As the remaining non-expansion states consider expanding Medicaid eligibility, a new study offers encouraging evidence that Medicaid patients’ access to surgical care can be maintained even when enrollment surges. In the American Journal of Surgery, my co-authors and I compared patients’ use of high-quality colorectal surgeons after the Affordable Care Act’s (ACA’s) Medicaid expansion in two states: New York, an expansion state, and Florida, a non-expansion state.

Jason Tong, MD is an LDI Associate Fellow, a general surgery resident at the University of Pennsylvania, and a candidate for a Masters of Science in Health Policy Research as a National Clinical Scholar.

We observed 73,866 patients in two geographically large and diverse states that differed in their Medicaid expansion status. Using state claims data, we compared patients’ use of high-volume surgeons and colorectal-boarded surgeons (markers of high quality) before the implementation of the ACA’s Medicaid expansion (2012-2013) and after (2016-2017) in both states. We adjusted for patient characteristics, including age and comorbidities.

During the study period, the Medicaid population grew by 68% in New York, compared to only 6% in Florida. Following expansion, Medicaid patients’ use of high-quality surgeons held steady at 16% in New York and 23% in Florida. However, commercially insured patients in New York were less likely to use a high-volume colorectal surgeon than their counterparts in Florida. We also found a 6% decrease in the number of high-volume surgeons in New York, compared to a 31% increase in Florida.

The decrease in commercial patients’ use of high-volume colorectal surgeons is a puzzling, and potentially concerning, finding. It may reflect several potential market changes over time in both states, including shifts in surgeon workforce composition, narrowing of commercial plan networks, crowd out in the commercial market, or changes in provider reimbursement. To explain this phenomenon, future research on coverage expansions should consider changes in provider costs, network sizes, and payer mix, among other factors. Further work should assess and compare the impact of coverage expansion across different specialties and multiple states.

Overall, our work suggests that states can successfully expand Medicaid coverage without negatively impacting access to high-quality surgical care for the Medicaid population. This finding—coupled with new incentives in the American Rescue Plan Act—should encourage non-expansion states to take a closer look at expansion.

The study, The Impact of the Affordable Care Act on Surgeon Selection Amongst Colorectal Surgery Patients, was published in the American Journal of Surgery in February 2021. Authors include Jason Tong, Ezra S. Brooks, Catherine L. Mavroudis, Christopher Wirtalla, Cary B. Aarons, Nicole M. Saur, Najjia N. Mahmoud, Giorgos C. Karakousis, & Rachel R. Kelz.