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US hospitals that care for vulnerable populations, "safety-net hospitals" (SNHs), are more likely to incur penalties under the Hospital Readmissions Reduction Program, which penalizes hospitals with higher-than-expected readmissions. Understanding whether SNHs face unique barriers to reducing readmissions or whether they underuse readmission-prevention strategies is important.We surveyed leadership at 1600 US acute care hospitals, of whom 980 participated, between June 2013 and January 2014. Responses on 28 questions on readmission-related barriers and strategies were compared between SNHs and non-SNHs, adjusting for nonresponse and sampling strategy. We further compared responses between high-performing SNHs and low-performing SNHs.We achieved a 62% response rate. SNHs were more likely to report patient-related barriers, including lack of transportation, homelessness, and language barriers compared with non-SNHs (P-values0.001). Despite reporting more barriers, SNHs were less likely to use e-tools to share discharge summaries (70.1% vs. 73.7%, P0.04) or verbally communicate (31.5% vs. 39.8%, P0.001) with outpatient providers, track readmissions by race/ethnicity (23.9% vs. 28.6%, P0.001), or enroll patients in postdischarge programs (13.3% vs. 17.2%, P0.001). SNHs were also less likely to use discharge coordinators, pharmacists, and postdischarge programs. When we examined the use of strategies within SNHs, we found trends to suggest that high-performing SNHs were more likely to use several readmission strategies.Despite reporting more barriers to reducing readmissions, SNHs were less likely to use readmission-reduction strategies. This combination of higher barriers and lower use of strategies may explain why SNHs have higher rates of readmissions and penalties under the Hospital Readmissions Reduction Program.

BACKGROUND: One of the potential benefits of insurance reform is greater stability of insurance and reduced coverage disparities by race and ethnicity. OBJECTIVES: We examined the temporal trends in insurance coverage by racial/ethnic group before and after Massachusetts Insurance Reform by abstracting records across two urban safety net hospital systems. RESEARCH DESIGN: We examined adjusted odds of being uninsured and incident rate ratios of gaining and losing insurance over time by race and ethnicity. We used billing records to capture the payer for each episode of care. SUBJECTS: We included data from January 2005 through December 2013 on patients with hypertension between the ages of 21 and 64 years. We compared four racial and ethnic groups: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian and Hispanic. MEASURES: We examined individual patients’ insurance coverage status in 6 month intervals. We compared odds of being uninsured in the transition and post insurance reform period to the pre reform period, adjusting for age, sex, comorbidities practice location and education and income by Census tract. RESULTS: Among 48,291 patients with hypertension, reduction in rates of uninsurance with insurance reform was greater for Hispanic (29.7%), non-Hispanic Black (24.8%) and non-Hispanic Asian (26.8%) than non-Hispanic White (14.9%) patients. The odds of becoming uninsured were reduced in all racial and ethnic groups (OR 0.27–0.41). CONCLUSIONS: Massachusetts Insurance Reform resulted in stable insurance coverage and a reduction in disparities in insurance instability by race and ethnicity.

Medicaid expansions aim to improve access to primary care, which could reduce nonemergent (NE) use of the emergency department (ED). In contrast, Medicaid enrollees use the ED more than other groups, including the uninsured. Thus, the expected impact of Medicaid expansion on ED use is unclear.To estimate changes in total and NE ED visits as a result of California's early Medicaid expansion under the Affordable Care Act. In addition to overall changes in the number of visits, changes by payer and safety net hospital status are examined.We used a quasi-experimental approach to examine changes in ED utilization, comparing California expansion counties to comparison counties from California and 2 other states in the same region that did not implement Medicaid expansion during the study period.Regression estimates show no significant change in total number of ED visits following expansion. Medicaid visits increased by 145 visits per hospital-quarter in the first year following expansion and 242 visits subsequent to the first year, whereas visits among uninsured patients decreased by 129 visits per hospital-quarter in the first year and 175 visits in subsequent years, driven by changes at safety net hospitals. We also observe an increase in NE visits per hospital-quarter paid for by Medicaid, and a significant decrease in uninsured NE visits.Medicaid expansions in California were associated with increases in ED visits paid for by Medicaid and declines in uninsured visits. Expansion was also associated with changes in NE visits among Medicaid enrollees and the uninsured.