Women's Health Issues 30-5 (2020) 338–344

www.whijournal.com

Intimate Partner Violence

Changes in Incidents and Payment Methods for Intimate

Partner Violence Related Injuries in Women Residing in the
United States, 2002 to 2015
Tatiana L. Mariscal, MS a,*, Charmayne M.L. Hughes, PhD a,
Sepideh Modrek, PhD a,b
a
Health Equity Institute, San Francisco State University, San Francisco, California
b
Department of Economics, San Francisco State University, San Francisco, California

Article history: Received 2 May 2019; Received in revised form 28 April 2020; Accepted 15 May 2020

a b s t r a c t
Background: Violence in interpersonal relationships is a substantial health and social problem in the United States and is
associated with a myriad of immediate and long-term physical, behavioral, and neurocognitive impairments. The
present study sought to determine the incidence of U.S. emergency department (ED)-attended intimate partner violence
(IPV) from 2002 to 2015 and examine the differences in payment sources before and after implementation of the
Affordable Care Act.
Methods: We analyzed ED visits among female patients aged 15 years or older between 2002 and 2015 from the National
Hospital Ambulatory Medical Care Survey. Using International Classification of Disease, Ninth Revision, Clinical Modifi-
cation, codes from patient visit records, we classified each ED visit to determine the frequency and estimate the relative
proportion and national frequency of IPV visits. We explored bivariate and multivariate associations between IPV-
related injuries with age, race, ethnicity, method of payment, and region, noting changes over time.
Results: Between 2002 and 2015, female patients visited EDs an estimated 2,576,417 times for IPV-related events, and
the proportion of ED visits for IPV increased during that time period. The percentage of ED visits for IPV-related events
did not differ significantly by region, race, or ethnicity. Compared with women 25–44 years of age, women aged 65 to 74
(odds ratio, 0.15; 95% confidence interval, 0.05–0.43; p < .001) and 75 years and older (odds ratio, 0.20; 95% confidence
interval, 0.08–0.53; p ¼ .001) were less likely to visit an ED for IPV. Women were more likely to pay for IPV-related
services out-of-pocket (i.e., self-pay) (odds ratio, 1.85; 95% confidence interval, 1.24–277; p ¼ .003) before the enact-
ment of the Affordable Care Act.
Conclusions: The increase in the percentage of IPV-related ED claims paid by private insurance suggests that the
Affordable Care Act may have increased women’s willingness and ability to seek medical attention for IPV-related in-
juries and disclose IPV as the source of injuries.
Ó 2020 The Authors. Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Intimate partner violence (IPV) is one of the most common
forms of violence against women, with 4.0% of women residing in
the United States reporting being physically assaulted by a current
or former sexual partner in the past 12 months (Black et al., 2011).
This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
* Correspondence to: Tatiana Mariscal, Health Equity Institute, San Francisco
State University, 1600 Holloway Ave, San Francisco, CA 94132. Phone: (415) 405-
2540.
E-mail address: tlmariscal20@gmail.com (T.L. Mariscal).
Women who experience physical injuries owing to IPV seek
medical care in a variety of places (e.g., emergency departments
[EDs], offices of general practitioners, and dentists [Black et al.,
2011; Bonomi et al., 2006]), and are more likely to use health
care services than women without IPV experience, regardless of
whether those injuries were sustained from a recent physical
assault (Tjaden & Thoennes, 2000) or were for injuries unrelated
to IPV (Bonomi, Anderson, Rivara, & Thompson, 2009; Fishman,
Bonomi, Anderson, Reid, & Rivara, 2010).
There is emerging evidence that the medical costs associated
with IPV-related injuries are borne by the victim (Max, Rice,

1049-3867/$ - see front matter Ó 2020 The Authors. Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.whi.2020.05.002
 T.L. Mariscal et al. / Women's Health Issues 30-5 (2020) 338–344
Finkelstein, Bardwell, & Leadbetter, 2004; National Center for
Injury Prevention and Control, 2003). For example, the National
Center for Injury Prevention and Control (2003) collated data
from multiple sources (i.e., the 1995–1996 National Violence
Against Women Survey, the 1996 Medical Expenditure Panel
Survey, and the Medicare 5% Sample Beneficiary Standard Ana-
lytic Files) and reported that 28.6% of physical and 32.0% of mental
health costs were paid out of pocket by IPV survivors. Similarly,
using national survey data (i.e., the 1995 National Violence
Against Women Survey and the 1995 Medical Expenditure Panel
Survey) Max et al. (2004) estimated that 48.3% of physical assault
costs were borne by the individual’s private insurance and/or
group plan, 20.1% by public insurance plans (i.e., Medicare and
Medicaid), 30.4% by the IPV victim, and 1.2% by other sources.
