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 Affordable Care Act’s (ACA) Medicaid expansion has increased coverage among millions of low-income Americans, but its impact on care for common surgical conditions remains unknown. Objective: To evaluate the impact of the ACA’s Medicaid expansion on access to timely and recommended care for common and serious surgical conditions. Design: Quasi-experimental difference-in-differences study design, using hospital administrative data to compare patient-level outcomes in expansion vs. non-expansion states, before (2010- 2013) versus after (2014-2015) expansion. Setting: Academic medical centers and affiliated hospitals in 27 Medicaid expansion states and 15 non-expansion states. Participants: Patients aged 18 to 64 years admitted to a study hospital between January 2010 and September 2015 with appendicitis, cholecystitis, diverticulitis, peripheral artery disease (PAD) or aortic aneurysm (N=293,529). Exposure(s): State adoption of Medicaid expansion Main Outcome(s) and Measure(s): 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; limb- salvage for PAD). Results: Medicaid expansion was associated with a 7.5 percentage-point decreased probability of patients being uninsured (95% CI -12.2 to -2.9; P=0.002) and an 8.6 percentage-point increased probability of having Medicaid (95% CI 6.1 to 11.1; P<0.001). Medicaid expansion was associated with a 1.8 percentage-point increase in the probability of early uncomplicated presentation (95% CI 0.7 to 2.9; P=0.001), and a 2.6 percentage-point increase in the probability of receiving optimal management (95% CI 0.8 to 4.4; P=0.006). Conclusions and Relevance: The ACA’s Medicaid expansion was associated with increased insurance coverage and improved receipt of timely care for five common surgical conditions.