The Patient Protection and Affordable Care Act, more commonly referred to as Obamacare, aims to ensure millions of low-income Americans are able to get access to the health care they need. Earlier this year, Medicaid was expanded in some states. But how will it affect the use of inpatient surgery in the US? A new study published in JAMA Surgery investigates.

Obamacare was rolled out in 2010. Once it is fully implemented in the US, it is estimated to provide cover for up to 25 million previously uninsured individuals.

From January 1st this year, some states received additional funding to expand their Medicaid programs, meaning adults under the age of 65 who earn up to 133% of the federal poverty level could be covered.

But the research team, led by Chandy Ellimoottil of the University of Michigan, says it has not been fully considered how the reform will impact complex and expensive hospital-based care, such as inpatient surgery.

"For instance," the researchers say, "owing to a large unmet need, insurance expansion might yield greater utilization of surgery across the board. An alternative scenario is that rates of surgery will change mainly for certain procedures and patient populations."

2006 Massachusetts health care reform used for estimation

The researchers note that past studies have used the 2006 health care reform in Massachusetts to estimate the effects Obamacare would have in the US, so the researchers did the same.

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Researchers used the 2006 health care reform in Massachusetts to estimate how Obamacare may impact the rates of inpatient surgery going forward.

They analyzed information from inpatient databases in Massachusetts between January 1st, 2003, and January 1st, 2010.

They used July 1st, 2007, as a transition point between prereform and postreform periods. "We selected this date because although the law was enacted in April 2006, its provisions were implemented in a staggered fashion, and the number of uninsured individuals did not decline significantly until 2007," the team explains.

They also analyzed data from the inpatient databases of two other states - New Jersey and New York - to act as controls over the same time periods.

Specifically, the team set out to identify patients between the ages of 19 and 64 who underwent discretionary surgery (elective procedures such as back surgery and joint replacements) and nondiscretionary surgery (required procedures such as cancer surgery or acute appendicitis).

'Half a million new discretionary surgical procedures could take place by 2017'

During the 7-year period, researchers identified 836,311 surgical procedures. Of these, 22.2% took place in Massachusetts, 54.7% took place in New York and 22.9% took place in New Jersey.

In Massachusetts, the team found that insurance expansion was associated with a 9.3% increase in discretionary surgical procedures and a 4.5% decrease in nondiscretionary surgical procedures. From this, the researchers estimate that Obamacare could result in 465,934 extra discretionary surgical procedures by 2017.

The researchers note that their findings build on previous studies suggesting that the use of health care increases when previously uninsured individuals become insured. But the team says this effect does not appear to be uniform for inpatient surgical care.

"Instead," they add, "patients in need of imperative or nondiscretionary inpatient surgery appear to get this care whether or not they have insurance. In contrast, insurance expansion is an important driver of utilization rates for the relatively large population of patients who are potential candidates for discretionary or elective procedures."

"Our collective findings suggest that insurance expansion leads to greater utilization of discretionary inpatient procedures that are often performed to improve quality of life rather than to address immediately life-threatening conditions.

Moving forward, research in this area should focus on whether greater utilization of such procedures represents a response to unmet need or changes in treatment thresholds driven by patients, providers or some combination of the two."

The team points out that their findings are subject to limitations. For example, they say there is no standard definition for discretionary and nondiscretionary surgery, therefore it is impossible to know for certain whether a procedure was discretionary or not.

In addition, they say that using the Massachusetts health care reform act to predict the outcome of Obamacare may have its flaws, as it was rolled out in different circumstances. "Nonetheless," they add, "the Massachusetts experience is the most reasonable natural experiment of broad insurance expansion and has been used widely to forecast effects of the Affordable Care Act."

Medical News Today recently reported on research from the Centers for Disease Control and Prevention, suggesting that Obamacare will lead to better public health because of a greater focus on preventive medicine.