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The Effect of Pre-Affordable Care Act (ACA) Medicaid Eligibility Expansion in New York State on Access to Specialty Surgical Care

Aliu, Oluseyi MD, MS*; Auger, Katherine A. MD, MS; Sun, Gordon H. MD, MS; Burke, James F. MD, MS§; Cooke, Colin R. MD, MSc, MS; Chung, Kevin C. MD, MS; Hayward, Rodney A. MD#,**

doi: 10.1097/MLR.0000000000000175
Original Articles

Background: Critics argue that expanding health insurance coverage through Medicaid may not result in improved access to care. The Affordable Care Act provides reimbursement incentives aimed at improving access to primary care services for new Medicaid beneficiaries; however, there are no such incentives for specialty services. Using the natural experiment of Medicaid expansion in New York (NY) State in October 2001, we examined whether Medicaid expansion increased access to common musculoskeletal procedures for Medicaid beneficiaries.

Methods: From the State Inpatient Database for NY State, we identified 19- to 64-year-old patients who underwent lower extremity large joint replacement, spine procedures, and upper/lower extremity fracture/dislocation repair from January 1998 to December 2006. We used interrupted time series analysis to evaluate the association between Medicaid expansion and trends in the relative and absolute number of Medicaid beneficiaries who underwent these musculoskeletal procedures.

Results: Before Medicaid expansion, we observed a slight but steady temporal decline in the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries. After expansion, this trend reversed, and by 5 years after Medicaid expansion, the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries was 4.7 percentage points [95% confidence interval, 3.9–5.5] higher than expected, based on the preexpansion time trend.

Conclusion: Medicaid expansion in NY State significantly improved access to common musculoskeletal procedures for Medicaid beneficiaries.

Supplemental Digital Content is available in the text.

*Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI

Division of Hospital Medicine and James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Partnership for Health Analytic Research, LLC, Beverly Hills, CA

Departments of §Neurology

Internal Medicine

Section of Plastic Surgery, Department of Surgery

#Department of Internal Medicine, The University of Michigan Health System

**VA Center for Clinical Management Research, Ann Arbor, MI

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the Robert Wood Johnson Foundation Clinical Scholars (O.A., K.A.A., G.H.S., J.F.B., and R.H.), and by the Veterans Affairs Administration (O.A., G.H.S., J.F.B., and R.H.). Also, supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (to K.C.C.), and the Methods Core of the Michigan Center for Diabetes Translational Research [NIDDK of The National Institutes of Health (P60 DK-20572)] (R.H.).

The authors declare no conflict of interest.

Reprints: Oluseyi Aliu, MD, MS, 2800 Plymouth Road, Building #10, Room G016, Ann Arbor, MI 48109. E-mail:

© 2014 by Lippincott Williams & Wilkins.