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Research Letter |

Hospitalizations of Low-Income Children and Children With Severe Health Conditions Implications of the Patient Protection and Affordable Care Act

Jeffrey D. Colvin, MD, JD1; Matt Hall, PhD2; Laura Gottlieb, MD, MPH3; Jessica L. Bettenhausen, MD1; Samir S. Shah, MD, MSCE4; Jay G. Berry, MD, MPH5; Paul J. Chung, MD, MS6,7
[+] Author Affiliations
1Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri–Kansas City School of Medicine
2Children’s Hospital Association, Overland Park, Kansas
3Department of Family and Community Medicine, University of California–San Francisco
4Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
5Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
6Department of Pediatrics, University of California–Los Angeles
7Department of Health Policy & Management, University of California–Los Angeles
JAMA Pediatr. 2016;170(2):176-178. doi:10.1001/jamapediatrics.2015.3366.
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Specific provisions of the Patient Protection and Affordable Care Act may pose a disproportionate risk to children’s hospitals because they carry the greatest burden of care costs of any type of hospital.

Medicaid reimbursement often falls below health care costs (Medicaid shortfall). Therefore, hospitals face financial losses from caring for both uninsured and Medicaid-insured patients. The US government provides disproportionate share hospital (DSH) payments to institutions with large uninsured and Medicaid populations. Anticipating decreased numbers of uninsured patients, the Patient Protection and Affordable Care Act (ACA) reduces DSH payments.1 The ACA also penalizes hospitals for readmissions.2 There will not be large decreases in the number of uninsured children since only a small percentage of children are uninsured. In contrast, a high percentage of children have Medicaid insurance, and institutions will continue to face Medicaid shortfalls. The loss of DSH payments may not be matched by reductions in financial losses from decreases in the number of uninsured patients. In addition, the readmission penalties of the ACA may not adequately adjust for low-income patients or patients with severe health conditions, thereby adversely affecting hospitals with high proportions of these patients.3 We sought to determine which hospitals with pediatric patients may be at highest financial risk from decreases in DSH payments and readmission penalties by identifying hospitals with a disproportionate per-hospital number of discharges of pediatric patients receiving Medicaid and those with a disproportionate per-hospital number of discharges of low-income patients or those who have severe health conditions, respectively.

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