The impact of Medicaid expansion and travel distance on access to transplantation.

Most transplant centers require candidates be insured before they can join the waitlist for a deceased donor organ. After the Affordable Care Act, many uninsured Americans gained improved access to Medicaid. I examine the effect of this increase in access to insurance and find that Medicaid expansions significantly increase Medicaid-insured waitlist registrations by 39% and deceased donor transplants received by 44%, but the increase in registrations is larger for candidates who live closer to a transplant center. Additionally I show that most of these registrations would have been privately insured otherwise but provide suggestive evidence that this is better explained by improved access to subsidized private coverage due to other ACA reforms than from candidates with private coverage before the ACA switching to Medicaid coverage after expansion. This suggests that although the ACA improved access to the transplantation system, access is still limited for candidates who live far from centers.

Efforts by critical access hospitals to increase health equity through greater engagement with social determinants of health.

PURPOSE: Greater health care engagement with social determinants of health (SDOH) is critical to improving health equity. However, no national studies have compared programs to address patient social needs among critical access hospitals (CAHs), which are lifelines for rural communities. CAHs generally have fewer resources and receive governmental support to maintain operations. This study considers the extent to which CAHs engage in community health improvement, particularly upstream SDOH, and whether organizational or community factors predict involvement. METHODS: Using descriptive statistics and Poisson regression, we compared 3 types of programs (screening, in-house strategies, and external partnerships) to address the patient social needs between CAHs and non-CAHs, independent of key organizational, county, and state factors. FINDINGS: CAHs were less likely than non-CAHs to have programs to screen patients for social needs, address unmet social needs of patients, and enact community partnerships to address SDOH. When we stratified hospitals according to whether they endorsed an equity-focused approach as an organization, CAHs matched their non-CAH counterparts on all 3 types of programs. CONCLUSIONS: CAHs lag relative to their urban and non-CAH counterparts in their ability to address nonmedical needs of their patients and broader communities. While the Flex Program has shown success in offering technical assistance to rural hospitals, this program has mainly focused on traditional hospital services to address patients' acute health care needs. Our findings suggest that organizational and policy efforts surrounding health equity could bring CAHs in line with other hospitals in terms of their ability to support rural population health.