Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts.
JAMA Health Forum. 2021 Oct 8;2(10):e213083. doi: 10.1001/jamahealthforum.2021.3083. eCollection 2021 Oct.
There is limited evidence on whether the Affordable Care Act Medicaid expansion beginning in 2014 improved access to elective procedures. Uninsured individuals are at higher risk of obesity and may have experienced improved uptake of bariatric surgery following Medicaid expansion.
To examine the association between Medicaid expansion and the receipt of inpatient elective bariatric surgery among Medicaid-covered and uninsured individuals aged 26 to 64 years.
This cohort study used difference-in-differences analysis of all-payer data (2010-2017) of 637 557 elective bariatric surgeries for patients aged 26 to 74 years from 11 Medicaid expansion states and 6 nonexpansion states. Nonexpansion states and individuals aged 65 to 74 years were control cohorts. Data analysis was performed from July 6, 2020, to July 23, 2021.
Living in a Medicaid expansion state.
The main outcomes were the (1) number of elective bariatric surgeries, (2) population count, and (3) rate of bariatric surgery (number of surgeries per 10 000 population) among Medicaid-covered and uninsured individuals.
Of the 600 798 elective bariatric surgeries in adults aged 26 to 64 years between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states. A total of 296 798 patients (78.9%) in expansion states were women vs 177 386 (78.9%) in nonexpansion states. Among individuals aged 26 to 64 years, the median age was 44 (IQR, 37-52) years. Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%. Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in nonexpansion states. Medicaid expansion was associated with a 36.6% annual increase (95% CI, 8.2% to 72.5%) in surgery volume, a 9.0% annual increase (95% CI, 3.8% to 14.5%) in the population, and a 25.5% change (95% CI, -1.3% to 59.4%) in the rate of bariatric surgery. By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic (28.9%; 95% CI, -24.4% to 119.8%) individuals.
This cohort study found that Medicaid expansion was associated with increased rates of bariatric surgery among lower-income non-Hispanic White individuals, but not among Hispanic and non-Hispanic Black individuals.
重要性：目前关于 2014 年开始实施的平价医疗法案（Affordable Care Act）的医疗补助（Medicaid）扩大计划是否改善了选择性手术的可及性，证据有限。未参保的个人肥胖风险较高，在医疗补助扩大后，可能已经增加了减重手术的利用率。
目的：评估医疗补助扩大与医疗补助覆盖和未参保的 26 至 64 岁人群接受住院择期减重手术之间的关联。
设计、地点和参与者：本队列研究使用了来自 11 个医疗补助扩大州和 6 个非扩大州的所有支付者数据（2010-2017 年），对 26 至 74 岁的 637557 例择期减重手术患者进行了差异分析。非扩大州和 65 岁至 74 岁的个体为对照组队列。数据分析于 2020 年 7 月 6 日至 2021 年 7 月 23 日进行。
暴露因素：生活在医疗补助扩大州。
主要结局和测量指标：主要结局是（1）择期减重手术的数量，（2）人口数量，以及（3）医疗补助覆盖和未参保人群的减重手术率（每 10000 人口的手术数量）。
结果：在 2010 年至 2017 年期间，17 个研究州的 26 至 64 岁成年人中，有 600798 例择期减重手术，其中医疗补助覆盖和未参保人群分别占扩大州和非扩大州总手术量的 18.3%和 14.5%。在扩大州，296798 名患者（78.9%）为女性，而非扩大州为 177386 名（78.9%）。在 26 至 64 岁的人群中，中位数年龄为 44 岁（IQR，37-52 岁）。种族和民族分布为非西班牙裔白人，占 60.2%；非西班牙裔黑人，占 17.7%；西班牙裔，占 16.6%；和其他种族，占 5.5%。在 2013 年至 2017 年期间，医疗补助覆盖和未参保患者的减重手术量每年在扩大州增加 30.3%，而非扩大州增加 16.5%。医疗补助扩大与手术量每年增加 36.6%（95%CI，8.2%至 72.5%）、人口增加 9.0%（95%CI，3.8%至 14.5%）和减重手术率增加 25.5%（95%CI，-1.3%至 59.4%）相关。按种族和民族划分，医疗补助扩大与非西班牙裔白人人群的减重手术率增加相关（31.6%；95%CI，6.1%至 63.0%），但与非西班牙裔黑人（5.9%；95%CI，-19.8%至 39.9%）和西班牙裔（28.9%；95%CI，-24.4%至 119.8%）人群无显著变化。
结论和相关性：本队列研究发现，医疗补助扩大与较低收入的非西班牙裔白人人群减重手术率的增加相关，但与西班牙裔和非西班牙裔黑人人群无关。
