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Objective: To estimate changes in the emergency department (ED) visit rate, hospitalization share of ED visits, and ED visit volumes associated with Medicaid expansion among Hispanic, Black, and White adults. Data Collection/Extraction Methods: For the population of adults aged 26-64 with no insurance or Medicaid coverage, we obtained census population and ED visit counts during 2010-2018 in nine expansion and five nonexpansion states. Main Outcomes and Measures: The primary outcome was the annual number of ED visits per 100 adults ('ED rate'). The secondary outcomes were the share of ED visits leading to hospitalization, total number ('volumes') of all ED visits, ED visits leading to discharge ('treat-and-release') and ED visits leading to hospitalization ('transfer-to-inpatient'), and the share of the study population with Medicaid ('Medicaid share'). Study Design: An event-study difference in differences design that contrasts pre-versus post-expansion changes in outcomes in Medicaid expansion and nonexpansion states. Principal Findings: In 2013, the ED rate was 92.6, 34.4, and 59.2 ED visits among Black, Hispanic, and White adults, respectively. The expansion was associated with no change in ED rate in all three groups in each of the five post-expansion years. We found that expansion was associated with no change in the hospitalization share of ED visits and the volume of all ED visits, treat-and-release ED visits, and transfer-to-inpatient ED visits. The expansion was associated with an 11.7% annual increase (95% CI, 2.7%-21.2%) in the Medicaid share of Hispanic adults, but no significant change among Black adults (3.8%; 95% CI, -0.04% to 7.7%). Conclusion: ACA Medicaid expansion was associated with no changes in the rate of ED visits among Black, Hispanic, and White adults. Expanding Medicaid eligibility may not change ED use, including among Black and Hispanic subgroups. KEYWORDS Affordable Care Act, ED to hospitalization, emergency department use, ethnicity, Medicaid expansion, race What is known on this topic * Insurance expansion may lead to an increase (due to reduced cost-related barriers) or decrease (due to expanded outpatient care access) in ED use. * ACA Medicaid expansion was associated with a larger decrease in uninsurance rate among Black and Hispanic adults than among White adults. * Baseline level of ED visit rate is higher among Black adults relative to White adults. What this study adds * Among adults aged 26-64 with no insurance or Medicaid coverage, expansion was associated with no change in ED rate among Black, Hispanic, and White groups in each of the five post-expansion years. * Expansion was associated with no change in the volume of ED visits and in the proportion of ED visits that led to hospitalization. * Expansion was associated with an increase in Medicaid share among Hispanic adults but not Black adults., 1 | INTRODUCTION The complex association between the lack of health insurance and emergency department (ED) use has come under renewed attention following the Affordable Care Act (ACA)'s Medicaid expansion. [...]

Objective: Guidelines recommend emergency medical services (EMS) patients to be transported to the nearest appropriate emergency department (ED). Our objective was to estimate the prevalence of EMS transport to an ED other than the nearest ED ('potential bypassing'). Data sources: Illinois Prehospital Patient Care Report Data of EMS transports (July 2019 to December 2019). Data collection/extraction methods: We identified all EMS ground transports with an advanced life-support (ALS) paramedic to an ED for patients aged 21 years and older. Using street address of incident location, we performed geocoding and driving route analyses and obtained estimated driving distance and time to the destination ED and alternative EDs. Main outcome and measures: Our main outcomes were dichotomous indicators of potential bypassing of the nearest ED based on distance and time. As secondary outcomes we examined potential bypassing indicators based on excess driving distance and time. Study design: We used Poisson regression models to obtain adjusted relative rates of potential bypassing indicators by acuity level, primary impression, patient demographics and geographic characteristics. Principal findings: Our study cohort of 361,051 EMS transports consisted of 5.8% critical, 37.2% emergent and 57.0% low acuity cases transported to 222 EDs. The observed rate of potential bypassing was approximately 34% of cases for each acuity level. Treating the cardiovascular primary impression code group as the reference case, we found small to no differences in potential bypassing rates across other primary impression code groups of all acuity levels, with the exception of critical acuity trauma cases for which potential bypassing rate was 64% higher (incidence rate ratio = 1.64, 95% confidence interval, 1.54-1.74). Compared to zip codes with one ED within a 5-mile vicinity, potential bypassing was higher in areas with no ED or multiple EDs within a 5-mile vicinity. Conclusion: Approximately one-third of EMS transports potentially bypassed the nearest ED. EMS transport destination may be motivated by factors other than proximity. KEYWORDS ambulance, bypassing, destination, emergency department, emergency medical services, hospital, 1 | INTRODUCTION Emergency medical services (EMS) response, care and transport remains a vital conduit to acute care. Nearly 80% of EMS patients are transported to an emergency department (ED), [...]

