The Affordable Care Act state-level Medicaid expansion in 2014 was associated with an increased rate of bariatric surgery in lower-income non-Hispanic White patients but not in Hispanic and non-Hispanic Black patients, according to a study in JAMA Health Forum.
Investigators aimed to evaluate changes in the volume and rates of bariatric surgery among adults aged 26 to 64 years since the Medicaid expansion. They used inpatient discharge data from 2010 to 2017 from 11 Medicaid expansion states (Arizona, Arkansas, California, Colorado, Illinois, Iowa, Kentucky, New Jersey, New York, Oregon, and Pennsylvania) and 6 states that did not expand Medicaid before December 31, 2017 (Florida, Georgia, North Carolina, Texas, Virginia, and Wisconsin).
A total of 637,557 bariatric surgeries were performed in patients aged 26 to 74 years from 2010 to 2017; 78.9% were women in both the expansion and nonexpansion states. Overall, median patient age was 44 (IQR, 37-52) years, 17.7% were Black, 16.6% were Hispanic, 60.2% were White, and 5.5% were classified as other. The combined share of surgery volume for Medicaid-covered and uninsured patients in this age group was 18.3% in the expansion states and 14.5% in the nonexpansion states.
Medicaid expansion was associated with an increase in surgery volume for Medicaid-covered and uninsured patients by 42.8% (95% CI, 10.6%-84.3%) in the second year postexpansion and 43.8% (95% CI, 9.3%-89.3%) in the third year. From 2014 to 2017, the annual change was 36.6% (95% CI, 8.2%-72.5%). The volume for patients with Medicaid increased by 45.8% (95% CI, 6.2%-100.1%). Surgery volume change was not significant for uninsured patients (-10.6%; 95% CI, -42.7% to 39.5%) or privately insured patients (8.0%; 95% CI, -13.6% to 35.0%).
When the analyses were stratified according to race and ethnicity, Medicaid expansion was associated with an annual increase in surgery volume of 44.7% (95% CI, 13.5%-84.4%) in White patients. The annual change in Black (15.6%; 95% CI, -10.0% to 48.3%) and Hispanic patients (26.8%; 95% CI, -20.5% to 102.1%) was not statistically significant. Medicaid expansion was associated with an increase in Medicaid-covered and uninsured populations among White (10.1%; 95% CI, 3.9%-16.6%) and Black patients (12.1%; 95% CI, 5.6%-18.9%), but not among Hispanic patients (6.7%; 95% CI, -1.2% to 15.2%).
The rate of bariatric surgery increased in White patients (31.6%; 95% CI, 6.1%-63.0%), but the change in Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic patients (28.9%; 95% CI, -24.4% to 119.8%) was not significant.
The investigators noted that other sources of unobserved confounding cannot be ruled out, especially from other state and national policy changes. Additionally, the estimates have wide CIs due to standard errors clustered at the state level, and the data do not include information regarding the appropriateness of the bariatric surgeries performed.
“This study suggests that additional policy changes and clinical programs may be necessary to address barriers disproportionately faced by racial and ethnic minority populations to ensure more equitable access to evidence-based treatment of obesity,” the researchers commented.
Hanchate AD, Qi D, Paasche-Orlow MK, et al. Examination of elective bariatric surgery rates before and after US Affordable Care Act Medicaid expansion. JAMA Health Forum. 2021;2(10):e213083. doi:10.1001/jamahealthforum.2021.3083