Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions

Abstract

IMPORTANCE Lack of insurance coverage has been associated with delays in seeking care, more complicated diseases at the time of diagnosis, and decreased likelihood of receiving optimal surgical care. The Patient Protection and Affordable Care Act's (ACA) Medicaid expansion has increased coverage among millions of low-income Americans, but its effect on care for common surgical conditions remains unknown. OBJECTIVE To evaluate the association of the ACA's Medicaid expansion with access to timely and recommended care for common and serious surgical conditions. DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, difference-in-differences study used hospital administrative data to compare patient-level outcomes in expansion vs nonexpansion states before (2010-2013) vs after (2014-2015) expansion. A total of 293 529 patients aged 18 to 64 years with appendicitis, cholecystitis, diverticulitis, peripheral artery disease (PAD), or aortic aneurysm admitted to an academic medical center or affiliated hospital in 27 Medicaid expansion states and 15 nonexpansion states from January 1, 2010, through September 31, 2015, were included in the study. Data analysis was performed from November 1, 2016, to March 3, 2017. EXPOSURES State adoption of Medicaid expansion.MAIN OUTCOMES AND MEASURES Presentation with early uncomplicated disease (diverticulitis without abscess, fistula, or sepsis; nonruptured aortic aneurysm at time of repair; and PAD without ulcerations or gangrene) and receipt of optimal management (cholecystectomy for acute cholecystitis, laparoscopic approach for cholecystectomy or appendectomy, and limb salvage for PAD). RESULTSOf the 293 529 study patients (128 392 [43.7%] female and 165 137 [56.3%] male), 225 572 had admissions in Medicaid expansion states and 67 957 had admissions in nonexpansion states. Medicaid expansion was associated with a 7.5-percentage point decreased probability of patients being uninsured (95% CI, −12.2 to −2.9; P = .002) and an 8.6-percentage point increased probability of having Medicaid (95% CI, 6.1-11.1; P < .001). Medicaid expansion was associated with a 1.8-percentage point increase in the probability of early uncomplicated presentation (95% CI, 0.7-2.9; P = .001) and a 2.6-percentage point increase in the probability of receiving optimal management (95% CI, 0.8-4.4; P = .006). CONCLUSIONS AND RELEVANCEThe ACA's Medicaid expansion was associated with increased insurance coverage and improved receipt of timely care for 5 common surgical conditions. Health care systems and policymakers should be aware of the influence of insurance coverage expansion (or its repeal) on presentation with and management of surgical disease.

Effects of Medicaid expansion on access, treatment and outcomes for patients with acute myocardial infarction

“…The difference-in-differences approach has been used in other studies examining the effect of the Medicaid expansion. [17,43] This design estimates the effect of a policy change by comparing the change in an outcome for an affected population to the change in outcomes for an unaffected population. The design controls for baseline differences between the two groups as well as changing demographics to estimate the independent effect of the policy change.…”

“…after AMI that we identified adds to a growing body of literature that has shown some improvements in care from the inpatient to outpatient settings after the Medicaid expansion. [15,17,18,43] It is possible that the Medicaid expansion affected the outpatient environment, [15,17,18,43,[47][48][49] such as through increased access to follow-up care for AMI patients, which prevented the need for readmission. These findings suggest that for Medicaid and uninsured patients, who tend to have higher readmission rates after AMI relative to privately insured patients, expanding Medicaid eligibility may mitigate these risks.…”

“…[13,14] At this time, 14 states have not adopted the Medicaid expansion. Early studies on the ACA's Medicaid expansion indicate that it has led to increased access to and quality of primary care, [15,16] improved quality of care for common surgical conditions, [17] better outcomes after cardiac surgery, [18] and a decrease in cardiovascular mortality. [19] The literature has not yet described whether Medicaid expansion has affected acute care for AMI including access to care and outcomes.…”

Impact of Expanded Medicaid Eligibility on the Diabetes Continuum of Care Among Low-Income Adults: A Difference-in-Differences Analysis

“…A total of 31 states and Washington DC expanded eligibility to all nonpregnant adults with incomes of ≤138% federal poverty level (FPL) by 2018. Many quasi-experimental studies have shown that the expansion improved a broad range of access, 13−18 quality of care, 14,15,19 and clinical outcomes 20−27 among low-income adults. However, studies on people with diabetes have either relied on descriptive techniques that do not adjust for secular trends, 28,29 focused on general health access, 30 analyzed data limited to 2016, 31,32 or omitted outcomes such as treatment.…”

New Approaches In Medicaid: Work Requirements, Health Savings Accounts, And Health Care Access

“…1–6 But much of the debate at the state level since the 2016 election has shifted away from whether to expand Medicaid to what alternative approaches to take within the program. This article explores several new approaches (implemented or proposed) in Medicaid, using a novel survey of three Midwestern states.…”