Medicaid expansion doesn’t improve minority access to complex surgical care

Medicaid expansion under the Affordable Care Act (ACA) failed to improve access to care for minorities and low-income patients with complex surgical needs, researchers reported in the Sept. 13 online edition of the Journal of the American College of Surgeons.

Senior investigator Waddah B. Al-Refaie, MD, led a team of Georgetown researchers who examined the medical records of 166,588 patients at 468 hospitals across five states—three of which opted to expand Medicaid effective in 2014, and two of which decided against expansion. The team focused on high-volume hospitals, which are associated with better patient outcomes and higher-quality surgical care.

Al-Refaie, Surgeon-in-Chief for the Georgetown Lombardi Comprehensive Cancer Center and Regional Chief of Surgical Oncology at MedStar Georgetown University Hospital, said in a release the ACA, first signed into law in March of 2010, has in many cases improved access to care for vulnerable populations.

“We know that the ACA has led to a large reduction in the rate of uninsured patients, but concerns remain as to whether increased coverage has translated into improved access to quality care hospitals,” he said.

Al-Refaie et al.’s study looked at patient treatment from 2012 through the end of 2014 and was supplemented by data from the State Inpatient Databases, American Hospital Association Annual Survey Database and Area Resource File from Health Resources and Services Administration.

While the authors found more patients overall had better access to complex surgeries—including heart bypass surgery, pancreatic cancer surgery, total hip replacement and total knee replacement—a disparity remained between wealthy white patients and those lower on the socioeconomic totem pole.

“White and high-income patients were more likely to receive these complex surgeries at high-volume hospitals relative to disadvantaged patients,” Al-Refaie said. “Indeed, we also observed that ACA’s expansion did not accelerate access to complex surgery at high-volume hospitals overall."

He said the biggest driver to access of care is usually the availability of insurance, but Medicaid expansion didn’t seem to improve utilization of complex surgical care.

“We are surprised at the results, because we already know, from other studies, that the ACA’s Medicaid expansion has increased access to surgical care overall,” he said. “But we found that the expansion did not improve access to complex surgery that is typically centralized to high-volume hospitals.”

Al-Refaie said a slew of patient, physician and hospital factors could contribute to the gap in care, but regardless, Medicaid expansion under the ACA showed a “flat effect.”

“These early results may be highlighting what could be a continuing potential limitation of the program to persons with complex surgical problems,” he said.