Did Medicaid Expansion Broaden Minoritized Patients Access to Anti-Incontinence Procedures?

Objective: The Affordable Care Act (ACA) expanded Medicaid eligibility in 2014. Since expansion, primary care and preventative services’ access improved, however access to surgical services is less well known. We aimed to determine if access to anti-incontinence procedures supported by Medicaid increased after expansion. We also aimed to determine whether Medicaid supported anti-incontinence procedures differed by US region, and if expansion affected access to anti-incontinence procedures by minoritized individuals.


Methods: The 2012-2018 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) was reviewed for anti-incontinence surgeries. HCUP-NIS reports regional data (Northeast(NE), Midwest(M), South(S) and West(W)) on procedures performed and patient data including insurance type, race, ethnicity and income level. The NE(89%) had the most states which expanded Medicaid followed by the W(77%), M(58%), and S(47%) in 2018. Percent of anti-incontinence surgeries paid for by Medicaid were compared by region and year, and among marginalized populations.


Results: A total of 66,510 anti-incontinence surgeries were performed during the study period. Medicaid as a primary payer for anti-incontinence procedures increased from 10 to 12% (p=0.008) between 2012 and 2018. The percentage of Medicaid anti-incontinence surgeries performed in the N(13%) and W(17%) were greater than M(9%) and S(8%) (p < 0.001). The percentage of Medicaid supported anti-incontinence procedures among Black, Hispanic or lowest income quartile patients were lowest in the South and did not increase after expansion during the study period (2012 vs 2018, p = 0.67, p= 0.77, p=0.23, respectively). The N(p=0.042) and W(p= < 0.001) had significant increases in the percentage of surgeries covered by Medicaid following expansion while the M(p=0.610) and S(p=0.764) did not. When controlling for confounders, the M(OR 0.58; 95% CI 0.46-0.74 ) and S(OR 0.33; 95% CI 0.26-0.42) were less likely to have Medicaid covered anti-incontinence surgeries compared to the N(ref) and W(OR 1.04; 95% CI 0.84-1.29).


Conclusions: Nationally, the percentage of Medicaid-supported anti-incontinence procedures increased after expansion. In regions that adopted expansion, access to anti-incontinence procedures increased, and access by minoritized populations broadened. The South, with the lowest rates of expansion, had the most limited access to anti-incontinence procedures for minoritized individuals. These inequities illustrate the negative impact of limiting health insurance access for minoritized populations.