Association of Medicaid Expansion Policy with Outcomes in Homeless Patients Requiring Emergency General Surgery

  • Ramiro Manzano-NunezEmail author
  • Cheryl K. Zogg
  • Nizar Bhulani
  • Justin C. McCarty
  • Juan P. Herrera-Escobar
  • Kaye Lu
  • Tomas Andriotti
  • Tarsicio Uribe-Leitz
  • Elzerie de Jager
  • Molly P. Jarman
  • Adil H. Haider
  • Gezzer Ortega
Original Scientific Report



Medicaid expansion has reduced obstacles faced in receiving care. Emergency general surgery (EGS) is a clinical event where delays in appropriate care impact outcomes. Therefore, we assessed the association between non-Medicaid expansion policy and multiple outcomes in homeless patients requiring EGS.


We used 2014 State Inpatient Database to identify homeless individuals admitted with a primary EGS diagnosis who underwent an EGS procedure. States were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression was used to examine associations between non-Medicaid expansion states and (1) length of stay and (2) total index hospital charges within the homeless population. Multivariable logistic regression was used to assess the associations between non-Medicaid expansion and (1) mortality, (2) surgical complications, (3) discharge against medical advice, and (4) home healthcare.


A total of 6930 homeless patients were identified. Of these, 435 (6.2%) were in non-expansion states. Non-Medicaid expansion was associated with higher charges (coef: $46,264, 95% CI 40,388–52,139). There were non-significant differences in mortality (OR 1.4, 95% CI 0.79–2.62; p = 0.2) or surgical complications (OR 1.16, 95% CI 0.7–1.8; p = 0.4). However, homeless individuals living in non-expansion states did have higher odds of being discharged against medical advice (OR 2.1, 95% CI 1.08–4.05; p = 0.02), and lower odds of receiving home healthcare (OR 0.6, 95% CI 0.4–0.8; p = 0.01).


Homeless patients living in Medicaid expansion states had lower odds of being discharged against medical advice, higher likelihood of receiving home healthcare and overall lower total index hospital charges.



This paper was written at the Center for Surgery and Public Health (CSPH) at Brigham and Women’s Hospital. RMN would like to thank the CSPH members for sharing their knowledge and expertise.

Compliance with ethical standards

Informed consent

Because this was a retrospective study that used de-identified data from the SID database it was deemed exempt from full review by the institutional review board of Partners Healthcare.


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Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Ramiro Manzano-Nunez
    • 1
    • 2
    Email author
  • Cheryl K. Zogg
    • 1
    • 3
  • Nizar Bhulani
    • 1
  • Justin C. McCarty
    • 1
  • Juan P. Herrera-Escobar
    • 1
  • Kaye Lu
    • 4
  • Tomas Andriotti
    • 1
  • Tarsicio Uribe-Leitz
    • 1
  • Elzerie de Jager
    • 1
  • Molly P. Jarman
    • 1
  • Adil H. Haider
    • 1
  • Gezzer Ortega
    • 1
  1. 1.Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical SchoolHarvard T.H. Chan School of Public HealthBostonUSA
  2. 2.Department of Surgery, Clinical Research CenterFundacion Valle del LiliCaliColombia
  3. 3.Yale University School of MedicineNew HavenUSA
  4. 4.Tufts University School of MedicineBostonUSA

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