The Effect of Medicaid Expansion on Route of Hysterectomy

INTRODUCTION: There are disparities in the route of hysterectomy despite the gold standard recommendation of a minimally invasive approach. Privately insured patients are more likely to have access to minimally invasive hysterectomy compared to patients with Medicaid insurance. The Affordable Care Act offered the opportunity for state-specific expansion of Medicaid, improving access to gynecologic care for many patients. Studies have shown Medicaid expansion has improved access to hysterectomies in general, but the association between expansion status and access to minimally invasive techniques is unknown. OBJECTIVE: The aim of this study is to understand the association of state Medicaid expansion status with route of hysterectomy (abdominal vs minimally invasive). We hypothesize that states with expanded Medicaid will have a lower proportion of abdominal hysterectomies compared to non-expansion states. METHODS: We compared state-specific rates of abdominal versus minimally invasive hysterectomy in 2018 using Medicaid claims data. CPT codes identified patients who underwent hysterectomies using the CMS Transformed Medicaid Statistical Information system (T-MSIS) Analytic Files (TAF). Patients were excluded if a hysterectomy was done at the time of cesarean delivery or was for oncologic indications. The rate of hysterectomy per 100,000 Medicaid enrollees was calculated. Rates of abdominal (AH) and minimally invasive hysterectomy (MIH) were calculated for each state. Regional rates were also calculated (Census Bureau Regions: Northeast, South, Midwest, West). Analytic statistics were performed to evaluate any associations with Medicaid expansion. RESULTS: The analysis included hysterectomies in 46 states and one district. Three states were excluded from analysis due to low surgical volume; one state was excluded due to lack of geographic data. There were 66,998 procedures included in the analysis and 49,277,237 Medicaid enrollees. Medicaid expansion states had a rate of 176 hysterectomies per 100,000 Medicaid enrollees, compared to 135 hysterectomies per 100,000 Medicaid enrollees in non-expansion states (p-value .035). There was no difference in regional rates of hysterectomy per 100,000 Medicaid enrollees (p-value .505). In states with Medicaid expansion, the rate of AH was 0.033% and the rate of MIH was 0.142%. In states without expansion, the rate of AH was 0.020% and the rate of MIH was 0.115%. There was a statistically significant difference between the rate of AH in expansion and non-expansion states with a p-value of <.001. There was no statistically significant difference in comparison of MIH rates in expansion and non-expansion states with a p-value of .117. CONCLUSIONS: The rate of total hysterectomies in non-expansion states was statistically higher in Medicaid expansion states compared to non-expansion states. Abdominal hysterectomies were less likely to occur in non-expansion states, and there was no difference in rates of MIH between non-expansion and expansion states. Further investigation should explore the shift in care before and after the expansion as well as types of pathology encountered.