The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care.
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ABSTRACT: Introduction
This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures.Methods
We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion.Results
117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]).Conclusions
Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.
SUBMITTER: Eguia E
PROVIDER: S-EPMC6917909 | biostudies-literature | 2020 Jan
REPOSITORIES: biostudies-literature
Publications
The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care.
Eguia Emanuel E Baker Marshall S MS Chand Bipan B Sweigert Patrick J PJ Kuo Paul C PC
American journal of surgery 20190709 1
<h4>Introduction</h4>This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures.<h4>Methods</h4>We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion.<h4>Results</h4>117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both lapar ...[more]
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Project description:BackgroundCritics argue that expanding health insurance coverage through Medicaid may not result in improved access to care. The Affordable Care Act provides reimbursement incentives aimed at improving access to primary care services for new Medicaid beneficiaries; however, there are no such incentives for specialty services. Using the natural experiment of Medicaid expansion in New York (NY) State in October 2001, we examined whether Medicaid expansion increased access to common musculoskeletal procedures for Medicaid beneficiaries.MethodsFrom the State Inpatient Database for NY State, we identified 19- to 64-year-old patients who underwent lower extremity large joint replacement, spine procedures, and upper/lower extremity fracture/dislocation repair from January 1998 to December 2006. We used interrupted time series analysis to evaluate the association between Medicaid expansion and trends in the relative and absolute number of Medicaid beneficiaries who underwent these musculoskeletal procedures.ResultsBefore Medicaid expansion, we observed a slight but steady temporal decline in the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries. After expansion, this trend reversed, and by 5 years after Medicaid expansion, the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries was 4.7 percentage points [95% confidence interval, 3.9-5.5] higher than expected, based on the preexpansion time trend.ConclusionMedicaid expansion in NY State significantly improved access to common musculoskeletal procedures for Medicaid beneficiaries.
| S-EPMC4262819 | biostudies-literature
Project description:ObjectiveThis study aims to evaluate the trends in cancer (CA) admissions and surgeries after the Affordable Care Act (ACA) Medicaid expansion.MethodsThis is a retrospective study using HCUP-SID analyzing inpatient CA (pancreas, esophagus, lung, bladder, breast, colorectal, prostate, and gastric) admissions and surgeries pre- (2010-2013) and post- (2014) Medicaid expansion. Surgery was defined as observed resection rate per 100 cancer admissions. Nonexpansion (FL) and expansion states (IA, MD, and NY) were compared. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID).ResultsThere were 317, 858 patients in our sample which included those with private insurance, Medicaid, or no insurance. Pancreas, breast, colorectal, prostate, and gastric CA admissions significantly increased in expansion states but decreased in nonexpansion states. (IRR 1.12, 1.14, 1.11, 1.34, 1.23; P < .05) Lung and colorectal CA surgeries (IRR 1.30, 1.25; P < .05) increased, while breast CA surgeries (IRR 1.25; P < .05) decreased less in expansion states. Government subsidized, or self-pay patients had greater odds of undergoing lung, bladder, and colorectal CA surgery (OR 0.45 vs 0.33; 0.60 vs 0.48; 0.47 vs 0.39; P < .05) in expansion states after reform.ConclusionsIn states that expanded Medicaid coverage under the ACA, the rate of surgeries for colorectal and lung CA increased significantly, while breast CA surgeries decreased less. Parenthetically, these cancers are subject to population screening programs. We conclude that expanding insurance coverage results in enhanced access to cancer surgery.
