- The Medicaid expansion prompted by the Affordable Care Act (ACA) has helped support patient access to surgical care, according to a group of researchers from the Harvard T.H. Chan School of Public Health.
The study, published in JAMA Surgery, pointed out that lack of health payer coverage has considerable effects on patient access to care and healthcare quality.
“Uninsured and underinsured patients are significantly more likely to delay care and present with more complicated disease for conditions including appendicitis, cholecystitis, diverticulitis, aortic aneurysms, and lower extremity peripheral artery disease (PAD),” the researchers said.
“Insurance status is also associated with decreased probability of receiving optimal care for such diagnoses, including a lower likelihood of minimally invasive surgery, a lower likelihood of receiving immediate cholecystectomy for acute cholecystitis, and a higher likelihood of amputation for vascular disease,” they added.
So far, some studies have proven that the ACA’s Medicaid expansion – which, to date, has offered better insurance coverage to 20 million patients – has been effective in expanding patient access to primary care and preventive care services. However, few studies have analyzed at the impacts of Medicaid expansion on patient access to surgical care.
The researchers posited that when more patients have health insurance access, they will present in the hospital earlier with less dire disease prognosis. In turn, care quality and clinical effectiveness could be greater.
The researchers used patient-level outcomes data in expansion and non-expansion states to investigate the before and after impacts of the ACA’s Medicaid expansion option. The team compared results for 27 expansion states and 15 non-expansion states.
Specifically, the researchers looked at patients with five common surgical needs: appendicitis, cholecystitis, diverticulitis, peripheral artery disease (PAD), or aortic aneurysm. The researchers investigated these conditions because the diagnoses are usually urgent, making delays in care a pressing issue. They are also highly morbid when left untreated.
In total, the researchers analyzed data for nearly 290,000 patients admitted for one of those surgical issues. Of those patients, 225,572 were admitted in an expansion state and 67,957 in a non-expansion state.
Patients benefitting from Medicaid expansion tended to see better health outcomes, the researchers found. Medicaid expansion was tied to a 7.5 percentage point increase in the likelihood of insurance coverage at the time of care. Expansion also resulted in an 8.6 percentage point increase in the probability that the patient was covered by Medicaid.
As a result, patient health improved. Medicaid expansion was tied to a 1.8 percentage probability that the patient received treatment earlier on in their ailment, and a 2.6 percentage probability that the patient received the type of treatment they needed earlier on.
“The Medicaid expansion was also associated with a significantly greater likelihood of patients presenting with earlier, less complicated disease at the time of admission and an increased likelihood of receiving optimal care after admission,” the researchers said. “As expected, these changes were concentrated among Medicaid and uninsured patients, who were most likely to benefit from coverage expansion, rather than those with private insurance.”
The researchers also pointed out that the Medicaid expansion had positive implications for hospitals and healthcare organizations such as reducing the likelihood of uncompensated care, they said.
“Having presented earlier in the clinical progression or deterioration of their conditions, patients may be more likely to receive optimal management with decreased morbidity and improved outcomes,” the team explained. In addition, hospitals may be more willing to provide care for newly insured individuals who previously lacked coverage.”
These results have implications for healthcare policy going forward, according to senior author Benjamin Sommers, associate professor of health policy and economics at Harvard Chan School.
“The fate of the ACA and Medicaid remains a key policy debate,” Sommers noted in a statement. “As policymakers continue to discuss major changes to the ACA, and the Trump administration advances reforms that could lead to fewer people covered by Medicaid, our findings provide important new evidence that Medicaid expansion is improving the quality of care for serious conditions affecting tens of thousands of Americans every year.”
Previous research has indicated that patient access to primary care has likewise thrived in Medicaid expansion states. A 2017 study published in JAMA Internal Medicine found that primary care access improved by 5.4 percent for patients benefitting from Medicaid expansion since a similar study conducted in 2013.
The researchers reported a negligible increase in patient access to primary care for privately-insured patients. Privately-insured patients still saw more expansive appointment availability than Medicaid patients.
That finding notwithstanding, the researchers said these survey results should ease some concerns related to the ACA and Medicaid expansion.
“The appointment availability results should ease concerns that the Affordable Care Act would exacerbate the primary care shortage,” the researchers concluded. “Primary care practices may be adapting to an influx of new patients with shorter visits and more rigorous management of no-shows.”
These patient access to both surgical and primary care studies indicate that the Medicaid expansion delivered as a part of the ACA is helping in improving patient access to care, ideally improving patient health.