Although there are a number of reasons why female survivors
of IPV pay for services using their own funds rather than using
private insurance, recent research has indicated that women often
pay out of pocket out of fear that their abuser will find out they
have sought medical attention and/or that their insurance pro-
vider would use their IPV history to deny, revoke, or increase their
health insurance premiums (Duplessi & Levenson, 2014; Fromson
& Durborow, 2016; Reeve, 2014). Indeed, before 2010, U.S. insur-
ance companies could classify IPV as a preexisting condition. In
practical terms, the insurance company would calculate potential
treatment costs for a current/former IPV victim (e.g., mental health
treatment, surgery, postinjury treatment, and medications), and
require the individual to pay a higher premium (or deny them
coverage) if the costs associated with treatment were found to be
substantial (Fromson & Durborow, 2016).
Recent changes in U.S. health policy have improved health care
access and coverage for survivors of IPV. Specifically, the Afford-
able Care Act (ACA) sought to expand coverage to individuals and
improve the quality and efficiency of preventive services (Oehme
& Stern, 2014). One provision particularly important for women
experiencing IPV is the prohibition on insurance companies
denying or revoking coverage or charging higher premiums based
on preexisting conditions (Jones et al., 2006; Reeve, 2014).
Figure 1. Intimate partner violence (IPV)-related emergency department estimated visits. This figure uses 2002–2015 National Hospital Ambulatory Medical Care Survey data
(N ¼ 188,448) to show the secular trend of IPV-related ED visits.
339
To examine how the ACA might have influenced the use of
emergency care for IPV-related injuries, the aim of the current
study was to examine ED visits by female patients aged 15 years
or older using the National Hospital Ambulatory Medical Care
Survey (NHAMCS) data, a nationally representative sample of all
ED visits in the United States between 2002 and 2015. We esti-
mate national frequencies and document the secular trends in
IPV-related ED visits. We explore time trends and potential dif-
ferences in the proportion of ED visits for IPV-related injuries by
race, ethnicity, payment method, and U.S. region. Finally, we
examine the payment sources for IPV-related injury before and
after implementation of the ACA.
Methods
Data Source
We conducted a secondary analysis of the NHAMCS ED
database for 2002 to 2015. The NHAMCS is a four-stage proba-
bility sample collected by the National Center for Health Statis-
tics and the Centers for Disease Control and Prevention of visits
to the emergency and outpatient departments during a
randomly assigned 4-week data period (Centers for Disease
Control and Prevention, 2017). In the NHAMCS, EDs and out-
patients are randomly selected from primary sampling units (i.e.,
county or other geographical units) from the 50 states and the
District of Columbia. The NHAMCS stratifies each primary sam-
pling unit by socioeconomic and demographic variables, and
then selects primary sampling units with a probability propor-
tional to their size. NHAMCS collects approximately 234 vari-
ables each year, including patient demographics (e.g., race,
ethnicity, and age), hospital demographics (e.g., geographical
region, metropolitan area, and ownership), administrative visit
information (e.g., length of visits, length of stay, waiting time,
time of arrival, and payment type), and medical variables (e.g.,
physician diagnoses, cause of injury, vital signs, and procedures).
This study used and merged hospital ED data from 2002 to 2015.
