Affordable Care Act Expansion and the Trauma Care Paradox: Increased Mortality Amid Improved Insurance Coverage

BACKGROUND: The association between insurance status and survival among critically injured patients has been shown to be profound, yet the impact of the Affordable Care Act (ACA) on trauma outcomes remains unclear. We evaluated the association between ACA implementation and changes in insurance status, discharge disposition, and in-hospital mortality among trauma patients. STUDY DESIGN: We conducted a retrospective analysis of adult trauma patients admitted to Level I and II trauma centers in the National Trauma Data Bank. The pre-ACA period was defined as 2007 to 2013, with 2014 as a washout year and 2015 to 2019 as the post-ACA period. Bivariate and multivariable analyses compared insurance status, in-hospital mortality, and discharge disposition. RESULTS: Among 3,171,236 patients, uninsured rates declined (28.9% to 20.1%, p < 0.001) and Medicaid coverage increased (15.4% to 25.4%, p < 0.001) post-ACA. Odds of discharge to postacute care (odds ratio [OR] 1.16; 95% CI 1.15 to 1.17) and home with services were also increased (OR 1.47; 95% CI 1.45 to 1.49; p < 0.001). Although unadjusted mortality decreased slightly (2.7% to 2.6%, p < 0.001), adjusted mortality was higher post-ACA (OR 1.13; 95% CI 1.11 to 1.15, p < 0.001). Patients treated at Level II centers (34.0% to 38.2%, p < 0.001) and nonteaching centers (9.6% to 12.0%, p < 0.001) increased, but transfers to Level I centers (24.5% to 23.9%, p < 0.001) decreased post-ACA. Insurance status was independently associated with higher odds of mortality post-ACA (Medicaid: OR 1.12; 95% CI 1.09 to 1.16; uninsured: OR 2.17; 95% CI 2.10 to 2.24 compared with private insurance). CONCLUSIONS: Despite improved insurance coverage, mortality increased post-ACA. Our findings suggest evolving trauma care patterns in the post-ACA era, including greater reliance on Level II centers and fewer transfers, underscoring the importance of developing a national trauma system under changing policy conditions.