Objective. Veterans' utilization of Veterans Affairs (VA) health care is likely influenced by community factors external to the VA, including Medicaid eligibility and unemployment, although such factors are rarely considered in models predicting such utilization. We measured the sensitivity of VA utilization to changes in such community factors (hereafter, 'external determinants'), including the 2014 Medicaid expansion following the Affordable Care Act.Data Sources/Study Setting. We merged VA health care enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices, and non-VA physician availability (2008-2014).Study Design. For veterans aged 18-64 and >65, we estimated the sensitivity of annual individual VA health care utilization, measured by the cost ($) of care received, to changes in external determinants using longitudinal regression models controlling for individual fixed effects.Principal Findings. All external determinants were associated with small but significant changes in VA health care utilization. In states that expanded Medicaid in 2014, this expansion was associated with 9.1 percent ($826 million) reduction in VA utilization among those aged 18-64; sizable changes occurred in all services used (inpatient, outpatient, and prescription drugs).Conclusions. Changes in alternative insurance coverage and other external determinants may affect VA health care spending. Policy makers should consider these factors in allocating VA resources to meet local demand.Key Words. Veterans, health care utilization, economic conditions, unemployment, Medicaid, insurance coverage, The Department of Veterans Affairs (VA) must 'anticipate and proactively prepare for the needs' (Department of Veterans Affairs 2010) of veterans to provide timely and adequate health care services for [...]

Objective. To examine whether Massachusetts (MA) health reform affected substance (alcohol or drug) use disorder (SUD)-related hospitalizations in acute care hospitals. Data/Study Setting. 2004-2010 MA inpatient discharge data. Design. Difference-indifferences analysis to identify pre- to postreform changes in age- and sex-standardized population-based rates of SUD-related medical and surgical hospitalizations, adjusting for secular trends. Data Extraction Methods. We identified 373,751 discharges where a SUD related diagnosis was a primary or secondary discharge diagnosis. Findings. Adjusted for age and sex, the rates of drug use-related and alcohol use-related hospitalizations prereform were 7.21 and 8.87 (per 1,000 population), respectively, in high-uninsurance counties, and 8.58 and 9.63, respectively, in low-uninsurance counties. Both SUD related rates increased after health reform in high- and low-uninsurance counties. Adjusting for secular trends in the high- and low-uninsurance counties, health reform was associated with no change in drug- or alcohol-related hospitalizations. Conclusions. Massachusetts health reform was not associated with any changes in substance use disorder-related hospitalizations. Further research is needed to determine how to reduce substance use disorder-related hospitalizations, beyond expanding insurance coverage. Key Words. Health reform, substance use, Substance (alcohol or drug) use disorders are a major public health problem in the United States, causing significant morbidity and mortality. Alcohol use disorders contribute to 88,000 deaths annually in [...]

Objective. To obtain near-national rates of potentially preventable hospitalization (PPH)--a marker of barriers to outpatient care access--for Hispanics; to examine their differences from other race-ethnic groups and by Hispanic national origin; and to identify key mediating factors. Data Sources/Study Setting. Data from all-payer inpatient discharge databases for 15 states accounting for 85 percent of Hispanics nationally. Study Design. Combining counts of inpatient discharges with census population for adults aged 18 and older, we estimated age-sex-adjusted PPH rates. We examined county-level variation in race-ethnic disparities in these rates to identify the mediating role of area-level indicators of chronic condition prevalence, socioeconomic status (SES), health care access, acculturation, and provider availability. Principal Findings. Age-sex-adjusted PPH rates were 13 percent higher among Hispanics (1,375 per 100,000 adults) and 111 percent higher among blacks (2,578) compared to whites (1,221). Among Hispanics, these rates were relatively higher in areas with predominantly Puerto Rican and Cuban Americans than in areas with Hispanics of other nationalities. Small area variation in chronic condition prevalence and SES fully accounted for the higher rates among Hispanics, but only partially among blacks. Conclusions. Hispanics and blacks face higher barriers to outpatient care access; the higher barriers among Hispanics (but not blacks) seem mediated by SES, lack of insurance, cost barriers, and limited provider availability. Key Words. Hispanics, disparities, potentially preventable hospitalizations, ambulatory care sensitive condition admissions, In 2001, Hispanics became the largest minority in the United States (Clementson 2003); however, there is as yet little national evidence for Hispanics using health care utilization data. National surveys [...]

Objective. Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety-net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if [...]