Expanding Medicaid access increases use of subspecialty surgical services in New York State

Researchers in the department of surgery at the University of Michigan have found that expanding access to Medicaid in New York State increased beneficiaries' use of subspecialty surgical services. The study, published in the May issue of the Journal of the American College of Surgeons, presents a model at the state level that shows expanding access to Medicaid successfully provided patients who did not have previous access to certain surgical procedures with access to these operations.

The Patient Protection and Affordable Care Act, signed into law March 23, 2010, required states to expand their Medicaid eligibility requirements. The goal was to allow more people to gain health coverage through the program. In June 2012, the Supreme Court ruled in favor of the states that protested the requirement, allowing them to opt out of expanding their state's Medicaid eligibility and coverage.

The study comes out amid the national debate on the value of Medicaid expansion in the short and long-term. As of April, 26 states have chosen to expand their Medicaid programs. Twenty-four states have chosen not to expand their Medicaid access, according to the WhiteHouse.gov website.

For the University of Michigan study, the researchers looked at patient data in the State Inpatient Database on 185,526 patients from 19 to 64 years of age who had at least one of three specific procedures between 1998 and 2006. New York State expanded its Medicaid program in 2001.

"I think the primary importance of understanding Medicaid expansion-especially because it's so actively debated-is what happens if certain states expand," said Aviram M. Giladi, MD, a sixth-year resident in the section of plastic surgery at the University of Michigan. "For states, the debate is between saving money or covering more people. But the bottom line is that people need to get to their doctors."

Dr. Giladi and his colleagues focused on whether a Medicaid expansion in New York actually did help people seek three particular surgical procedures-breast cancer reconstruction, lower-extremity trauma management, and panniculectomy, a procedure to remove excess skin and tissue, usually after dramatic weight loss.

These procedures were chosen to be the focus of the study because all of these operations result in a hospital stay. Two of the procedures require a referral (breast cancer reconstruction and panniculectomy), while lower extremity trauma surgery is generally performed on an emergent or urgent basis. These procedures also had high enough numbers to do a more thorough analysis, and these specialty procedures are different from the primary care services that have typically been included in studies about Medicaid expansion, the authors note.

The researchers found that expanding access to Medicaid in New York increased Medicaid recipients' use of surgical care services, specifically:

• There was a 5.5 percent increase of the proportion of breast cancer reconstruction patients covered by Medicaid.
• Among panniculectomy patients, the proportion of Medicaid recipients increased by 2.5 percent.
• There was a small increase in the proportion of Medicaid patients who received lower-extremity trauma management services, but the increase was not statistically significant.

The analysis showed "a significant post-expansion change in the probability that any patient receiving the selected subspecialty surgical procedures was a Medicaid beneficiary," the authors wrote.

"This finding suggests that the Medicaid expansion can work to improve access to sub-specialty services," Dr. Giladi said.

Dr. Giladi said he expects critics to point out that the health care providers could have simply cared for people who were previously uninsured and now enrolled in Medicaid. "But we're showing that there was not a replacement effect," he explained. "They didn't take patients from one pool and put them in another. These are people who were not getting surgical care and then got care after Medicaid expansion. However, surgeons did not leave the uninsured behind. They also got surgical care, and the volume of care given to the uninsured did not change across the years in our study."

To confirm this finding Dr. Giladi and his colleagues looked at discharge data that would have shown whether a patient was enrolled in Medicaid or remain uninsured. "The way we know that uninsured patients still received care at the same rates pre and post-expansion is by using the same modeling we used for Medicaid and following the trend results," Dr. Giladi explained. "These results showed that there was no change in the proportion of cases provided to the uninsured, indicating that the same amount of charity care was still being provided."

Other studies have echoed Giladi's conclusions. When Oregon expanded its Medicaid program in 2008, it didn't change how many people were diagnosed and treated for hypertension or high cholesterol, but it did increase the probability of being diagnosed with and treated for diabetes. It also increased the use of preventive services and drastically cut patients' out-of-pocket expenses, according to a study published in the New England Journal of Medicine.

Another study, published in the New England Journal of Medicine, looked at Medicaid expansions in New York, Maine, and Arizona and compared them with neighboring states that had not expanded coverage. Results showed that mortality decreased significantly, especially among seniors, ethnic minorities, and low-income patients.

"When you see the effect that expanding Medicaid can have on patient access to needed care," Giladi said, "the data suggest continuing to support Medicaid expansion in states that are in need."