States that have expanded Medicaid under the Affordable Care Act reported fewer hospitalizations for uninsured acute ischemic stroke patients than states that did not expand Medicaid.

  • In non-expansion states, many low-income patients are uninsured and are at risk of adverse outcomes from a stroke.
  • Hospitals in both Medicaid-expansion and non-expansion states can help uninsured and underinsured stroke patients by creating a therapy gym in the acute care setting.
  • Another tactic is to create an equipment gym from which patients can take home equipment for stroke therapy.

New research involving acute ischemic stroke shows that Medicaid expansion is associated with fewer hospitalizations among the uninsured and more rehabilitation at skilled nursing facilities (SNFs).1

“About a dozen states have declined to expand Medicaid under the Affordable Care Act (ACA), and the vast majority of these states are in the stroke belt — a region of increased mortality from stroke, primarily in the Southeastern United States,” says Blake McGee, PhD, RN, assistant professor at Georgia State University’s Lewis College of Nursing and Health Professions. “You have an overlap of a region where low-income patients remain uninsured and are also at risk of adverse outcomes from a stroke. We were interested in what these Medicaid expansion decisions at the state level had for ischemic stroke patients.”

From a case management perspective, discharges and transitions are simpler in Medicaid expansion states because insured patients will have more post-acute care options. But regardless of the state or expansion status, some of the same principles apply, says Karen Seagraves, PhD, MPH, APRN, enterprise vice president of the Neurosciences Institute for Atrium Health in Charlotte, NC.

Stroke patients might not have access to a SNF if they lack Medicaid or other insurance funding. But it is possible for hospitals and case managers to help them with functional recovery while they are in the acute care setting. “People who have more intensive therapy for stroke have better long-term outcomes,” Seagraves notes.

People can regain functional recovery when they are provided the resources and therapy. Seagraves suggests several ways to help stroke patients with no insurance or too few financial resources to obtain the therapy they need:

Create a therapy gym in acute care. Seagraves worked for more than eight years at a public safety net hospital in the Southeast with a large homeless population. The hospital opened a science center to treat people with ischemic strokes.

“Once you have these patients, they don’t have funding and it’s impossible to place them,” Seagraves says. “They can languish in bed, waiting, because they are not safe for us to discharge.”

One potential solution is to bring acute inpatient rehabilitation to them. “We took a patient room offline and fully equipped it as a physical therapy gym,” Seagraves says.

The traditional hospital physical therapy (PT) is limited to people walking up and down a hall and spending 10 minutes or so with a physical therapist, she notes. With the hospital’s new PT gym, patients could use a variety of equipment, including parallel bars and a bathroom to practice transfers to the commode and in and out of the shower.

“It was a real-life experience, and this was rehab in the acute setting,” Seagraves says. “We did this to help people improve enough to go home and to educate them and their family members on how to continue to rehabilitate them at home. The longer you work with them after the acute inpatient setting, the better they do.”

Create an equipment library. Another tactic employed by Atrium Health is to create an environment in which stroke patients can obtain equipment to use at home.

“You can have a library of equipment where people donate all kinds of equipment,” Seagraves says. “This can be normal equipment like walkers, wheelchairs, and hospital beds. This is equipment that [uninsured] patients could not afford.”

Patients can take the equipment home, use it as long as needed, and either keep it or return it if they like.

“Several organizations have a program where families can turn in equipment when it’s no longer needed,” Seagraves says.

This service can be offered in conjunction with programs that provide medication to underfunded patients. “We work closely with social services, case managers, nurses on the unit, and families,” Seagraves says. “These might be patients who are not homeless, but who don’t have any resources financially to manage even the equipment they need to be successful at home.”

Case managers and others teach families how to use the provided resources to help patients through the recovery trajectory. “We work with them to collect all the resources they’ll need in a post-acute setting,” Seagraves explains. “It’s a commitment on the hospital’s part to work closely with these patients.”

Negotiate with rehab settings. A large health system that refers many insured patients to an acute inpatient rehabilitation facility might negotiate for the facility to accept some uninsured patients as well.

“When you are negotiating contracts, you can make arrangements for a certain number of patients who are unfunded or underfunded to have access to that rehab,” Seagraves says.

Hospitals need to transition stroke patients to safe settings for necessary rehabilitation and care. When patients lack insurance coverage, they might have to stay in the hospital long-term because there is not a safe environment for discharge. This is disadvantageous to both the hospital and the patients.

“It uses a lot of hospital resources. Being in a hospital is not a good thing for long periods of time because patients are more vulnerable [to infections, etc.],” Seagraves says.

The study’s findings present a mixed picture of how Medicaid expansion affected acute stroke care nationwide.

“We were not surprised to find that the number of stroke hospitalizations covered by Medicaid increased 5.3%,” McGee says. “There was a net decline of 3.5% in uninsured stroke hospitalizations in states that expanded Medicaid vs. states that did not.”

Under the ACA, declines in uninsured hospitalizations occurred across the board, but the decline was wider in Medicaid expansion states. Medicaid expansion reduced the risk of financial hardship for many low income patients.

“In terms of outcomes for [stroke] patients, we found that after even adjusting for differences in hospital characteristics, Medicaid expansion was associated with 33% increased odds of discharge to a skilled nursing facility,” McGee says. “It also was associated with decreased probability of being sent straight home from the hospital.”

Investigators did not find an association with the odds of discharge to an inpatient rehabilitation facility. “That might have implications for what resources are available for patients after stroke in the community,” McGee says. “Medicaid coverage for inpatient rehab vs. SNF care is variable.”

Also, the concentration and quantity of inpatient rehab beds in a community varies by region. Inpatient rehab facilities often require upfront discharge plans before a patient can be transferred. This barrier could affect both Medicaid and uninsured stroke patients.

“Many Medicaid members might lack the resources or caregiving support to have that in place when they’re discharged from the hospital. [This] is one reason why we might have seen an uptick in transfers to skilled nursing facilities, but not to inpatient rehab facilities,” McGee explains.

In the stroke study, investigators looked at a national database in which more than 2,000 hospitals participate. They compared states with expanded Medicaid before 2018 with those that had not expanded Medicaid at all by that time.

“What we had to do is exclude a handful of states that had expanded health insurance coverage to low-income adults on a large scale prior to the ACA’s Medicaid expansion,” he adds. “The states not included were New York, Vermont, Massachusetts, Delaware, Wisconsin, and the District of Columbia.”

Few states in the Southeast expanded Medicaid. Only Louisiana and Kentucky had accepted Medicaid expansion. Arkansas used a hybrid model that covered the same population.

“The vast majority of patients in our non-expansion sample were in the Southeast, and the majority in the expansion sample were outside the Southeast,” he says. “We adjusted for demographic and clinical differences between those populations as well as differences in hospital characteristics.”

The study’s findings make a strong business case for Medicaid expansion, McGee says. “I think the politics of it make it complicated because of the connection or association people have between Medicaid expansion and Obamacare,” he says.

Some states are considering adopting a hybrid model similar to that in Arkansas to expand coverage to low-income, working-age adults. They sometimes are more interested in exploring private-public hybrid models that can achieve some of the same goals, McGee says.

“It may be more politically palatable in holdout states,” he adds.


  1. McGee BT, Seagraves KB, Smith EE, et al. Association of Medicaid expansion with access to care, severity, and outcomes for acute ischemic stroke. Circ Cardiovasc Qual Outcomes 2021 Sep 30;CIRCOUTCOMES121007940. doi: 10.1161/CIRCOUTCOMES.121.007940. [Online ahead of print].