340 T.L. Mariscal et al. / Women's Health Issues 30-5 (2020) 338–344

We excluded data from males, girls younger than 15 years of age, Table 1
and incidents with poison-related causes from all analyses. Demographic Characteristics, Percent of ED Visits for IPV (N ¼ 2,576,417), and OR
(95% CI) for IPV-related ED Visits (N ¼ 150,396), United States, 2002–2015
Furthermore, data from 2004 were excluded because cases of IPV
were substantially different, suggesting potential coding error or Characteristics Percent of IPV-related IPV-related ED
coding changes relative to other years. More information on ED Visits, n (%) Visits OR (95% CI)

procedure, coding, and data reporting is available at www.cdc. Year

gov/nchs. 2002 118,055 (4.58) Reference
2003 110,529 (4.29) 1.03 (0.56–1.91)
2005 155,022 (6.02) 1.43 (0.80–2.56)
Case Definition of IPV 2006 136,059 (5.28) 1.19 (0.68–2.08)
2007 147,544 (5.72) 1.24 (0.67–2.29)
Although this study focuses on violence against women 2008 249,976 (9.70) 1.79 (0.98–3.26)
2009 221,343 (8.59) 1.60 (0.90–2.82)
inflicted by an intimate partner, we included causes directly
2010 238,280 (9.24) 2.04 (1.19–3.47)*
related to IPV and incidents in which women were abused or 2011 172,494 (6.69) 1.42 (0.77–2.61)
assaulted by another adult. IPV cases were identified using the 2012 219,952 (8.53) 1.82 (0.98–3.38)
International Classification of Disease, Ninth Revision, Clinical 2013 239,821 (9.31) 2.37 (1.14–4.02)y
Modification (ICD-9-CM) codes found in the cause of injury (rape 2014 353,530 (13.72) 2.63 (1.33–5.23)*
2015 213,806 (8.29) 1.78 (0.86–3.70)
[E960.1], spouse abuse [E967.3]) and diagnosis (adult abuse
c2 96.10y
[995.80–995.83, 995.85], history of violence [V15.41, V15.42], Race
and counseling [V61.10, V61.11]) fields. These IPV ICD-9-CM White 1737,861 (67.45) Reference
codes were selected based on prior research (Btoush et al., Black 729,046 (26.84) 1.05 (0.72–1.55)
Other 109,508 (4.25) 1.11 (0.56–2.17)
2009; Rovi & Johnson, 1999; Rudman, 2000; Weiss, Ismailov,
c2 21.72
Lawrence, & Miller, 2004) and the belief that they would cap- Ethnicityz
ture the various forms of IPV that might present at an ED Non-Hispanic 181,9483 (86.85) Reference
(Btoush et al., 2008). Furthermore, codes such as rape and adult Hispanic 275,314 (13.14) 0.95 (0.67–1.36)
abuse were included in this study because women are more c 2
0.74
Age (y)
likely to be raped and abused by an intimate partner (Smith et al.,
15–24 2,815,962 (31.67) 1.20 (0.89–1.63)
2017). 25–44 1,118,983 (43.43) Reference
45–64 560,514 (21.75) 0.81 (0.51–1.28)
Statistical Analysis 65–74 24,288 (0.94) 0.15 (0.05–0.43)x
75 56,669 (2.19) 0.20 (0.08–0.53)x
c2 253.37x
We classified each ED visit to identify one outcome: an IPV Census region
event. For the outcome of interest (i.e., IPV), we calculated the Northeast 473,831 (18.39) Reference
frequency (number) of diagnoses and/or causes by year, as well Midwest 716,407 (27.80) 1.09 (0.75–1.59)
as the proportion of all ED visits during which the outcome of South 936,834 (36.36) 0.87 (0.59–1.28)
West 449,343 (17.44) 0.93 (0.64–1.33)
interest was diagnosed by year. Furthermore, we used weights
c2 20.28
included in the data to calculate national estimates of IPV-ED Payment method
visit frequencies by year. Secular trends were assessed with the Private 717,337 (27.84) Reference
weighted c2 test for trend. We then examined bivariate re- Medicare 152,152 (5.90) 0.74 (0.35–1.55)
lationships between patient demographic and visit characteris- Medicaid 821,356 (31.87) 1.30 (0.88–1.92)
Workers’ compensation 5,520 (0.21) 0.31 (0.04–2.27)
tics (i.e., age, race, ethnicity, geographic region, and method of Self-pay 504,710 (19.58) 1.46 (1.02–2.08)y
payment) and visit rates. Pearson’s c2 was used to evaluate the Charity/no charge 42,527 (1.65) 1.18 (0.50–2.79)
significance of comparison. Other 93,436 (3.62) 1.23 (0.68–2.20)
Subsequently, multivariable logistic regression was used to Blank 49,167 (1.90) Not enough
observations
assess differences in IPV-related ED visits by patient de-
Unknown 190,205 (7.38) Not enough
mographics and payment method before and after the ACA went observations
into effect. Bivariate group difference analysis included the c2 282.59x
following payment methods: private, Medicare, Medicaid, Abbreviations: CI, confidence interval; ED, emergency department; IPV, intimate
workers’ compensation, self-pay, charity/no charge, other, un- partner violence; OR, odds ratio.
known, and blank. Self-pay and charity/no charge were com- This table uses 2002–2015 National Hospital Ambulatory Medical Care Survey
bined to form a single group for the interacted model presented. data. Observations from 2004 were excluded owing to coding changes and/or
potential survey administrator coding error.
