Repeal of the Affordable Care Act—and with it a likely elimination of Medicaid expansion—could prove particularly costly for hospitals that treat victims of gun violence, according to a new study.
The Urban Institute studied the cost of treating gun violence at hospitals in six states from 2010 to 2014.
States that expanded Medicaid saw the program pick up a larger share of the costs while most states that opted out of the expansion saw few changes to their payment mix. The average hospital cost per patient ranged from $9,000 to $18,000 among the states studied.
Early Medicaid expansion adopters such as Kentucky saw uncompensated care for gun victims fall from 54% in 2010 to 13% in 2014, with Medicaid accounting for 68% of coverage.
In Florida, the share of uncompensated hospital costs remained unchanged during the study period, increasing slightly from 31.2% in 2010 to 31.9% in 2014. Public coverage also remained flat, with Medicaid making up 40.4% of hospital costs in 2014 compared to 40.5% of costs in 2010. Had Florida expanded coverage, the state's hospitals would have received more payment.
In 2010 Wisconsin's Medicaid program through a Section 1115 waiver covered single adults earning up to 200% of the federal poverty level, but the state capped the program by not allowing new individuals to enroll. Wisconsin then used state funds to expand its program to cover all adults with incomes up to 100% of the poverty level. The result was a decrease in hospital costs that were uncompensated, from 24% in 2010 to 11% by 2014, and an increased share of costs paid by public coverage, going from 55% in 2010 to 67% by 2014.
By contrast, Arizona did not see a decline in hospital uncompensated care while the share of costs paid by Medicaid remained relatively unchanged, from 63% in 2010 to 57% by 2014. Arizona expanded Medicaid in 2014, but already had in place since 2010 coverage for all adults earning up to 100% of the poverty level through a 1115 waiver.
Study lead author Embry Howell said both Arizona and Wisconsin show what could happen if Republican leaders change Medicaid to a block grant program, as supported by President Donald Trump.
A fixed amount per person without limits on the number of people that can enroll could possibly offer coverage to more individuals than a model that puts caps in the number of people who can enroll.
When states began expanding Medicaid to all adults earning up to 138% of the poverty level, many hospitals took advantage of presumptive eligibility to connect many of their low-income, uninsured patients to the program. Many other adults who were eligible before the law but became aware of Medicaid due to the expansion signed up for the program in what has been called the “woodwork effect”.
Overall the report indicates a reduction of Medicaid would likely shift the cost burden onto victims, hospitals and private payers since hospitals might raise rates to cover higher levels of uncompensated care.
The cost to treat victims of gun violence, who are increasingly facing a better chance at survival but more costly rehabilitation, grew during the study period. The average cost among the six states increased by 1.2% between 2010 and 2014. Only Arizona and Florida saw a decrease in cost.
The analysis follows a 2013 Urban Institute report that estimated healthcare costs related to gun violence cost U.S. hospitals more than $620 million in 2010, resulting in more than 36,000 emergency department visits and more than 25,000 hospitalizations.