摘要：Objectives. We determined how preinjury insurance status and injury-related outcomes among able-bodied, community-dwelling adults treated at a Level I Trauma Center in central Massachusetts changed after health care reform. Methods. We compared insurance status at time of injury among non-Medicare-eligible adult Massachusetts residents before (2004–2005) and after (2009–2010) health care reform, adjusted for demographic and injury covariates, and modeled associations between insurance status and trauma outcomes. Results. Among 2148 patients before health care reform and 2477 patients after health care reform, insurance rates increased from 77% to 84% ( P < .001). Younger patients, men, minorities, and penetrating trauma victims were less likely to be insured irrespective of time period. Uninsured patients were more likely to be discharged home without services (adjusted odds ratio = 3.46; 95% confidence interval = 2.65, 4.52) compared with insured patients. Conclusions. Preinjury insurance rates increased for trauma patients after health care reform but remained lower than in the general population. Certain Americans may be in “double jeopardy” of both higher injury incidence and worse outcomes because socioeconomic factors placing them at risk for injury also present barriers to compliance with an individual insurance mandate. The burden of uncompensated care on the health care system and risk of personal financial ruin of uninsured individuals who experience a health shock (unexpected serious illness or accident) 1 are among the leading arguments in favor of an individual mandate in the 2010 federal health care reform legislation. Modeled after the Massachusetts health care reform implemented in 2006, 2,3 comprehensive federal health care reform is presumed to result in the greatest gains of health insurance among able-bodied adults aged 18 to 64 years mandated to enroll in subsidized or unsubsidized insurance plans. Although opponents of an individual mandate may argue that otherwise healthy adults with minimal health care needs should not be required to purchase health insurance, 4 no individual, irrespective of age or baseline health status, is immune to risk of injury. Trauma represents a significant health shock experienced by able-bodied, community-dwelling adults aged 18 to 64 years and is a leading cause of death and disability in this demographic group. 5,6 Another federal mandate enacted by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide emergency care to individuals experiencing a health shock, regardless of whether they are insured. 7 Not surprisingly, emergency department (ED) resource use in response to health shocks has been shown to be independent of insurance status. 8 In Massachusetts, implementation of health care reform did not affect trends in ED use. 9 Patient care in the face of a health shock, however, rarely stops in the ED. When injured patients without insurance arrive at a trauma center, they are not only stabilized, as mandated by EMTALA, but also provided comprehensive trauma care as required of verified trauma centers in our proven national and state-level trauma systems. 10,11 Even after stabilization, injured patients often cannot be released because they are critically ill or require treatments (e.g., intravenous antibiotics, chest tube monitoring) that for practical reasons or out-of-pocket costs cannot be rendered outside of the hospital. These uninsured patients are often provided ongoing free care at the presenting hospital or transferred once stabilized to safety-net hospitals that typically do not refuse patients on the basis of insurance. 12 Depending on governance structure (publicly managed, publicly funded, or private nonprofit), 5% to 16% of patients at safety-net hospitals are provided free care. 13 Data from the 2004 Medical Expenditure Panel Survey suggested that only 35% (95% confidence interval [CI] = 26%, 45%) of charges to uninsured patients for non–life-threatening emergency services were recouped by hospitals. 14 In the case of injuries too severe to be treated and released, the burden of the cost of care is therefore assumed one way or another by the health care system, raising costs for everyone. Furthermore, uninsured patients often incur greater costs of care compared with their insured counterparts, as they must remain hospitalized until they can be safely discharged home because no similar laws mandate uncompensated home health services, skilled nursing, or rehabilitation often required by medically stable injured patients. 15–17 Proponents of an individual mandate might presume that improved rates of insurance in the general population would result in fewer uninsured injured patients treated at trauma centers, but the effect of an individual mandate on insurance coverage among injured patients is unknown. Therefore, the effects of health care reform on the burden of uncompensated trauma care in Massachusetts may have important national implications on the potential effect of national health care reform on our nation’s trauma system. We undertook this study to determine how an individual mandate affected insurance status among injured Massachusetts residents. We hypothesized that we would have treated fewer uninsured patients after implementation of Massachusetts health care reform. Presumably, the individual mandate would have resulted in rates of insurance among our patients as observed statewide.