A p value of less than .05 was considered to be statistically
* p < .01.
significant. y
p < .05.
Data management and analysis were performed using the z
Ethnicity percentage denote the proportion of women who reported their
survey [svy] commands in Stata software (version 13.1, Stata ethnicity; observations of those who did not report their ethnicity were excluded
Corporation, College Station, TX). Institutional review board (N ¼ 2,094,798). Column 1 presents estimated number and percentage of
national IPV ED visits and Column 2 presents results from logistic regression
exemption was granted by the institutional review board at San based on the sample of IPV ED visits after controlling for year, race, ethnicity, age,
Francisco State University because data were de-identified and region, and payment method.
x
publicly available. p < .001.

Results
After appropriate weighting, this represents 2,576,417 national
In a total sample of 188,448 ED visits, there were 652 cases of ED visits for IPV-related injuries from a total of 749,418,720 na-
ED visits for IPV (0.35%) in female ED visits from 2002 to 2015. tional ED visits. Figure 1 presents the annual rates of IPV-related
 T.L. Mariscal et al. / Women's Health Issues 30-5 (2020) 338–344
Table 2
OR (95% CI) for IPV-related U.S. ED Visits before and after ACA Enactment
IPV ED Visits OR (95% CI)
Pre-ACA (N ¼ 93,336) Post-ACA (N ¼ 55,527)
Private Reference Reference
Self-pay/charity 1.85 (1.24–2.77)* 1.08 (0.60–1.96)
Medicare 0.70 (0.23–2.16) 0.74 (0.28–1.91)
Medicaid 1.37 (0.91–2.08) 1.23 (0.66–2.26)
Other 1.04 (0.50–2.16) 1.34 (0.60–3.02)
Abbreviations: ACA, Affordable Care Act; CI, confidence interval; ED, emergency
department; OR, odds ratio.
This table uses 2002–2015 National Hospital Ambulatory Medical Care Survey.
Observations from 2004 were excluded owing to coding changes and/or po-
tential survey administrator coding error. Workers’ compensation, unknown,
and blank observations were excluded from payment method category
(N ¼ 244,892). Colum 1 presents results from 2002 to 2009 and column 2 pre-
sents results from 2010 to 2015 logistic regression based on the sample of inti-
mate partner violence ED visits after controlling for year, race, ethnicity, age,
region, and payment method.
* p < .01.
ED visits. Between 2002 and 2015, the annual rate of IPV-related
ED visits ranged from 24 to 55 visits per 10,000 ED visits, with an
average of 34 IPV-related ED visits per 10,000 ED visits (0.34%
[Supplemental Table 1]). Using linear regression, we estimate
that the annual rate of increase for IPV-related ED visits was
4.27%.
As seen in Table 1 column 1, there were significant differences
by age, c2 (4, N ¼ 188,443) ¼ 253.37, p < .0001; payment method,
c2 (8, N ¼ 188,443) ¼ 282.59, p < .0001; and timing, c2 (12,
N ¼ 188,443) ¼ 96.10, p ¼ .0365; in IPV-related ED visits in
univariate analyses. In Table 1 column 2, we present multivariate
logistic regression models including indicator variables for year,
race, ethnicity, age, geographical region, and payment method.
Based on a sample of 150,396 ED visits, women were more likely
to visit an ED for an IPV-related injury in 2010 (odds ratio [OR],
2.04; 95% confidence interval [CI], 1.19–3.47; p ¼ .009), 2013 (OR,
2.37; 95% CI, 1.14–4.02; p ¼ .021), and 2014 (OR, 2.63; 95% CI,
1.33–5.23; p ¼ .006), compared with 2002. In addition, we found
that women were more likely to self-pay for IPV-related care (OR,
1.46; 95% CI, 1.02–2.08; p ¼ .039) than to use insurance. In
comparison with women aged 25–44 years, women aged 65 to
74 (OR, 0.15; 95% CI, 0.05–0.43; p < .001) and 75 years and older
(OR, 0.20; 95% CI, 0.08–0.53; p ¼ .001) were less likely to visit an
ED owing to IPV. We did not find significant differences by race,
ethnicity, or census region in the proportion of ED visits for IPV-
related injuries.
