Skip to main content

Advertisement

SpringerLink
Log in

The Effects of the Affordable Care Act on Utilization of Bariatric Surgery

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Introduction

The Affordable Care Act (ACA) expanded Medicaid (ME) and instituted Essential Health Benefits (EHB) that included bariatric surgery coverage on a state-by-state opt-in basis, increasing insurance coverage of bariatric surgery.

Materials and Methods

Using a difference-in-differences framework, changes in bariatric surgery rates, defined as utilization in the population of people with obesity, before and after the ACA were evaluated in four states. Bariatric surgery procedure data were taken from the Healthcare Cost and Utilization Project’s State In-patient Database 2012–2015. Adjusted multivariable regressions were run in the Medicaid and commercially insured populations.

Results

We identified 36,456 bariatric surgeries across the 286 Health Service Areas and time periods, with 31,732 covered by commercial insurers and 4724 covered by Medicaid. An unadjusted increase in utilization rates was seen in the Medicaid and Commercial populations in both ME- and EHB-covered states as well as non-expansion and EHB opt-out states over time. In the Medicaid population, after adjusting for confounders, there was a significant increase of 24.77 cases per 100,000 people with obesity (95% confidence interval: 12.41, 37.13) in the expansion states relative to the control and pre-period. The commercial population experienced a nonsignificant change in the rates of bariatric surgery, decreasing by 2.89 cases per 100,000 people with obesity (95% confidence interval: − 21.59, 15.81).

Conclusions

There was a significant increase in bariatric surgery rates among Medicaid beneficiaries associated with Medicaid expansion, but there was no change among the commercially insured.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–14.

    Article  CAS  Google Scholar 

  2. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief, no 360. Hyattsville: National Center for Health Statistics; 2020.

    Google Scholar 

  3. Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA. 2003;289:187–93.

    Article  Google Scholar 

  4. Obesity and Cancer Risk. National Cancer Institute. Web. Accessed 14 Apr 2016.

  5. Wang YC, Pamplin J, Long MW, et al. Severe obesity in adults cost state Medicaid programs nearly $8 billion in 2013. Health Aff. 2015;34(11):1923–31.

    Article  Google Scholar 

  6. Cawley J, Rizzo JA, Haas K. Occupation-specific absenteeism costs associated with obesity and morbid obesity. J Occup Environ Med. 2007;49(12):1317–24.

    Article  Google Scholar 

  7. Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials. BMJ. 2013;347:f5934.

    Article  Google Scholar 

  8. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systemic review and meta-analysis. JAMA. 2004;292(14):1724–8.

    Article  CAS  Google Scholar 

  9. Fouse T, Schauer P. The socioeconomic impact of morbid obesity and factors affecting access to obesity surgery. Surg Clin North Am. 2016;96(4):669–79. https://doi.org/10.1016/j.suc.2016.03.002.

    Article  PubMed  Google Scholar 

  10. Cremieux PY, Buchwald H, Shikora SA, et al. A study on the economic impact of bariatric surgery. Am J Manag Care. 2008;14(9):589–96.

    PubMed  Google Scholar 

  11. Gulliford MC, Charlton J, Prevost T, Booth H, Fildes A, Ashworth M, Littlejohns P, Reddy M, Khan O, Rudisill C. Costs and outcomes of increasing access to bariatric surgery: cohort study and cost-effectiveness analysis using electronic health records. Value Health. 2017;20(1):85–92. https://doi.org/10.1016/j.jval.2016.08.734.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Martin M, Beekley A, Kjorstad R, et al. Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis. Surg Obes Relat Dis. 2010;6:8–15.

    Article  Google Scholar 

  13. Alexander JW, Goodman HR, Hawver LRM, et al. The impact of Medicaid status on outcome after gastric bypass. Obes Surg. 2008;18:1241–5. https://doi.org/10.1007/s11695-008-9615-7.

    Article  PubMed  Google Scholar 

  14. Status of state action on the Medicaid expansion decision. Kaiser Family Foundation. 14 March 2016. Web. Accessed 14 Apr 2016.

  15. Eligibility. medicaid.gov. Web. Accessed 14 Apr 2016.

  16. Yang YT, Pomeranz JL. States variations in the provision of bariatric surgery under affordable care act exchanges. Surg Obes Relat Dis. 2015;11:715–20.

    Article  Google Scholar 

  17. HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2005–2009. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp. Accessed 20 Mar 2021.

  18. U.S. Census Bureau. State Population Estimates. 2014.

  19. RWJF. The State of Obesity 2014. Princeton, NJ. Available at: https://www.rwjf.org/en/library/research/2014/09/the-state-of-obesity.html. Accessed 8 Aug 2020.

  20. The Dartmouth Atlas Project. Variation in the Care of Surgical Conditions 2014. Lebanon, NJ. Available at: https://www.dartmouthatlas.org/downloads/atlases/Surgical_Atlas_2014.pdf. Accessed 8 Aug 2020.

  21. StataCorp. Stata Statistical Software: Release 15. College Station: StataCorp LLC; 2017.

    Google Scholar 

  22. Gould KM, Zeymo A, Chan KS, DeLeire T, Shara N, Shope TR, Al-Refaie WB. Bariatric surgery among vulnerable populations: the effect of the Affordable Care Act’s Medicaid expansion. Surgery. 2019;166(5):820–8. https://doi.org/10.1016/j.surg.2019.05.005.