| S-EPMC6675622 | biostudies-literature
Project description: Not available
| S-EPMC5885934 | biostudies-literature
Project description:ObjectiveTo examine the impact of the Affordable Care Act on preventable hospitalizations and associated charges for patients living with systemic lupus erythematosus, before and after Medicaid expansion.MethodsA retrospective, quasi-experimental study, using an interrupted time series research design, was conducted to analyze data for 8 states from the Healthcare Cost and Utilization Project state inpatient databases. Lupus hospitalizations with a principal diagnosis of predetermined ambulatory-care sensitive (ACS) conditions were the unit of primary analysis. The primary outcome variable was access to care measured by preventable hospitalizations caused by an ACS condition.ResultsThere were 204,150 lupus hospitalizations in the final analysis, with the majority (53.5%) of lupus hospitalizations in states that did not expand Medicaid. In unadjusted analysis, Medicaid expansion states had significantly lower odds of having preventable lupus hospitalizations (odds ratio [OR] 0.958); however, after adjusting for several covariates, Medicaid expansion states had increased odds of having preventable lupus hospitalizations (OR 1.302). Adjusted analysis showed that those individuals with increased age, public insurance (Medicare or Medicaid), no health insurance, rural residence, or low income had significantly higher odds of having a preventable lupus hospitalization. States that expanded Medicaid had $523 significantly more charges than states that did not expand Medicaid. Older age and rural residence were associated with significantly higher charges.ConclusionOur findings suggest that while Medicaid expansion increased health insurance coverage, it did not address other issues related to access to care that could reduce the number of preventable hospitalizations.
| S-EPMC6992496 | biostudies-literature
Project description:INTRODUCTION:Community health centers (CHCs) care for vulnerable patients who use tobacco at higher than national rates. States that expanded Medicaid eligibility under the Affordable Care Act (ACA) provided insurance coverage to tobacco users not previously Medicaid-eligible, thereby potentially increasing their odds of receiving cessation assistance. We examined if tobacco users in Medicaid expansion states had increased quit rates, cessation medications ordered, and greater health care utilization compared to patients in non-expansion states. METHODS:Using electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of January 1, 2014, we identified patients aged 19-64 with tobacco use status documented in the EHR within 6 months prior to ACA Medicaid expansion and ?1 visit with tobacco use status assessed within 24 months post-expansion (January 1, 2014 to December 31, 2015). We propensity score matched these patients to tobacco users from 108 CHCs in six non-expansion states (n = 27 670 matched pairs; 55 340 patients). Using a retrospective observational cohort study design, we compared odds of having a quit status, cessation medication ordered, and ?6 visits within the post-expansion period among patients in expansion versus non-expansion states. RESULTS:Patients in expansion states had increased adjusted odds of quitting (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.28-1.43), having a medication ordered (aOR = 1.53, 95% CI: 1.44-1.62), and having ?6 follow-up visits (aOR = 1.34, 95% CI: 1.28-1.41) compared to patients from non-expansion states. CONCLUSIONS:Increased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population. IMPLICATIONS:CHCs care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the ACA provided insurance coverage to a large number of tobacco users not previously Medicaid-eligible. We found that expanded insurance coverage was associated with increased cessation assistance and higher odds of tobacco cessation. Continued provision of insurance coverage could lead to increased quit rates among high-risk populations, resulting in improvements in population health outcomes and reduced total health care costs.
| S-EPMC7249916 | biostudies-literature
Project description:ImportanceDental coverage for adults is a state option in Medicaid, and despite significant gains in coverage after the Medicaid expansion under the Affordable Care Act (ACA), dental outcomes among adults in expansion states remain unexplored.ObjectiveTo explore the association of state coverage of dental benefits through Medicaid expansion with clinical dental outcomes.Design, setting, and participantsThis cross-sectional study analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2018. Included participants were low-income adults aged 19 to 64 years with income up to 138% of the federal poverty level. The study used a difference-in-differences analysis to compare changes from before to after ACA expansion in expansion states vs in control states. Changes were examined in the full sample and separately in states that did and did not provide Medicaid adult dental benefits. We defined a state as providing Medicaid adult dental benefits if it covered services beyond emergency dental benefits in 2014. Data were analyzed from November 2020 to March 2021.ExposuresMedicaid expansion under the ACA.Main outcomes and measuresRates of health coverage, having a dental visit, affordability of dental care in the past year, poor oral health, and teeth flossing were obtained from self-reported data. Mean number of missing teeth and prevalence of untreated decayed teeth, filled