Obesity Surgery

, Volume 28, Issue 1, pp 44–51 | Cite as

The Inequity of Bariatric Surgery: Publicly Insured Patients Undergo Lower Rates of Bariatric Surgery with Worse Outcomes

  • Dietric L. Hennings
  • Maria Baimas-George
  • Zaid Al-Quarayshi
  • Rachel Moore
  • Emad Kandil
  • Christopher G. DuCoin
Original Contributions



Bariatric surgery has been shown to be the most effective method of achieving weight loss and alleviating obesity-related comorbidities. Yet, it is not being used equitably. This study seeks to identify if there is a disparity in payer status of patients undergoing bariatric surgery and what factors are associated with this disparity.


We performed a case-control analysis of National Inpatient Sample. We identified adults with body mass index (BMI) greater than or equal to 25 kg/m2 who underwent bariatric surgery and matched them with overweight inpatient adult controls not undergoing surgery. The sample was analyzed using multivariate logistic regression.


We identified 132,342 cases, in which the majority had private insurance (72.8%). Bariatric patients were significantly more likely to be privately insured than any other payer status; Medicare- and Medicaid-covered patients accounted for a low percentage of cases (Medicare 5.1%, OR 0.33, 95% CI 0.29–0.37, p < 0.001; Medicaid 8.7%, OR 0.21, 95% CI 0.18–0.25, p < 0.001). Medicare (OR 1.54, 95% CI 1.33–1.78, p < 0.001) and Medicaid (OR 1.31, 95% CI 1.08–1.60, p = 0.007) patients undergoing bariatric surgery had an increased risk of complications compared to privately insured patients.


Publicly insured patients are significantly less likely to undergo bariatric surgery. As a group, these patients experience higher rates of obesity and related complications and thus are most in need of bariatric surgery.


Bariatric surgery Obesity Medicare Medicaid Insurance 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


