Did the Affordable Care Act Increase Medicaid Coverage for Isolated Facial Trauma? A National Cohort Study

Patients with facial fractures are disproportionately uninsured or underinsured, creating a substantial economic burden for trauma systems. Although the Affordable Care Act (ACA) significantly expanded Medicaid eligibility, its effect on insurance coverage among adults with facial trauma remains poorly defined.

The purpose of the study was to evaluate the association between ACA implementation and Medicaid coverage among adults presenting with isolated facial fractures.

This was a retrospective cohort study using the American College of Surgeons National Trauma Data Bank from 2008 to 2019. Adults with isolated facial fractures were included. Patients with polytrauma or missing data were excluded.

The primary predictor was time period relative to ACA implementation, defined as pre-ACA (2008 to 2013) or post-ACA (2014 to 2019).

The primary outcome was insurance payor at the time of encounter (Medicaid vs non-Medicaid).

Covariates included demographic (age, sex), clinical (Charlson comorbidity index), injury-related (injury severity score, fracture location), and hospital characteristics (teaching status, bed size).

Descriptive, bivariate, and multivariable logistic regression statistics were performed to evaluate the association between ACA implementation and Medicaid coverage. A threshold of P < .001 was considered significant for all analyses.

A total of 187,803 subjects were included of which 47,315 (25%) were treated pre-ACA and 140,488 (75%) were treated post-ACA. The cohort had a mean age of 44.8 ± 20.2 years, was 73% male (n = 137,408), and 64% White (n = 119,674). Medicaid coverage increased from 16% pre-ACA to 24% post-ACA, with a corresponding decrease in self-pay from 30 to 20% (P < .001). After adjustment for demographic, clinical, injury-related, and hospital covariates, post-ACA treatment was associated with significantly higher odds of Medicaid coverage (odds ratio [OR]: 1.93, 95% CI: 1.88 to 1.99, P < .001). The relative increase in Medicaid coverage was greater at non-level 1 centers (OR: 1.93, 95% CI: 1.82 to 2.04, P < .001) compared to level 1 centers (OR: 1.34, 95% CI: 1.29 to 1.40, P < .001).

ACA implementation was associated with increased Medicaid coverage and reduced uninsured status. Medicaid expansion improved access to care; similar efforts may enhance the sustainability of facial trauma services within modern trauma systems.