Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion

Abstract

BACKGROUND: While Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. To determine whether Medicaid expansion was associated with increased compared utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid). METHODS: Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011-2016 (Illinois' Medicaid expansion date: 1/1/2014). RESULTS: The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri-2013: 2.7%; 2016: 2.6%). A difference-indifference analysis (adjusted for patient age and sex, county-level Area Deprivation Index, and number of orthopaedic *

Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care

“…Reflecting this difference, we observed a notably larger shift in Medicaid payer mix after Medicaid expansion (6.0%) than has been shown previously for hip and knee arthroplasty (1.5%). 6 Beyond orthopedic conditions, the impact of Medicaid expansion on elective spine surgical care should be interpreted within the context of the broader surgical and economic literature. We observed an overall 17% increase in elective spine surgical volume, similar to rate changes found in studies that evaluated major general surgery procedures such as gastric bypass surgery (8%), paraesophageal hernia or reflux disease surgery (17%), cancer surgical procedures (12%), hernia repair (16%), and vascular surgery (20%).…”

“…38,42,43 Finally, previous evidence suggests that the shift to ambulatory surgical procedures has occurred in similar proportions across states and geographic regions, making a differential impact associated with Medicaid expansion status unlikely. 44,45 Another limitation is that despite the inclusion of a larger sample of states than many comparable studies, [6][7][8] our sample size still limited our ability to test for heterogeneity in effects across states, such as variations related to the expansion strategies of individual states. 17 Finally, the study data set did not allow us to investigate the exact mechanisms that led to the observed changes, such as increased imaging and referral rates by primary care physicians versus changes in decision-making among spine surgeons.…”

“…Medicaid expansion also improved access to some forms of elective surgical care. 6,[8][9][10] Evidence has been more limited for elective orthopedic disease. For example, one study in New York State found increased use of a variety of orthopedic procedures after Medicaid expansion, 9 and Medicaid expansion was associated with improved access to joint arthroplasty.…”

“…For example, one study in New York State found increased use of a variety of orthopedic procedures after Medicaid expansion, 9 and Medicaid expansion was associated with improved access to joint arthroplasty. 6 Nonetheless, other studies have shown that Medicaid patients face ongoing barriers to accessing elective orthopedic care. 11 Ensuring access to degenerative spine care is a particularly important priority, given that degenerative spine disease is among the most common and disabling health conditions in the United States and worldwide.…”

Medicaid expansion and accessibility to healthcare: The Illinois experience

“…Moreover, there can be historical, cultural, political, and demographic differences among states coupled with individual level factors such as personal experience using health insurance, access to primary care, and levels of health literacy (McCullough & Dalstrom, 2018; Singh & Wilk, 2019), which might partially explain the differences in outcomes. Finally, there is not a consensus in how access to healthcare is measured with some researchers focusing on reduced financial barriers (Miller & Wherry, 2017; Sommers et al., 2016), unmet needs (Benitez et al., 2018), use (Dy et al., 2019), or ability to access care when needed (Singh & Wilk, 2019).…”