    Article  PubMed  Google Scholar 

  23. Cazzo E, Ramos AC, Pareja JC, Chaim EA. Nationwide macroeconomic variables and the growth rate of bariatric surgeries in Brazil. Obes Surg. 2018;28(10):3193–8. https://doi.org/10.1007/s11695-018-3318-5.

    Article  PubMed  Google Scholar 

  24. Cazzo E, Ramos AC, Chaim EA. Bariatric surgery offer in Brazil: a macroeconomic analysis of the health system’s inequalities. Obes Surg. 2019;29(6):1874–80. https://doi.org/10.1007/s11695-019-03761-3.

    Article  PubMed  Google Scholar 

  25. Chhabra KR, Fan Z, Chao GF, Dimick JB, Telem DA. Impact of statewide essential health benefits on utilization of bariatric surgery. Obes Surg. 2019;30(1):374–7.

    Article  Google Scholar 

  26. Ellimoottil C, Miller S, Ayanian JZ, Miller DC. Effect of insurance expansion on utilization of inpatient surgery. JAMA Surg. 2014;149(8):829–36. https://doi.org/10.1001/jamasurg.2014.857.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Crocker AB, Zeymo A, Chan K, et al. The Affordable Care Act’s Medicaid expansion and utilization of discretionary vs. non-discretionary inpatient surgery. Surgery. 2018;164(6):1156–61. https://doi.org/10.1016/j.surg.2018.05.007.

    Article  PubMed  Google Scholar 

  28. Afonso BB, Rosenthal R, Li KM, Zapatier J, Szomstein S. Perceived barriers to bariatric surgery among morbidly obese patients. Surg Obes Relat Dis. 2010;6(1):16–21. https://doi.org/10.1016/j.soard.2009.07.006.

    Article  PubMed  Google Scholar 

  29. Wharton S, Serodio KJ, Kuk JL, Sivapalan N, Craik A, Aarts MA. Interest, views and perceived barriers to bariatric surgery in patients with morbid obesity. Clin Obes. 2016;6(2):154–60. https://doi.org/10.1111/cob.12131.

    Article  PubMed  CAS  Google Scholar 

  30. Imbus JR, Voils CI, Funk LM. Bariatric surgery barriers: a review using Andersen’s Model of Health Services Use. Surg Obes Relat Dis. 2018;14(3):404–12. https://doi.org/10.1016/j.soard.2017.11.012.

    Article  PubMed  Google Scholar 

  31. Doumouras AG, Lee Y, Babe G, Gmora S, Tarride JE, Hong D, Anvari M. The hidden cost of an extensive preoperative work-up: predictors of attrition after referral for bariatric surgery in a universal healthcare system. Surg Endosc. 2020;34(2):988–95. https://doi.org/10.1007/s00464-019-06894-9.

    Article  PubMed  Google Scholar 

  32. Angrisani L, Santonicola A, Iovino P, Ramos A, Shikora S, Kow L. Bariatric Surgery Survey 2018: similarities and disparities among the 5 IFSO chapters. Obes Surg. 2021;31(5):1937–48. https://doi.org/10.1007/s11695-020-05207-7.

    Article  PubMed  Google Scholar 

  33. Dixon JB. Regional differences in the coverage and uptake of bariatric-metabolic surgery: a focus on type 2 diabetes. Surg Obes Relat Dis. 2016;12(6):1171–7. https://doi.org/10.1016/j.soard.2015.11.027.

    Article  PubMed  Google Scholar 

  34. Global Health Observatory [Internet]. Geneva (Switzerland): World Health Organization. c2017- [cited 2021 July 19] Available from: https://www.who.int/data/gho. Accessed 15 Jul 2021.

Download references

Funding

This project was funded by a Leonard Davis Institute Pilot Project Grant.

Author information

Author notes

  1. Ezra Brooks and Elizabeth Bailey contributed equally to this work.

Authors and Affiliations

  1. Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 5th floor, Philadelphia, PA, 19104, USA

    Ezra S. Brooks

  2. Department of Plastic Surgery, University of Pittsburgh, 3550 Terrace Street, 6B Scaife Hall, Pittsburgh, PA, 15261, USA

    Elizabeth A. Bailey

  3. Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA

    Elizabeth A. Bailey, Catherine L. Mavroudis, Christopher J. Wirtalla & Rachel R. Kelz

  4. Metabolic and Bariatric Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA

    Victoria M. Gershuni & Noel N. Williams

Authors
  1. Ezra S. Brooks
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elizabeth A. Bailey
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Catherine L. Mavroudis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Christopher J. Wirtalla
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Victoria M. Gershuni
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Noel N. Williams
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Rachel R. Kelz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ezra S. Brooks.

Ethics declarations

Ethics Approval and Informed Consent

This article does not contain any studies with human participants or animals performed by any of the authors. Informed consent does not apply.

Conflict of Interest

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Key Points

• Bariatric surgery rates have been increasing over time in all populations, but the procedure remains underutilized.

• ME resulted in more bariatric operations in expansion states relative to non-expansion states.

• Coverage of bariatric surgery by EHB had no significant effect on a state’s surgery rates.

• Poor insurance coverage of this surgery is only one of many factors resulting in its underutilization.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 18 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Brooks, E.S., Bailey, E.A., Mavroudis, C.L. et al. The Effects of the Affordable Care Act on Utilization of Bariatric Surgery. OBES SURG 31, 4919–4925 (2021). https://doi.org/10.1007/s11695-021-05669-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-021-05669-3

Keywords

Search

Navigation