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adult provision led to an increase of 2.5 percent- ever, childbirth tends to be the most costly part
age points (95% confidence interval [CI], 1.6 to of pregnancy and payment sources for childbirth
3.4) in private-insurance reimbursement a probably are similar to payment sources for con-
9.9% relative increase from baseline. Medicaid current care.
payments decreased by 2.1 percentage points Yaa AkosaAntwi, Ph.D.
(95% CI, 3.0 to 1.3), and self-payments decreased Indiana UniversityPurdue University Indianapolis
by 0.3 percentage points (95% CI, 0.5 to 0.2). Indianapolis, IN
Most of the changes involved payments for yakosaan@iupui.edu
Mean
Difference-
Average Average Average Mean Average Average Average Mean in-
Volume, Volume, Absolute State Volume, Volume, Absolute State Differences
2013 2014 Difference P Value Change 2013 2014 Difference P Value Change Result P Value
percent percent
Inpatient
admissions
Total 74.8 74.2 0.60 0.23 0.1 71.7 71.6 0.04 0.96 0.0 0.6 0.59
Commercial 44.1 43.0 1.1 0.04 2.5 40.8 41.1 0.3 0.50 1.0 1.5 0.04
insurance
Medicaid 24.4 27.5 3.2 0.004 14.8 21.6 21.8 0.2 0.71 2.1 3.0 0.005
No insurance 6.3 3.7 2.7 0.008 33.2 9.4 8.8 0.6 0.4 7.1 2.1 0.06
Emergency depart-
ment visits**
Total 286.6 293.9 7.0 0.03 2.8 324.7 332.7 8.1 0.14 2.6 1.0 0.87
Correspondence
Commercial 133.0 134.0 1.0 0.61 0.7 134.9 142.3 7.4 0.03 6.0 6.5 0.10
insurance
Medicaid 91.6 119.8 28.2 0.009 40.4 101.5 108.7 7.2 0.02 9.0 21.0 0.01
Downloaded from nejm.org on February 10, 2017. For personal use only. No other uses without permission.
197
correspondence
payer (excluding Medicare) and Medicaid expan- 2. Centers for Medicare and Medicaid Services. Medicaid &
CHIP: March 2015 Monthly Applications, Eligibility Determi-
sion status. Two-sided hypothesis tests were nations and Enrollment Report (http://www .medicaid .gov/
used to measure differences according to payer, medicaid-chip-program-information/program-information/
and difference-in-differences tests were used to downloads/2015-march-enrollment-report.pdf).
3. The Health System haves and have-nots of ACA expansion,
measure differences according to expansion sta- Price Waterhouse Cooper. September 2014 (http://www .pwc
tus. In expansion states, there were significant .com/us/en/health-industries/health-research-institute/assets/
decreases in admissions covered by commercial pwc-hri-medicaid-report-final.pdf).
4. Weaver C. Hospitals expected more of a boost from health
insurance and not covered by insurance (self- law (http://www.wsj.com/articles/hospitals-expected-more-of-a
payment) and significant increases in Medicaid -boost-from-health-law-1433304242).
admissions. The difference-in-differences results 5. Robert Wood Johnson Foundation. RWJF project tracks im-
pact of reform on hospital utilization (http://www.rwjf.org/en/
showed significant changes for admissions cov- about-rwjf/newsroom/newsroom-content/2014/06/r wjf-project
ered by Medicaid and commercial insurance. In -tracks-impact-of-reform-on-hospital-utilization.htm).
both groups of states, Medicaid-covered emer- DOI: 10.1056/NEJMc1507366
Correspondence Copyright 2016 Massachusetts Medical Society.
gency department visits increased and visits by
self-paying patients decreased significantly, and
instructions for letters to the editor
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