Bariatric Surgeries Increased After ACA Expansion, But Not for All Racial/Ethnic Backgrounds

Amresh D. Hanchate, PhD

A new study from Wake Forest School of Medicine is detailing the effects of the Affordable Care Act (ACA) Medicaid expansion on access to bariatric surgery among patients with obesity.

Results of the study, which examined bariatric procedures performed from 2010-2017, indicates use of bariatric surgery increased by 31% each year after expansion among White patients with Medicaid coverage or who were uninsured but also demonstrates no significant change occurred among non-Hispanic Black and Hispanic patients.

“As the number of adults with severe obesity continues to grow in the United States, bariatric surgery is the most effective treatment available,” said lead investigator Amresh D. Hanchate, PhD, professor of public health sciences at Wake Forest School of Medicine, in a statement. “The rapid increase and high rate of obesity in the United States, particularly among populations with low incomes and who are underserved, has exacerbated disease burden, low quality of life, premature death and healthcare costs. As an elective procedure primarily for people younger than 65, bariatric surgery is a marker of healthcare access to both primary and specialist clinicians.”

As the obesity epidemic continues to balloon and evidence surrounding bariatric surgery continues to grow, Hanchate and a team of colleagues designed the current study to assess whether the ACA Medicaid expansion was associated with a change in uptake of elective bariatric surgery. A difference-in-differences analysis, investigators planned to leverage all-payer data from 2010-2017 for elective bariatric surgeries for patients 26-74 years of age from 11 expansion states and 6 nonexpansion states.

The 11 expansion states included were Arizona, Arkansas, California, Colorado, Illinois, Iowa, Kentucky, New Jersey, New York, Oregon, and Pennsylvania. The 6 nonexpansion states included were Florida, Georgia, North Carolina, Texas, Virginia, and Wisconsin. Together, these states accounted for 63% of the national population and provided data related to 637,557 elective bariatric surgeries.

The primary outcomes of interest for the analyses were the number of elective bariatric surgeries, population count, and rate of bariatric surgeries per 10,000 people among Medicaid-covered and uninsured individuals. For the purpose of analysis, data from nonexpansion states and individuals aged 65-74 years were used as control cohorts.

Upon analysis, investigators determined Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states between 2010 and 2017. Among those 26-64 years of age, women accounted for 78.9% of individuals in both expansion states and nonexpansion states. In comparison to surgery recipients with private insurance, higher proportions of Medicaid-covered recipients were younger, women, and Black or Hispanic.

When assessing number of surgeries following expansions, the number of bariatrics surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states in 16.5% in nonexpansion states from 2013-2017. Additionally, results suggested Medicaid expansion was associated with a 36.6% (95% CI, 8.2 to 72.5%) annual increase in surgery volume, a 9.0% (95% CI, 3.8 to 14.5%) in the population, and a 25.5% (95% CI, -1.3 to 59.4%) in the rate of bariatric surgery.

When assessing the outcomes according to race and ethnicity, results indicated Medicaid expansion was associated with an increase in rate of bariatric surgery among non-Hispanic White individuals (31.6% [95% CI, 6.1 to 63.0%]). However, no significant change in rate was observed among non-Hispanic Black (5.9% [95% CI, -19.8 to 39.9%]) and Hispanic individuals (28.9% [95% CI, -24.4 to 119.8%]).

This study, “Examination of Elective Bariatric Surgery Rates Before and After US Affordable Care Act Medicaid Expansion,” was published in JAMA Health Forum.