: Number and Distribution of Discharges by Payer for States Included in Analysis, 2014 Q2
State Total Medicaid Discharges Uninsured Discharges Medicare Discharges Private Insurance Discharges
# # As a % of
Total Discharges
# As a % of
Total Discharges
# As a % of
Total Discharges
# As a % of
Total Discharges
All Expansion States
Total 1,836,900 448,350 24%  62,450 3%  778,250 42% 547,850 30%
Median 108,950    24,250 22%  3,075 3%  47,675 43%  35,025 32%
Arizona  121,900  29,350 24%  6,500 5%  52,700 43%  33,350 27%
California 604,050  176,550 29%  20,500 3%  235,300 39% 171,700 28%
Colorado  75,950  18,100 24%  2,700 4%  28,800 38%  26,350 35%
Hawaii  18,800  5,100 27%  350 2%  6,600 35%  6,750 36%
Iowa  56,950  8,300 15%  1,100 2%  29,550 52%  18,000 32%
Kentucky  96,000  26,400 28%  2,300 2%  42,650 44%  24,650 26%
Michigan 219,950  42,250 19%  3,450 2%  107,950 49%  66,300 30%
Minnesota  87,800  15,000 17%  1,050 1%  35,050 40%  36,700 42%
New Jersey 168,250  22,100 13%  13,350 8%  75,900 45%  56,900 34%
New York 387,250 105,200 27%  11,150 3%  163,750 42% 107,150 28%
All Non-Expansion States
Total 1,155,850 191,300 17% 108,450 9%  544,950 47% 311,150 27%
Median 140,525    21,225 15%  13,400 10%  64,550 46%  42,000 30%
Florida  81,150  81,150 18%  43,650 9%  236,550 50% 108,950 23%
Georgia  31,250  31,250 16%  27,600 16%  67,950 39%  45,600 26%
Indiana  20,150  20,150 16%  8,100 6%  60,700 48%  37,350 30%
Missouri  22,300  22,300 12%  13,750 10%  64,150 46%  38,400 28%
Virginia  17,400  17,400 18%  13,050 9%  64,950 46%  47,050 33%
Wisconsin  19,050  19,050 18%  2,300 2%  50,650 48%  33,800 32%
SOURCE: Kaiser Family Foundation analysis of hospital inpatient data from the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases and quarterly 2014 data. Data available at: http://www.hcup-us.ahrq.gov/faststats/landing.jsp.

The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.