We then examined differences in payment methods for IPV-
related ED visits before (i.e., 2002–2009, N ¼ 93,336) and after
the ACA (i.e., 2010–2015, N ¼ 55,527). In Table 2, we present
stratified multivariate analyses comparing payment methods
before and after the enactment of the ACA. Women were more
likely to use self-pay/charity for IPV-related ED visits relative to
other ED visits before ACA enactment. Self-pay/charity for IPV-
related ED visits was almost two times higher compared with
private insurance before ACA enactment (OR, 1.85; 95% CI, 1.24–
277; p ¼ .003). In contrast, there were no statistically significant
difference in payment method type post-ACA implementation.
Discussion
In this study, we examined ED visits by female patients aged
15 years or older using NHAMCS data between 2002 and 2015,
341
exploring time trends and potential differences in the proportion
of ED visits for IPV-related injuries by race, ethnicity, payment
method, and U.S. census region. We observed the following main
findings. First, the analysis of secular trends indicated that the
number of IPV-related ED visits increased between 2002 and
2015. Second, there were significant differences in ED visits for
IPV by age, but not race or ethnicity. Third, before the ACA, IPV-
related ED visits were more likely to be paid for by the survivors
relative to non–IPV-related ED visits. In contrast, after the ACA
took effect, there was no systematic difference in the method
that women used to pay for IPV-related ED visits compared with
non–IPV-related ED visits. This discussion focuses primarily on
these new findings.
The data from the present study indicate that from 2002 to
2015, 34 of every 10,000 ED visits were by women seeking care
for IPV-related injuries. Although differences in methodology
make comparisons of prevalence estimates difficult, the number
of ED visits obtained in the present study is slightly higher than
Btoush et al. (2009), who derived a national estimate of 21 per
10,000 visits between 1997 and 2001 using the NHAMCS dataset,
but lower than that reported by prior studies that used
population-based random telephone surveys (Black et al., 2011;
Bonomi et al., 2006; Breiding, 2014), family practice clinics
(Coker, Smith, Bethea, King, & McKeown, 2000; Hux, Schneider,
& Bennett, 2009), and ED-based convenience samples (Brokaw,
Fullerton-Gleason, Olson, Crandall, McLaughlin, & Sklar, 2002;
Ernst, Nick, Weiss, Houry, & Mills, 1997).
An analysis of secular trends indicated that there was a 4.3%
increase in the proportion of IPV-related injuries across the 13-year
period (Figure 1). Although it is possible that the rates of severe IPV
(e.g., broken bones, internal injuries, loss of consciousness) have
been increasing since the early 2000s, it is more plausible that these
findings are due to the changing social and cultural norms
regarding gender-based violence (Rivara et al., 2009), and insurance
policy changes and medical care access that have affected how in-
juries attributed to IPV are coded by hospital administrators
(Rudman, 2000). This finding is incongruent with prior studies
using survey-based methodologies (i.e., National Crime Victimiza-
tion Survey) that have reported a decrease in the prevalence of IPV
between 1993 and 2010 (Catalano, 2012, 2013; Truman & Morgan,
2016). This decrease is said to be due, in large part, to national and
statewide gender-based violence policies (e.g., the 1994 Violence
Against Women Act [Clark, Biddle, & Martin, 2002]), Violence Crime
Control and Law Enforcement Act (Amaranto, Steinberg, Castellano,
& Mitchell, 2003), female empowerment and the feminist move-
ment (Rivara et al., 2009), and the availability of resources for sur-
vivors (Dugan, Nagin, & Rosenfeld, 1999, 2003; Sev’er, Dawson, &
Johnson, 2004).
Alternatively, given the large body of literature indicating that
job instability directly affects marital conflict and IPV rates
(Benson, Fox, DeMaris, & Van Wyk, 2003; Fox, Benson, DeMaris,
Van Wyk, 2002; Schneider, Harknett, & McLanahan, 2016), it is
possible that the current findings are a result of financial insta-
bility during the Great Recession (starting in December 2007)
and the subsequent slow recovery that continued to affect
household resources well into 2014. For example, Schneider et al.