  1. 1.
    Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States. JAMA. 2000;291:1238–45.CrossRefGoogle Scholar
  2. 2.
    Ogden CL, Carroll MD, Kit BK, et al. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief. 2012;82:1–8.Google Scholar
  3. 3.
    Kelly T, Yang W, Chen CS, et al. Global burden of obesity in 2005 and projections to 2030. Int J Obes. 2008;32:1431–7.CrossRefGoogle Scholar
  4. 4.
    Sturm R. Increases in clinically severe obesity in the United States, 1986–2000. Arch Intern Med. 2003;163:2146–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Ruhm CJ. Current and future prevalence of obesity and severe obesity in the United States. Forum Health Econ Policy. 2007;10:1086.CrossRefGoogle Scholar
  6. 6.
    Boido A, Ceriani V, Cetta F, et al. Bariatric surgery and prevention of cardiovascular events and mortality in morbid obesity: mechanisms of action and choice of surgery. Nutr Metab Cardiovasc Dis. 2015;25(5):437–43.CrossRefPubMedGoogle Scholar
  7. 7.
    Prospective Studies Collaboration. Body-mass index and cause- specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373:1083–96.CrossRefPubMedCentralGoogle Scholar
  8. 8.
    Flegal KM, Kit BK, Orpana H, et al. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309(1):71–82.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Andreyeva T, Sturm R, Ringel JS. Moderate and severe obesity have large differences in health care costs. Obes Res. 2004;12:1936–43.CrossRefPubMedGoogle Scholar
  10. 10.
    Grieve E, Fenwick E, Yang HC, et al. The disproportionate economic burden associated with severe and complicated obesity: a systematic review. Obes Rev. 2013;14(11):883–94.CrossRefPubMedGoogle Scholar
  11. 11.
    Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature. Psychol Bull. 1989;105:260–75.CrossRefPubMedGoogle Scholar
  12. 12.
    McLaren L. Socioeconomic status and obesity. Epidemiol Rev. 2007;29(1):29–48.CrossRefPubMedGoogle Scholar
  13. 13.
    Gortmaker SL, Must A, Perrin JM, et al. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med. 1993;329(14):1008–12.CrossRefPubMedGoogle Scholar
  14. 14.
    Averett S, Korenman S. Black-white differences in social and economic consequences of obesity. Int J Obes. 1999;23:166–73.CrossRefGoogle Scholar
  15. 15.
    Nguyen N, Vu S, Kim E, et al. Trends in utilization of bariatric surgery, 2009-2012. Sure Endosc. 2016;30:2723–7.CrossRefGoogle Scholar
  16. 16.
    NIH conference. Gastrointestinal surgery for severe obesity. consensus development conference panel. Ann Intern Med 1991;115(12):956–961.Google Scholar
  17. 17.
    Sundbom M. Laparoscopic revolution in bariatric surgery. World J Gastroenterol. 2014;20(41):15135–43.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Li J, Lai D, Wu D. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy to treat morbid obesity-related comorbidities: a systematic review and meta-analysis. Obes Surg. 2016;26(2):429–42.CrossRefPubMedGoogle Scholar
  19. 19.
    Flanagan E, Ghaderi I, Overby DW, et al. Reduced survival in bariatric surgery candidates delayed or denied by lack of insurance approval. Am Surg. 2016;82(2):166–70.PubMedGoogle Scholar
  20. 20.
    Healthcare cost and utilization project. Overview of national inpatient sample. http://www.hcup-us.ahrq.gov/nisoverview.jsp. Updated 2013. Access 9, 2013.
  21. 21.
    Santry HP, Lauderdale DS, Cagney KA, et al. Predictors of patient selection in bariatric surgery. Ann Surg. 2007;245:59–67.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Dallal RM, Bailey L, Guenther L, et al. Comparative analysis of short-term outcomes after bariatric surgery between two disparate populations. Surg Obes Relat Dis. 2008;4:110–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Cunningham PJ, Nichols LM. The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: a community perspective. Med Care Res Rev. 2005;62(6):676–96.CrossRefPubMedGoogle Scholar
  24. 24.
    Decker SL. In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Aff. 2012;31(8):1673–9.CrossRefGoogle Scholar
  25. 25.
    Long SH, Settle RF, Stuart BC. Reimbursement and access to physicians’ services under Medicaid. J Health Econ. 1986;5(3):235–51.CrossRefGoogle Scholar
  26. 26.
    Showalter MH. Physicians’ cost shifting behavior: Medicaid versus other patients. Contemp Econ Policy. 1997;15(2):74–84.CrossRefGoogle Scholar
  27. 27.
    Angus LD, Cottam DR, Gorecki PJ, et al. DRG, costs and reimbursement following Roux-en-Y gastric bypass: an economic appraisal. Obes Surg. 2003;13(4):591–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Carbonell AM, Lincourt AE, Matthews BD, et al. National study of the effect of patient and hospital characteristics on bariatric surgery outcomes. Am Surg. 2005;71:308–14.PubMedGoogle Scholar
  29. 29.
    Martin LF, Tan T-L, Holmes PA, et al. Preoperative insurance status influences postoperative complication rates for gastric bypass. Am J Surg. 1991;161:625–34.CrossRefPubMedGoogle Scholar
  30. 30.
    LaPar DJ, Bhamidipati CM, Mery CM, et al. Primary payer status affects mortality for major surgical operations. Ann Surg. 2010;252(3):544–50.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Giacovelli JK, Egorova N, Nowygrod R, et al. Insurance status predicts access to care and outcomes of vascular disease. J Vasc Surg. 2008;48(4):905–11.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Rosen H, Saleh F, Lipsitz S, et al. Downwardly mobile: the accidental cost of being uninsured. Arch Surg. 2009;144(11):1006–11.CrossRefPubMedGoogle Scholar
  33. 33.
    Martin LF, Robinson A, Moore BJ. Socioeconomic issues affecting the treatment of obesity in the new millennium. PharmacoEconomics. 2000;18(4):335–53.CrossRefPubMedGoogle Scholar
  34. 34.
    Borisenko O, Adam D, Funch-Jensen P, et al. Bariatric surgery can lead to net cost savings to health care systems: results from a comprehensive European decision analytic model. Obes Surg. 2015;25(9):1559–68.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Warren JA, Ewing JA, Hale AL, et al. Cost-effectiveness of bariatric surgery: increasing the economic viability of the most effective treatement for type II diabetes mellitus. Am Surg. 2015;81(8):807–11.PubMedGoogle Scholar
  36. 36.
    Sanchez-Santos R, Sabench Pereferrer F, Estévez Fernandez S, et al. Is the morbid obesity surgery profitable in times of crisis? A cost-benefit analysis of bariatric surgery. Cir Esp. 2013;91(8):476–84.CrossRefPubMedGoogle Scholar
  37. 37.
    Ackroyd R, Mouiel J, Chevallier JM, et al. Cost-effectiveness and budget impact of obesity surgery in patients with type-2 diabetes in three European countries. Obes Surg. 2006;16:1488–503.CrossRefPubMedGoogle Scholar
  38. 38.
    Salem L, Devlin A, Sullivan SD, et al. A cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding and non-surgical weight loss. Surg Obes Relat Dis. 2008;4:26–32.CrossRefPubMedGoogle Scholar
  39. 39.
    Ikramuddin S, Klingman D, Swan T, et al. Cost-effectiveness of Roux-en-Y gastric bypass in type diabetes patients. Am J Manag Care. 2009;15:607–15.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Dietric L. Hennings
    • 1
  • Maria Baimas-George
    • 1
  • Zaid Al-Quarayshi
    • 1
  • Rachel Moore
    • 1
  • Emad Kandil
    • 1
  • Christopher G. DuCoin
    • 1
    • 2
  1. 1.Department of Surgery, Division of General SurgeryTulane University School of MedicineNew OrleansUSA
  2. 2.Division of Minimal Invasive, Robotic and Endoscopic SurgeryTulane University School of MedicineNew OrleansUSA

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