Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights from Massachusetts

Loehrer, Andrew P.; Hawkins, Alexander T.; Auchincloss, Hugh

doi:10.1016/j.jvs.2016.04.012

Cited by 8 publications

(9 citation statements)

References 34 publications

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“…34,35 These data also build on previous works from Massachusetts and the ACA's dependent coverage provision showing an association between insurance expansion and improved clinical care of acute onset diseases, including appendicitis, cholecystitis and lower extremity vascular disease. [13][14][15]36 Our findings are likely explained by several main factors. Newly insured individuals may be less likely to delay seeking care and thus present sooner when early symptoms develop.…”

Section: 43233mentioning

confidence: 69%

“…We selected these particular surgical conditions given extensive documentation of disparities in patient presentation with and subsequent care received based on insurance coverage, in addition to data suggesting an association between insurance expansion and care delivery for these conditions. [5][6][7][8][9][10][11][12][13][14] Surgery for appendicitis, cholecystitis, and diverticulitis represent the three most frequent and highest morbidity procedures in general surgery. 20 Vascular diseases, including aortic aneurysm and PAD, are increasingly prevalent in the U.S., and timely appropriate management has been shown to directly impact both mortality and major morbidity.…”

Section: Data Source and Outcomesmentioning

confidence: 99%

“…[13][14][15] However, it is unclear whether the Massachusetts experience generalizes to the ACA's Medicaid expansion.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2018

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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.

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Section: 43233mentioning

confidence: 69%

Section: Data Source and Outcomesmentioning

confidence: 99%

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

et al. 2018

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“…Patients may be presenting to clinicians with symptoms earlier given new insurance coverage and thus be more amenable to surgical resection. 32,33 Previous studies have demonstrated an association between reimbursement for and receipt of other cancer screening tests. 34 It is therefore possible that providers are increasing utilization of diagnostic testing such as computed tomography scans and tumor marker studies when patient present with subtle early signs such as abdominal pain, hyperbilirubinemia, or pancreatitis.…”

Section: Discussionmentioning

confidence: 99%

Health Insurance Expansion and Treatment of Pancreatic Cancer: Does Increased Access Lead to Improved Care?

Loehrer

Chang

Hutter

et al. 2015

Journal of the American College of Surgeons

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Background Pancreatic cancer is increasingly common and poised to become the second leading cause of cancer deaths by the year 2020. Surgical resection is only chance for cure yet significant disparities in resection rates exist by insurance status. The 2006 Massachusetts health care reform serves as natural experiment to evaluate the unknown impact of health insurance expansion on treatment of pancreatic cancer. Study Design Using the Agency for Healthcare Research and Quality State Inpatient Databases, this cohort study examines non-elderly, adult patients with no insurance, private coverage, or government-subsidized insurance plans who were admitted with pancreatic cancer in Massachusetts and three control states. Primary outcome was change in pancreatic resection rates. Difference-in-difference models were used to show impact of Massachusetts health care reform on resection rates for pancreatic cancer, controlling for confounding factors and secular trends. Results Prior to the Massachusetts reform, government-subsidized and self-pay patients (GSSP) had significantly lower rates of resection than privately-insured patients. The 2006 Massachusetts health reform was associated with a 15% increased rate of admission with pancreatic cancer (P=0.043) and a 67% increased rate of surgical resection (P=0.043) compared to control states. Measured disparities in likelihood of resection by insurance status decreased in Massachusetts while remaining unchanged in control states. Conclusions The 2006 Massachusetts health care reform was associated with increased resection rates for pancreatic cancer compared to control states. Our findings provide hopeful evidence that increased insurance coverage may help improve equity in pancreatic cancer treatment. Additional studies are needed to evaluate the longevity of these findings and generalizability in other states.

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“…10 Some authors have argued that race could be a marker for socioeconomic status (SES) and thus for healthcare access, as the reason for racial disparity in vascular outcomes. [11][12][13] Lack of access to care and regional clustering have been shown to affect black patients disproportionately. 3,7 Low SES has been clearly linked with higher prevalence of coronary artery disease (CAD), DM, hypertension, smoking, and physical inactivity as well as poor CAD outcomes such as myocardial infarction and cardiovascular death.…”

mentioning

confidence: 99%

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

Arya

Binney

Khakharia

et al. 2018

JAHA

171

117

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BackgroundBlack race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients.Methods and ResultsPatients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155 647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low‐SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30–1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06–1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation.ConclusionsBlack race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.

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Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights from Massachusetts

Cited by 8 publications

References 34 publications

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

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

Health Insurance Expansion and Treatment of Pancreatic Cancer: Does Increased Access Lead to Improved Care?

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

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