(2016) reported that women who experienced economic hard-
ship in the Great Recession were twice as likely to experience
violent or controlling behavior by their male intimate partners,
with an increase in violent and controlling behavior toward
women in situations where both adults were unemployed.
An analysis of NHAMCS data revealed significant differences
for age, but not race or ethnicity. Consistent with prior studies
342 T.L. Mariscal et al. / Women's Health Issues 30-5 (2020) 338–344
(Beach, Carpenter, Rosen, Sharps, & Gelles, 2016; Coker et al.,
2000; Crockett, Brandl & Dabby, 2015; Thompson et al., 2006;
Truman & Morgan, 2016; Yan & Chan, 2012), we found that
women 65 years of age and over were less likely to visit an ED for
IPV, compared with women ages 25–44 years of age. This finding
may be due to several factors related to aging, such as age-related
decreases in violent behavior and/or the death of the abuser
(Gerino, Caldarera, Curti, Brustia, & Rolle , 2018; Rivara et al.,
2009), injury miscategorization in older people who are less
likely to be asked about IPV (Beach et al., 2016; Zink, Fisher,
Regan, & Pabst, 2005), and shifts from physical to nonphysical
abuse over the course of the relationship (Harris, 1996; Kim,
Laurent, Capaldi, & Feingold, 2008; Quigley & Leonard, 1996).
The nonsignificant relationship between race or ethnicity and
the proportion of ED visits for IPV-related injuries is intriguing
given the large corpus of research indicating that Black (Black
et al., 2011; Cho, 2012; Lacey, West, Matusko, & Jackson, 2016;
Truman & Morgan, 2016) and Hispanic women (Caetano
Schafer, & Cunradi, 2017; Cunradi, Caetano & Schafer, 2002;
Stockman et al., 2015; West, 2005) are more likely to report
IPV victimization and are at a higher risk for severe and recurrent
violence inflicted by an intimate partner compared with non-
Hispanic White women (Black et al., 2011; Caetano, et al., 2017;
Lipsky, Caetano, Field, & Barargan, 2005). Given that our
methods were comparing rates of IPV-related ED visits with
non–IPV-related visits, it could be that Black and Hispanic
women have higher rates of ED visits overall compared with
non-Hispanic White women, which would mask differences in
IPV incidents. Although the risk of IPV victimization may be
similar across racial and ethnic groups, it is more likely that the
nonsignificant results obtained in the present study are due to
historical medical mistrust, perceived discrimination, and
structural inequities experienced by minoritized groups (Bell &
Mattis, 2000) that lead them to rely on informal (e.g., friends
and family) rather than formal support systems (Hampton,
Oliver, & Magarian, 2003; Karlsen & Nazroo, 2002).
We also found that IPV-related ED visits were higher in 2010,
2013, and 2014. It is possible that some of the increases in the
number of visits in 2013 and 2014 were related to changes in
reimbursement and coverage policies owing to the enactment of
key provisions of the ACA that affected IPV survivors in particular
(Lee et al., 2020). For example, the preventive health coverage
funds increased in 2013, which by extension increased federal
funding and resources for IPV services (i.e., mandatory IPV
screenings, supplemental physician training on IPV screenings,
and administrator training on IPV reporting [Oehme & Stern,
2014]). In addition, in 2014 insurance companies and health
care providers that received federal funds were prohibited from
denying health care coverage to survivors of IPV and sexual
violence (Duplessi & Levenson, 2014) and Medicaid coverage was
expanded in several states for previously ineligible adults. Fac-
tors outside the scope of this study are likely related to the higher
IPV-related ED visits in 2010.
Interestingly, multivariate analysis using stratified models,
separating the pre-ACA and post-ACA period (as shown in
Table 2), and models that interact the post-ACA period with
payment type (Supplemental Table 2) show similar results and
indicate that women were more likely to self-pay for IPV-related
services before the enactment of the ACA. One hypothesis for this
finding is that insurance companies could deny, cancel, exclude,
and increase health insurance premiums for preexisting condi-
tions such as IPV before the ACA (Shaw, Asomugha, Conway, &
Rein, 2014). This situation changed with the enactment of the
2014 ACA provision that prohibits insurance from engaging in
any form of discrimination based on IPV victimization (Shaw
et al., 2014). Furthermore, many women gained insurance
coverage under the expansion of Medicaid in certain states in
2014. Obtaining insurance could have made women more likely
to seek care for physical injuries.
