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Medicaid Expansion Didn't Fix Surgery Disparity for Minorities

Analysis  |  By Gregory A. Freeman  
   September 19, 2018

The expansion of Medicaid under the ACA did not lead to any increase in complex surgical procedures at high-volume hospitals for minorities and low-income patients. The study results suggest Medicaid expansion does not address these disparities.

Contrary to the expectations of many healthcare and government leaders, Medicaid expansion under the Affordable Care Act did not increase the use of complex surgical procedures at high-volume hospitals among ethnic/racial minorities and low-income populations, according to a recent study.

The study compared surgery records from high-volume hospitals in three states that opted in to the ACA's Medicaid expansion with similar hospitals in two states that did not. The researchers from Georgetown University Hospital concluded that Medicaid expansion under the ACA does not appear to reduce disparities in use of regionalized surgical care among vulnerable persons.

The study's senior investigator, Waddah B. Al-Refaie, MD, FACS, says the results were surprising.

"These early results may be highlighting what could be a continuing potential limitation of the program to persons with complex surgical problems," said in a statement released by the university.

Acting on evidence suggesting that vulnerable populations, such as racial and ethnic minorities and low-income individuals, are less likely to benefit from ongoing trends to regionalize complex surgical care to high volume hospitals, the study was designed to evaluate access to four intricate surgeries at high volume hospitals, which are known to provide higher-quality care.

These are highlights from the study:

  • The researchers examined the records of 166,588 patients, ages 18 to 64, at 468 hospitals in the five states.
  • The complex surgeries were heart bypass surgery, pancreatic cancer surgery, total hip replacement, and total knee replacement.
  • The three expansion states were Kentucky, Maryland, and New Jersey. The two non-expansion states were North Carolina and Florida. 
  • The researchers found that while more patients overall had access to these surgeries in the expansion states than before the ACA was enacted, the proportions of low-income individuals and racial/ethnic minorities receiving their complex surgery at high-volume hospitals did not increase.
  • White and high-income patients were more likely to receive these complex surgeries at high-volume hospitals, relative to disadvantaged patients.

The study authors suggest that a number of issues may explain the results, including patient, referring physician, and hospital factors. Patients may prefer to have their surgery at low-volume hospitals closer to where they live, for example, or are unable to travel to high-volume hospitals.

"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" Al-Refaie says. "We need to continue to evaluate and track how the ACA is providing access to quality care hospitals for complex surgery on both a national level and within states."

Gregory A. Freeman is a contributing writer for HealthLeaders.

Photo credit: iStockphoto


In states with Medicaid expansion, more patients overall had access to complex surgeries. But the gains went predominantly to white and high-income patients.

Vulnerable populations, such as racial and ethnic minorities and low-income individuals, are less likely to benefit from the regionalization of complex surgical care.

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