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Original Investigation |

Effect of Insurance Expansion on Utilization of Inpatient Surgery

Chandy Ellimoottil, MD1,2,3; Sarah Miller, PhD4; John Z. Ayanian, MD, MPP3,5,6,7; David C. Miller, MD, MPH1,2,3
[+] Author Affiliations
1Department of Urology, Medical School, University of Michigan, Ann Arbor
2Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor
3Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
4Robert Wood Johnson Foundation Scholar in Health Policy Research, University of Michigan, Ann Arbor
5Division of General Medicine, Medical School, University of Michigan, Ann Arbor
6Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
7Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor
JAMA Surg. 2014;149(8):829-836. doi:10.1001/jamasurg.2014.857.
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Importance  Enhanced access to preventive and primary care services is a primary focus of the Affordable Care Act, but the potential effect of this law on surgical care is not well defined.

Objective  To estimate the differential effect of insurance expansion on utilization of discretionary vs nondiscretionary inpatient surgery with Massachusetts health care reform as a natural experimental condition.

Design, Setting, and Participants  We used the state inpatient databases from Massachusetts and 2 control states (New Jersey and New York) to identify nonelderly adult patients (aged 19-64 years) who underwent discretionary vs nondiscretionary surgical procedures from January 1, 2003, through December 31, 2010. We defined discretionary surgery as elective, preference-sensitive procedures (eg, joint replacement and back surgery) and nondiscretionary surgery as imperative and potentially life-saving procedures (eg, cancer surgery and hip fracture repair).

Exposure  All surgical procedures in the study and control populations.

Main Outcomes and Measures  Using July 1, 2007, as the transition point between the prereform and postreform periods, we performed a difference-in-differences analysis to estimate the effect of insurance expansion on rates of discretionary and nondiscretionary surgical procedures in the entire study population and for subgroups defined by race, income, and insurance status. We then extrapolated our results from Massachusetts to the entire US population.

Results  We identified a total of 836 311 surgical procedures during the study period. Insurance expansion was associated with a 9.3% increase in the use of discretionary surgery in Massachusetts (P = .02). Conversely, the rate of nondiscretionary surgery decreased by 4.5% (P = .009). We found similar effects for discretionary surgery in all subgroups, with the greatest increase observed for nonwhite participants (19.9% [P < .001]). Based on the findings in Massachusetts, we estimated that full implementation of national insurance expansion would yield an additional 465 934 discretionary surgical procedures by 2017.

Conclusions and Relevance  Insurance expansion in Massachusetts was associated with increased rates of discretionary surgery and a concurrent decrease in rates of nondiscretionary surgery. If similar changes are seen nationally under the Affordable Care Act, the value of insurance expansion for surgical care may depend on the relative balance between increased expenditures and potential health benefits of greater access to elective inpatient procedures.

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Figure 1.
Changes in Rates of Discretionary and Nondiscretionary Surgical Procedures After Insurance Expansion in Massachusetts

Bar graphs represent the percentage change in the mean rates of discretionary and nondiscretionary surgical procedures before and after Massachusetts health care reform (July 1, 2007). Control states include New Jersey and New York. Net change in Massachusetts due to insurance expansion was determined using multivariable difference-in-differences analysis and represents the change in the rate of surgical procedures attributed to insurance expansion.

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Figure 2.
Changes in Rates of Discretionary Surgical Procedures After Insurance Expansion in Massachusetts by Subgroups

Bar graphs represent the percentage change in the mean rates of discretionary surgical procedures before and after Massachusetts health care reform (July 1, 2007). The nonwhite population includes black patients and those of Hispanic origin. Low income refers to patients residing in the tercile of Massachusetts counties with the lowest median income. Newly insured refers to patients residing in Massachusetts counties with high numbers of individuals gaining insurance from 2006 through 2008. Control states are New Jersey and New York. Net change in Massachusetts due to insurance expansion was determined using multivariable difference-in-differences analysis and represents the change inthe rate of surgical procedures attributable to insurance expansion.

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