Background: 

The utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) increased after Medicaid expansion under the U.S. Affordable Care Act (ACA), suggesting a potential unmet need for THA and TKA. We examined the timing of THA and TKA in patients after obtaining Medicaid expansion insurance coverage. We hypothesized that patients with Medicaid expansion insurance would undergo a surgical procedure sooner than patients in traditional Medicaid populations.

Methods: 

We used administrative data from a Medicaid managed care company to determine the timing of primary THA and TKA in patients who were 18 to 64 years of age in 4 states with Medicaid expansion (Illinois, Ohio, Oregon, and Washington) and 4 states without Medicaid expansion (Louisiana, Mississippi, Texas, and Wisconsin) from 2008 to 2015. The insurance types were Medicaid expansion, Medicaid plans for Supplemental Security Income (SSI), or Temporary Assistance for Needy Families (TANF). Roughly, these 3 groups correspond to relatively healthy childless adults, relatively unhealthy disabled adults, and parents of children with Medicaid insurance. The main outcome measure was time from enrollment to the surgical procedure. The primary exposure of interest was insurance type. We used a generalized linear regression model to adjust for patient age, sex, social deprivation, surgeon supply and reimbursement, and state-level Medicaid enrollment.

Results: 

In the unadjusted analysis of 4,117 patients, there was a significantly shorter time from enrollment to THA and TKA for the expansion group (median, 7.5 months) relative to the SSI group (median, 16.1 months; p < 0.0001) and the TANF group (median, 12.2 months; p < 0.0001). In the adjusted analysis, the time from enrollment to THA and TKA was significantly shorter in the expansion group (β, −1.21 [95% confidence interval (CI), −1.35 to −1.07]; p < 0.001) compared with the TANF group (β, −0.27 [95% CI, −0.38 to −0.17]; p < 0.001) and the SSI group (reference). Compared with the SSI group, these coefficients are equivalent to a 70% shorter time to the surgical procedure in the expansion group and a 24% shorter time to the surgical procedure in the TANF group.

Conclusions: 

Our findings suggest an unmet need for THA and TKA among newly enrolled Medicaid expansion beneficiaries. This need should be considered by surgeons, hospitals, and policymakers in ensuring access to care. Furthermore, consideration should be given to existing insurance-based disparities in access to orthopaedic care, as these may be exacerbated by an increased demand for THA and TKA from Medicaid expansion beneficiaries.

中文翻译：

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平价医疗法案扩大后，医疗补助受益人对全关节置换术的需求未得到满足。

背景： 

根据美国平价医疗法案 (ACA) 的医疗补助计划扩大后，全髋关节置换术 (THA) 和全膝关节置换术 (TKA) 的使用率增加，表明对 THA 和 TKA 的潜在需求未得到满足。我们检查了获得医疗补助扩展保险后患者接受 THA 和 TKA 的时机。我们假设有医疗补助扩展保险的患者会比传统医疗补助人群中的患者更早接受外科手术。

方法： 

我们使用来自 Medicaid 管理式医疗公司的行政数据来确定 4 个有 Medicaid 扩大的州（伊利诺伊州、俄亥俄州、俄勒冈州和华盛顿州）和 4 个没有 Medicaid 的州的 18 至 64 岁患者进行初次 THA 和 TKA 的时间2008 年至 2015 年的扩张（路易斯安那州、密西西比州、德克萨斯州和威斯康星州）。保险类型包括医疗补助扩张、补充保障收入医疗补助计划 (SSI) 或贫困家庭临时援助 (TANF)。粗略地说，这 3 组对应于相对健康的无子女成年人、相对不健康的残疾成年人和有医疗补助保险的孩子的父母。主要结局指标是从入组到手术的时间。主要的利益风险是保险类型。我们使用广义线性回归模型来调整患者的年龄、性别、

结果： 

在对 4,117 名患者进行的未经调整的分析中，与 SSI 组（中位数，16.1 个月；p < 0.0001）和 TANF 组相比，扩展组（中位数，7.5 个月）从入组到 THA 和 TKA 的时间显着缩短（中位数，12.2 个月；p < 0.0001）。在调整后的分析中，与 TANF 组相比，扩展组从入组到 THA 和 TKA 的时间显着缩短（β，-1.21 [95% 置信区间 (CI)，-1.35 至 -1.07]；p < 0.001） （β，-0.27 [95% CI，-0.38 至 -0.17]；p < 0.001）和 SSI 组（参考）。与 SSI 组相比，这些系数相当于扩张组手术时间缩短 70%，TANF 组手术时间缩短 24%。

结论： 

我们的研究结果表明，新登记的医疗补助扩展受益人对 THA 和 TKA 的需求未得到满足。外科医生、医院和政策制定者在确保获得护理时应考虑这种需求。此外，应考虑现有的基于保险的在获得骨科护理方面的差异，因为医疗补助扩展受益人对 THA 和 TKA 的需求增加可能会加剧这些差异。