• Will the ACA make more surgeries happen?

    Yes, according to a new study in JAMA Surgery. “Effect of Insurance Expansion on Utilization of Inpatient Surgery“:

    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.

    Researchers looked at three states from 2003 through 2010 – Massachusetts, New Jersey, and New York. Of course, Massachusetts had ACA-like reform passed in 2007. So this provided a way to look at how coverage reform might change the number and rate of surgical procedures versus states without coverage reform.

    What they found was that discretionary surgical procedures went up in Massachusetts by 9.3%. In addition, non-discretionary procedures went down 4.5%.

    The first thing to note is that, once again, more access leads to more access. Giving more people insurance leads to more utilization. This doesn’t mean that quality is going up, but it certainly means that access is improving. That’s what the ACA was designed to do, and it’s likely that it will work.

    Why did discretionary procedures go up and non-discretionary procedures go down? It’s possible that  people were getting preventive procedures and care done that prevented “emergencies” later. Whether this is true, or whether it leads to decreased spending and better outcomes is still unknown.

    Bottom line: just as we’ve seen in the emergency department, giving more people coverage leads to more utilization. It likely will at a national level, too.

    @aaronecarroll

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