teeth, and functional dentition were obtained from clinical examination data.ResultsAmong 7637 low-income adults, the mean (SD) age was 37.8 (13.4) years and 4153 (weighted percentage, 54.5 %) were women. At baseline, 1732 low-income adults in nonexpansion states compared with 2520 low-income adults in expansion states were more likely, as shown by weighted percentage, to be Black (473 individuals [21.0%] vs 508 individuals [15.1%]) and US born (1281 individuals [76.7%] vs 1613 individuals [69.6%]). In the full sample, Medicaid expansion, compared with nonexpansion, was associated with an increased rate of seeing a dentist in the prior year (12.4 percentage points; 95% CI 4.6 to 20.2 percentage points; P = .003). In expansion states that provided dental benefits, compared with nonexpansion states that provided dental benefits, the expansion was associated with increases in rates of Medicaid coverage (8.2 percentage points; 95%CI 0.5 to 15.8 percentage points; P = .04) and having seen a dentist in the previous year (11.4 percentage points, 95% CI, 3.7 to 19.1 percentage points; P = .006) and decreases in the uninsured rate (-12.6 percentage points, 95% CI -18.9 to -6.4 percentage points; P < .001) and prevalence of untreated decayed teeth (-16.8 percentage points; 95% CI, -25.5 to -8.0 percentage points; P = .001). In states without Medicaid dental benefits, the expansion was associated with an increase in the mean number of missing teeth (1.3 teeth; 95% CI 0.1 to 2.5 percentage points; P = .04) and a decrease in the prevalence of functional dentition (-8.7 percentage points; 95% CI, -14.1 to -3.3 percentage points; P = .003) compared with nonexpansion states.Conclusions and relevanceThis study found that the combination of Medicaid expansion and coverage of Medicaid dental benefits was associated with improved oral health among low-income adults.
| S-EPMC8485174 | biostudies-literature
Project description:BackgroundThe Affordable Care Act's Medicaid expansions (ME) increased insurance coverage for low-income Americans, among whom unmet need for mental health care is high. Empirical evidence regarding the impact of expanding insurance coverage on use of mental health services among low income and minority populations is lacking.MethodsData on mental health service use collected between 2007 and 2015 by the Medical Expenditures Panel Survey from nationally representative cross-sectional samples of low income (income<138% of the federal poverty line) adults were analyzed. Use trends among people in states that expanded Medicaid (ME states; n=29,827) were compared with concurrent trends among people in states that did not (non-ME states; n=22,873), with statistical adjustment for demographic characteristics and psychological distress.ResultsAnnual outpatient visits for mental health conditions increased by 0.513 (0.053-0.974) visits per person, from a baseline rate in ME states of 0.894 visits per person. However, no significant changes were observed in number of mental health related hospital stays, emergency department visits or prescription fills. The increase outpatient visits was limited to Hispanics and non-Hispanic Whites, with no increase in service use observed among non-Hispanic Blacks. There was no apparent increase in the number of users of outpatient mental health care (AOR=0.992, P=0.942) and a marginally significant (P=0.096) increase of 3.144 visits per user.DiscussionME had a limited but positive impact on use of mental health services by low income Americans, although it may also have increased racial/ethnic disparities.
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Project description:BackgroundThe Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act (ACA), was created to increase access to primary care, improve quality of care, and decrease healthcare costs. A key provision in the law that mandated expansion of state Medicaid programme changed when states were given the option to voluntarily expand Medicaid. Our study sought to measure the impact of ACA Medicaid expansion on preventable hospitalization (PH) rates, a measure of access to primary care.MethodsWe performed an interrupted time series analysis of quarterly hospitalization rates across eight states from 2012 to 2015. Segmented regression analysis was utilized to determine the impact of policy reform on PH rates.ResultsThe Affordable Care Act's Medicaid expansion led to decreased rates of PH (improved access to care); however, the finding was not significant (coefficient estimate: -0.0059, CI -0.0225, 0.0107, p = 0.4856). Healthcare system characteristics, such as Medicaid spending per enrollee and Medicaid income eligibility, were associated with a significant decrease in rates of PH (improved access to care). However, the Medicaid-to-Medicare fee index (physician reimbursement) and states with a Democratic state legislature had a significant increase in rates of PH (poor access to care).ConclusionHealth policy reform and healthcare delivery characteristics impact access to care. Researchers should continue evaluating such policy changes across more states over longer periods of time. Researchers should translate these findings into cost analysis for state policy-makers to make better-informed decisions for their constituents.Contribution to knowledgeAmbulatory care-sensitive conditions are a feasible method for evaluating policy and measuring access to primary care. Policy alone cannot improve access to care. Other factors (trust, communication, policy-makers' motivations and objectives, etc.) must be addressed to improve access.
