Medicaid Expansion: Is There a Storm Brewing?: Commentary on an article by Christopher J. Dy, MD, MPH, et al.: "Unmet Need for Total Joint Arthroplasty in Medicaid Beneficiaries After Affordable Care Act Expansion".

Abstract

Commentary Medicaid eligibility was expanded under the U.S. Affordable Care Act in 2014. This provided coverage in participating states for citizens with incomes up to 133% of the poverty line. Previous large database studies have shown that the expansion option has led to an increase enrollment in Medicaid with a concomitant greater utilization of health-care services, including orthopaedic procedures. With limited providers accepting Medicaid, there is a concern that this influx of new patients will cause further strain on the system and potentially lead to even greater health-care disparities if measures are not taken to ensure appropriate access to care. In their study, Dy et al. attempt to understand the impact that Medicaid expansion may have on the health-care system, specifically in terms of the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA). The authors hypothesized that patients who were newly enrolled in the Medicaid expansion would proceed to a surgical procedure following enrollment in the plan sooner than traditional Medicaid beneficiaries (Supplemental Security Income [SSI] and Temporary Assistance for Needy Families [TANF]), thereby representing a pent-up demand in these patients that may strain the health-care system. In their study, the authors indeed found a shorter time from enrollment to a surgical procedure in the patients in the expansion group compared with the patients in the SSI and TANF groups. The authors concluded that health-care providers and policymakers should be aware of this earlier demand for a surgical procedure in order to anticipate future needs. Although the study covers the important topic of health-care disparities, it did have several limitations, including the small sample size. Only 663 patients across 4 states were enrolled in the expansion program and underwent a THA or TKA through the managed care company during the study period. This small sample limits the ability of the reader to understand or predict the impact that further expansion of the program will have on the health-care system. Although the authors use the shorter time from enrollment to a surgical procedure to conclude that there is a pent-up demand, this abbreviated wait time also suggests that the health-care systems in participating states are not currently overwhelmed by the new patients. As the authors discuss, the shorter wait times for the patients in the expansion group could be due to several variables, including potential differences in reimbursement between plans by the managed care company, thereby incentivizing providers to offer services to the patients in the expansion group at the expense of the patients in the SSI and TANF groups. It would be interesting to compare the mean wait time for all Medicaid patients prior to, and following, state participation in the Medicaid expansion program, as an overall increased lag time would suggest strain on the system rather than simply shifting resources away from the patients in traditional Medicaid plans to the new patients in the expansion program. Although this article is a good initial step, larger studies will be helpful to better clarify the true impact that the Medicaid expansion program has on the health-care system.