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Study Shows Persistent Socioeconomic, Racial, and Ethnic Segregation in US Safety-Net Hospitals

Medicaid expansion did not lead to changes in the hospitals where patients with lower incomes received care and did not decrease racial and ethnic segregation

July 01, 2021

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BOSTON - 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 (BMC) 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 White patients in states that expanded Medicaid.

“While we thought that the expansion of Medicaid might lead some racial/ethnic minority patients to transfer their care to non-safety-net hospitals, where specialty care services can often be more accessible, our study results demonstrate that was not the case,” said Karen Lasser, MD, MPH, an internal medicine physician at BMC who is the study’s lead author.

Discharge data from 11 states that expanded Medicaid (NY, PA, NJ, KY, IL, IA, AR. CO, AZ, CA and OR) and six that did not expand Medicaid (TX, WI, FL, GA, NC and VA) between 2017 and 2021 were included in this study. This large data set included nearly 83 percent of the Hispanic population in the United States. 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– 59.4 percent of the discharges were in states with expanded Medicaid and 40.6 percent 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 percent and 39.2 percent, respectively) compared to white patients (22.6 percent), 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.

“Our study results could indicate that some patients with Medicaid are satisfied with their care and benefit from the services, such as case management and medical interpretation, available at many safety-net hospitals,” added Lasser, professor of medicine and public health at Boston University Schools of Medicine and Public Health. “However, we need to improve our understanding of what drives these patients to make decisions about where they receive care, and just as important, address the underlying structural racism that may play a role in these decisions.”

This study has been supported through a grant from the National Institutes of Health (R01MD011594, A. Hanchate, PI).

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About Boston Medical Center
Boston Medical Center (BMC) is a private, not-for-profit, 514-bed, academic medical center that is the primary teaching affiliate of Boston University School of Medicine. It is the largest and busiest provider of trauma and emergency services in New England. BMC offers specialized care for complex health problems and is a leading research institution, receiving more than $166 million in sponsored research funding in fiscal year 2019. It is the 13th largest funding recipient in the U.S. from the National Institutes of Health among independent hospitals. In 1997, BMC founded Boston Medical Center Health Plan, Inc., now one of the top ranked Medicaid MCOs in the country, as a non-profit managed care organization. Boston Medical Center and Boston University School of Medicine are partners in Boston HealthNet – 12 community health centers focused on providing exceptional health care to residents of Boston. For more information, please visit bmc.org.