ABSTRACT
The COVID-19 pandemic and racial justice movements have laid bare the structural problems in our
healthcare system. Lack of health insurance directly impacts health care access and outcomes. Uninsured
patients have catastrophic expenditures, higher rates of mortality, and more limited access to post-discharge
resources that are critical for returning to work. These negative impacts are exacerbated among racial and
ethnic minorities. We have an unprecedented and timely opportunity to study the uninsured in our nation. At
the end of 2018, nearly 14% of the US population were uninsured, a number that has further increased with
spikes in unemployment related to COVID-19. There is an urgent need to reduce insurance disparities.
A potential solution, Hospital Presumptive Eligibility (HPE), enables hospitals to apply for emergency insurance
for uninsured patients. HPE provides temporary Medicaid coverage (up to 60 days), but subsequently enables
patients to enroll in Medicaid in order to continue coverage. In light of COVID-19, several states are
broadening their HPE eligibility criteria. Little is currently known about factors influencing HPE acquisition, as
well as Medicaid enrollment post-HPE and its association with access to care. In our preliminary work, minority
patients, those with greater clinical severity, and patients requiring post-discharge services (including
rehabilitation, long-term care) were all more likely to be approved for HPE. Among approximately 1000 HPE
approved patients in 2018 at our institution, only 53% of those enrolled in Medicaid. We hypothesize that there
are modifiable patient- and system-level barriers inhibiting Medicaid enrollment after HPE. As administrative
and clinical registry data capture neither HPE approval nor Medicaid enrollment, we will analyze novel
customized insurance datasets through the California Department of Health Care Services (DHCS) to evaluate
HPE programs and identify improvement opportunities.
The proposed work will be accomplished through 2 specific aims: (SA1) Among eligible HPE-approved
patients, we will determine the sociodemographic, clinical and hospital factors associated with post-HPE
Medicaid enrollment, and (SA2) to understand patients' experiences of process factors that contributed to or
impeded enrollment in Medicaid following HPE approval.
The time of hospitalization can be leveraged to acquire sustainable insurance coverage that improves patients'
long-term health outcomes and reduces their risk of catastrophic health expenditures. Our study evaluates how
HPE programs can best be targeted toward improving health outcomes and access to care, particularly among
vulnerable minority patients.