| S-EPMC8101185 | biostudies-literature
Project description:INTRODUCTION:This study sought to empirically evaluate whether the Medicaid expansion under the Affordable Care Act increased smoking cessation among low-income childless adult smokers. METHODS:The effects of the Medicaid expansion on smoking quit attempts and the probability of 30- and 90-day smoking cessation were evaluated using logistic regression and data from the 2010-2011 and 2014-2015 waves of the Tobacco Use Supplement to the Current Population Survey. Using boosted logistic regression, the Tobacco Use Supplement was restricted to an analytic sample composed of childless adults with high probability of being <138% of the federal poverty level. Propensity score weighting was used to compare changes in smoking cessation among a sample of current and past smokers in states that expanded Medicaid with a control sample of current and past smokers in states that did not expand Medicaid with similar sociodemographic characteristics and smoking histories. This study additionally controlled for state socioeconomic trends, welfare policies, and tobacco control policies. Analysis was conducted between January 2018 and June 2019. RESULTS:After weighting by propensity score and adjusting for state socioeconomic trends, welfare policies, and tobacco control policies, the Medicaid expansion was not associated with increases in smoking quit attempts or smoking cessation. CONCLUSIONS:The Medicaid expansion did not appear to improve smoking cessation, despite extending health insurance eligibility to 2.3 million low-income smokers. Greater commitments to reducing barriers to cessation benefits and increasing smoking cessation in state Medicaid programs are needed to reduce smoking in low-income populations.
| S-EPMC6924922 | biostudies-literature
Project description:Background & methodsNational protests in the summer of 2020 drew attention to the significant presence of police in marginalized communities. Recent social movements have called for substantial police reforms, including "defunding the police," a phrase originating from a larger, historical abolition movement advocating that public investments be redirected away from the criminal justice system and into social services and health care. Although research has demonstrated the expansive role of police to respond a broad range of social problems and health emergencies, existing research has yet to fully explore the capacity for health insurance policy to influence rates of arrest in the population. To fill this gap, we examine the potential effect of Medicaid expansion under the Affordable Care Act (ACA) on arrests in 3,035 U.S. counties. We compare county-level arrests using FBI Uniform Crime Reporting (UCR) Program Data before and after Medicaid expansion in 2014-2016, relative to counties in non-expansion states. We use difference-in-differences (DID) models to estimate the change in arrests following Medicaid expansion for overall arrests, and violent, drug, and low-level arrests.ResultsPolice arrests significantly declined following the expansion of Medicaid under the ACA. Medicaid expansion produced a 20-32% negative difference in overall arrests rates in the first three years. We observe the largest negative differences for drug arrests: we find a 25-41% negative difference in drug arrests in the three years following Medicaid expansion, compared to non-expansion counties. We observe a 19-29% negative difference in arrests for violence in the three years after Medicaid expansion, and a decrease in low-level arrests between 24-28% in expansion counties compared to non-expansion counties. Our main results for drug arrests are robust to multiple sensitivity analyses, including a state-level model.ConclusionsEvidence in this paper suggests that expanded Medicaid insurance reduced police arrests, particularly drug-related arrests. Combined with research showing the harmful health consequences of chronic policing in disadvantaged communities, greater insurance coverage creates new avenues for individuals to seek care, receive treatment, and avoid criminalization. As police reform is high on the agenda at the local, state, and federal level, our paper supports the perspective that broad health policy reforms can meaningfully reduce contact with the criminal justice system under historic conditions of mass criminalization.
| S-EPMC8754343 | biostudies-literature