Study Reveals How the ACA Impacted Roux-en-Y Gastric Bypass Utilization

The number of patients undergoing bariatric surgery significantly increased after the passage of the Affordable Care Act (ACA) in 2010, especially among Black patients, Medicaid beneficiaries, and patients with low income, according to new research published in The American Surgeon.

The study also showed that, despite there being more patients undergoing high-risk surgeries since the ACA, these surgeries had better postoperative outcomes.

Bariatric surgery | Image credit: Olivier Le Moal – stock.adobe.com

These findings are based on an analysis of Medicaid data from 158,186 total Roux-en-Y Gastric Bypass (RYGB) surgery procedures performed during 2 periods: a pre-ACA period between 2007 and 2009 making up 30% of included procedures, and a post-ACA period between 2017 and 2019 accounting for the other 70% of RYGB procedures. The post-ACA timeline was selected as most states enacted the ACA in 2014, providing a transition period between 2014 and 2017. Data was pulled from the National Inpatient Sample (NIS) Database, the largest all-payer inpatient health care database in the US that is available to the public.

Compared with the pre-ACA period, the proportion of patients without insurance decreased post-ACA, going from 4.8% to 3.6% (P < .05), with the proportion of patients insured by Medicare specifically increasing from 10.2% to 13.9% (P < .005). Meanwhile, the proportion of patients with private insurance specifically decreased from 74.2% to 61.4% (P < 005) between the 2 periods, though the overall number did not necessarily decrease as well, as most patients who underwent the procedure post-ACA were still privately insured.

Also in the post-ACA period, the percentage of patients undergoing RYGB increased among:

• Patients aged older than 65, increasing from 3.1% to 6.2% (P < .001)
• Black patients, increasing from 12.5% to 18.5% (P < .001)
• Hispanic patients, increasing from 9.8% to 15.4% (P < .001)

The percentage of White patients undergoing RYGB decreased from 72.1% to 61.1% (P < .001) as the proportion of patients of other races increased, but the authors noted that the actual number of White patients undergoing the procedure was still higher than the rest.

Additionally, more patients of the lowest income quartile—defined as up to $49,999 in annual income—underwent RYGB during the 2017-2019 period (25.9%) compared with the 2007-2009 period (20.4%; P < .001). According to the authors, these shifts suggest improved access for patients from minority, low-income, and Medicaid-insured populations following ACA enactment.

“The favorable impact of the ACA on the accessibility of Roux-en-Y gastric bypass surgery and the reduction of postoperative complications highlights the benefits of similar policies on a national scale,” the study authors said. “Future health care reforms should retain the beneficial components of the ACA, recognizing its value in enhancing health care access and outcomes for patients.”

The authors also found differences between the pre– and post-ACA periods in terms of patient outcomes following the procedure. Post-ACA, patients were 84% less likely to have longer hospital stays, 71% less likely to experience in-hospital mortality, 75% less likely to have a surgical site infection, 76% less likely to have a post-op hemorrhage, and 86% less likely to have am anastomotic leak compared with patients who underwent RYGB in the pre-ACA period.

“These improvements may be attributed to heightened access to preventive and primary care under the ACA, facilitating early management of obesity and its comorbidities consequently optimizing patient conditions before surgery,” the authors said. “It is worth noting that some studies have reported minimal or no improvements in outcomes for specific surgeries post-ACA. Our research, by offering a large sample size, as well as a more focused evaluation of outcomes within a specific surgical procedure, adds granularity to the ongoing discussion.”

The study demonstrated that the enactment of the ACA led to a notable surge in the number of RYGB procedures, improving accessibility to this crucial obesity treatment, particularly for populations disproportionately affected by obesity. Additionally, the study suggested that the ACA contributed to enhanced surgical outcomes post-RYGB, evident in shorter hospital stays, decreased in-hospital mortality rates, and reduced postoperative complications. Despite these positive findings, the study acknowledges persistent disparities among demographic groups, emphasizing the importance of ongoing efforts to address health care inequities.

“In our future study, we plan to compare the states that have accepted the act and those who didn’t and employ a difference-in-differences analysis to address some of the limitations present in the current study,” the authors noted.

Reference

Weldeslase TA, Akinyemi OA, Keeling DJ, Enchill KA, Cornwell EE 3rd, Fullum TM. Utilization and outcomes of Roux-en-Y gastric bypass surgery following the Affordable Care Act in the United States. Am Surg. Published online January 12, 2024. doi:10.1177/00031348241227190