Catastrophic expenditures in California trauma patients after the Affordable Care Act: reduced financial risk and racial disparities

Abstract

Background: Hospital charges due to major injury can result in high out-of-pocket expenses for patients. We analyzed the effect of the Affordable Care Act (ACA) on catastrophic health expenditures (CHE) among trauma patients.

Methods: We identified trauma patients aged 19-64 admitted to a safety-net Level 1 trauma center in California from 2007 to 2017. Out-of-pocket expenditures and income were calculated using hospital charges, insurance status, and ZIP code. CHE was defined using the World Health Organization definition of out-of-pocket spending exceeding 40% of inflation-adjusted income minus food and housing expenditures. Multivariable logistic regression was performed to assess odds of CHE post-ACA (2014-2017) vs. pre-ACA (2007-2013).

Results: Of 7519 trauma patients, 20.6% experienced CHE, including 89.0% of uninsured patients. There was a 74% decrease in odds of CHE post-ACA (aOR: 0.26, 95% CI: 0.22-0.30), with greater decreases among Black (aOR: 0.09, 95% CI: 0.04-0.18) and Hispanic (aOR: 0.23, 95% CI: 0.19-0.29) patients.

Conclusions: ACA implementation was associated with markedly decreased odds of catastrophic expenditures and decreased racial disparities in financial protection among trauma patients in our study.

Keywords: Affordable Care Act; Catastrophic expenditures; Disparities; Health insurance; Medicaid; Out-of-pocket costs; Trauma.