Access to bariatric surgery increased by 31% annually for lower-income Medicaid-covered and uninsured white adults age 26 to 64 but not for Hispanic and Black adults after the expansion of the Affordable Care Act (ACA) Medicaid, according to researchers at Wake Forest School of Medicine.
"As the number of adults with severe obesity continues to grow in the US, bariatric surgery is the most effective treatment available," said the study's lead author, Dr Amresh D Hanchate, professor of public health sciences at Wake Forest School of Medicine. "The rapid increase and high rate of obesity in the US, 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."
Besides improving quality of life and conditions associated with obesity such as diabetes, hypertension and sleep apnoea, several studies have shown that bariatric surgery may also result in net savings of healthcare costs over a lifetime, Hanchate added.
The objective of the study, ‘Examination of Elective Bariatric Surgery Rates Before and After US Affordable Care Act Medicaid Expansion’, published in JAMA Health Forum, was to examine the association between Medicaid expansion and the rate of inpatient elective bariatric surgery among lower-income individuals aged 26 to 64. Researchers analysed data from 637,557 bariatric surgeries from 2010 to 2017 from 11 states that expanded Medicaid and six states that did not.
The researchers, including Dr Kristina Lewis Henderson, associate professor of public health sciences at Wake Forest School of Medicine, found that over the four years after expansion (2014-2017), use of bariatric surgery went up 31% each year among whites with Medicaid coverage or who were uninsured, but there was not a significant change in bariatric surgeries among non-Hispanic Black and Hispanic individuals.
The study showed that before the ACA's Medicaid expansion, lack of insurance may have been a major barrier for many lower-income patients eligible for bariatric surgery. However, insurance alone, while a necessary step toward improving bariatric surgery access, was not sufficient for Black and Hispanic patients in the study.
The study reported:
Between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in non-expansion states.
A total of 296,798 patients (78.9%) in expansion states were women vs 177,386 (78.9%) in non-expansion states.
Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%.
Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in non-expansion states.
Medicaid expansion was associated with a 36.6% annual increase in surgery volume, a 9.0% annual increase in the population and a 25.5% change in the rate of bariatric surgery.
By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, –19.8% to 39.9%) and Hispanic (28.9%; 95% CI, –24.4% to 119.8%) individuals.
Hanchate said additional research is needed to pinpoint reasons behind this disparity. For these populations, there may be other barriers to bariatric surgery that still need to be removed, he said.
Future studies could examine, for example, whether lower-income Hispanic and Black patients are less likely to be referred by their primary care physicians for surgical evaluation or more likely to be excluded during the pre-approval process.
"There are almost certainly other structural barriers facing minority patients, including ongoing racism and discrimination," Hanchate said.
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