Al-Refaie Waddah B, Zheng Chaoyi, Jindal Manila, Clements Michele Lee, Toye Patryce, Johnson Lynt B, Xiao David, Westmoreland Timothy, DeLeire Thomas, Shara Nawar
MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC.
J Am Coll Surg. 2017 Apr;224(4):662-669. doi: 10.1016/j.jamcollsurg.2016.12.044. Epub 2017 Jan 24.
Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities.
From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series.
The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion.
Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.
尽管《平价医疗法案》（ACA）扩大了医疗补助的覆盖范围，但尚不清楚这是否带来了更多获得复杂外科护理的机会。关于医疗补助扩大对获得外科癌症护理（复杂护理的一种代表）的影响的证据很少。我们以纽约2001年全州范围的医疗补助扩大作为一项自然实验，研究了这种扩大如何影响受益人群体总体以及少数族裔中外科癌症护理的使用情况。
我们从纽约州住院患者数据库（1997年至2006年）中识别出67685名接受癌症手术的非老年成年人（18至64岁）。根据支付方构成、外科癌症护理的总体使用情况以及少数族裔的使用比例，衡量2001年医疗补助扩大对获得护理机会的估计影响。每季度计算各项指标，在适当情况下对协变量进行调整，然后使用中断时间序列进行分析。
扩大后的5年里，由医疗补助支付的癌症手术比例从8.9%增至15.1%。扩大后，未参保患者的比例立即下降了21.3%（p = 0.01）。尽管扩大与医疗补助净病例量每年增加24例相关（p < 0.0001），但所有支付方的总体净病例量保持不变。此外，接受癌症手术的医疗补助受益人中少数族裔的调整比例未受扩大影响。
《平价医疗法案》实施前的医疗补助扩大并未增加外科癌症护理受益人的总体使用量，也未改变其种族构成。然而，它成功地将经济负担从患者/医院转移到了医疗补助。这些结果可能表明在《平价医疗法案》实施后的医疗补助扩大中会有类似影响。
