Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis

Yasmin A. Zerhouni, John W. Scott, Christina Ta, Paul Chiu Hsieh Hsu, Marie Crandall, Stephen C. Gale, Andrew J. Schoenfeld, Anthony J. Bottiggi, Edward E. Cornwell, Alexander Eastman, Jennifer Knight Davis, Bellal Joseph, Bryce R.H. Robinson, Shahid Shafi, Cassandra Q. White, Brian H. Williams, Elliott R. Haut, Adil H. Haider

Research output: Contribution to journalReview articlepeer-review

18 Citations (Scopus)


Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed.

Original languageEnglish
Pages (from-to)491-501
Number of pages11
JournalJournal of Trauma and Acute Care Surgery
Issue number2
Publication statusPublished - 1 Aug 2019
Externally publishedYes


  • Health care reform
  • emergency general surgery
  • practice management guideline
  • trauma patients
  • trauma systems


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