Implications for Practice and/or Policy
The results of the present study have implications for future
research and policy. First, the increasing incidence of ED visits for
IPV between 2002 and 2015 observed in the present study
highlights that IPV is a significant health problem in the United
States. However, it is not clear what changes have caused the
increase. Future research should explore whether these changes
are driven by increases in the severity of IPV incidence that
require immediate attention from health care systems and pro-
fessionals, such as changes in attitudes that lead to an increase in
patient disclosures, and/or changes in reimbursement and cod-
ing practices. Second, our finding that there was a differential
financial burden on IPV survivors for payment of ED-related
visits relative to non-ED related visits before, but not after, ACA
enactment highlights the importance of the ACA for women
generally and IPV survivors in particular. Current presidential
proposals and legal challenges to the ACA may lead to an envi-
ronment where women and IPV survivors will have to dispro-
portionately shoulder the cost of their victimization once again.
Any future changes to health insurance policy must consider its
effects on IPV survivors.
Study Strengths and Limitations
The present study’s main strength is its use of hospital-level
data that allowed for the examination of IPV-related injury
secular trends between 2002 and 2015. The NHAMCS stratifies
each primary sampling unit by socioeconomic and demographic
variables, and via the use of a four-stage probability sample,
enabled for the extrapolation of IPV-related injury national es-
timates by applying appropriate weights.
As with all research, this study has some limitations. First, the
NHAMCS codes patient visits, rather than individual patients.
Women who visited the ED on more than one occasion were
counted independently. Furthermore, the NHAMCS is an
administrative dataset, and the determination of race and
ethnicity is sometimes self-reported by the patient, inferred by
staff observation, transferred from another hospital record, or
inferred from the patient’s surname. We cannot rule out the
possibility that some patients’ race and ethnicity were
misclassified.
Second, we acknowledge that the use of a limited set of ICD-
9-CM codes to define IPV may have underestimated the magni-
tude of IPV-related ED visits, given that IPV is associated with a
multitude of health conditions (Black et al., 2011). Furthermore,
the present study examined cases of IPV that were severe enough
to require immediate medical attention. Our data set likely does
not include injuries treated in doctors’ offices, walk-in clinics,
and urgent care (e.g., sprains, strains, and headaches). Because
women seek medical attention from a variety of providers (Black
et al., 2011; Bonomi et al., 2006), future research should examine
care utilization across medical settings with varying levels of
charity care provision and Medicaid acceptance.
Third, IPV injuries are rare events among all ED visits. Our
analysis yielded 652 weighted cases out of 188,448 weighted ED
 T.L. Mariscal et al. / Women's Health Issues 30-5 (2020) 338–344
visits. Logistics regression can underestimate the probability of
such rare events, which may cause biases in estimated associa-
tions. However, our results were similar when we examined
linear probability models that are not affected by the rarity of the
events. Thus, we believe the results are valid.
Conclusions
This study examined IPV-related injuries that were severe
enough to require immediate medical attention and found a
4.27% increase in the proportion of ED visits for IPV-related in-
juries between 2002 and 2015. Before the implementation of the
ACA, women were more likely to pay out of pocket for IPV-
related services. Our findings suggest that the implementation
of the ACA may have reduced barriers to receiving medical care
for IPV-related injuries.
Supplementary Data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.whi.2020.05.002.
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Author Descriptions
Tatiana L. Mariscal, MS, is a Lecturer who uses her academic background in
movement science and public health to explore the health determinants associated
with intimate partner violence among the underserved female population in the
U.S and developing countries.
Charmayne M.L. Hughes, PhD, uses her background in motor control neuroscience
and engineering to elucidate the impact of violence and trauma on underlying
neurocognitive and neuromotor functioning, and to develop technological solutions
that benefit resource-constrained and vulnerable populations.
Sepideh Modrek, PhD, is an assistant professor of Health Economics at the Health
Equity Institute at San Francisco State University. Her research examines social
determinants and structural inequities that impact health outcomes.