The Impact of Medicaid Expansion on Access to Pelvic Organ Prolapse Surgery

Objectives: 1) To compare changes in the rates of publicly insured patients undergoing pelvic organ prolapse (POP) surgery between regions that underwent Medicaid expansion and those that did not. Hypothesis: In regions with a higher proportion of Medicaid expansion states, the rate of publicly insured patients undergoing POP surgery will be greater than that of regions with fewer Medicaid expansion states. [Table 1]
2) To compare the change in the rate of marginalized patients undergoing POP surgery between regions with more states that underwent Medicaid expansion and those with fewer Medicaid expansion states. Hypothesis: The rate of marginalized patients undergoing POP surgery will be higher in Medicaid expansion regions than in those with lower rates of Medicaid expansion. [Table 1]

Methods: We conducted a retrospective analysis of the 2012-2019 Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS), the largest publicly available, all-payer, inpatient healthcare database in the US. The HCUP-NIS does not report the states in which surgeries are performed but does report the region. Using regional data as a proxy for expansion, we identified patients who underwent POP procedures prior to and following Medicaid expansion using the ICD-9 and -10 diagnosis and procedure codes for POP. Variables included demographics, primary payor, comorbidities, and perioperative data. The main outcome was the number of POP surgeries performed per year, by primary payor and region. Regions were as defined by the US Census Bureau. Multivariable analysis was performed to control for confounding differences in region characteristics. Chi-squared test was used for categorical variables. Student t-test and Mann-Whitney U test were used for parametric and nonparametric continuous variables, respectively. Statistical significance was defined as P < .05.

Results: Between 2012 (pre-Medicaid expansion) and 2019, the proportion of POP repairs for patients with Medicaid rose from 6% to 11% for the entire country. For the Northeast region, where all states underwent Medicaid expansion by 2019, this proportion rose from 8% to 13%; for the South, where 8/17 states (representing 24% of the total population) underwent expansion, this proportion rose from 4% to 5%. [Table 1] The proportion of POP repairs for Black patients rose from 16% to 38% in the Northeast region between 2012 and 2019, while in the South region this proportion fell from 6% to 5%; the proportion of POP repairs for lowest income quartile patients rose from 18% to 21% in the Northeast region between 2012 and 2019 and 6% to 7% in the South. [Table 1]

Conclusions: Regions with a higher rate of Medicaid expansion were found to have higher rates of publicly insured and marginalized patients undergoing POP repair surgery.