title: Anticipating the impact of insurance expansion on inpatient urological surgery.
abstract: OBJECTIVE
  The Affordable Care Act (ACA) is expected to provide coverage for nearly twenty-five million previously uninsured individuals. Because the potential impact of the ACA for urological care remains unknown, we estimated the impact of insurance expansion on the utilization of inpatient urological surgeries using Massachusetts (MA) healthcare reform as a natural experiment.
  
  
  METHODS
  We identified nonelderly patients who underwent inpatient urological surgery from 2003 through 2010 using inpatient databases from MA and two control states. Using July 2007 as the transition point between pre- and post-reform periods, we performed a difference-indifferences (DID) analysis to estimate the effect of insurance expansion on overall and procedure-specific rates of inpatient urological surgery. We also performed subgroup analyses according to race, income and insurance status.
  
  
  RESULTS
  We identified 1.4 million surgeries performed during the study interval. We observed no change in the overall rate of inpatient urological surgery for the MA population as a whole, but an increase in the rate of inpatient urological surgery for non-white and low income patients. Our DID analysis confirmed these results (all 1.0%, p=0.668; non-whites 9.9%, p=0.006; low income 6.6%, p=0.041). At a procedure level, insurance expansion caused increased rates of inpatient BPH procedures, but had no effect on rates of prostatectomy, cystectomy, nephrectomy, pyeloplasty or PCNL.
  
  
  CONCLUSIONS
  Insurance expansion in Massachusetts increased the overall rate of inpatient urological surgery only for non-whites and low income patients. These data inform key stakeholders about the potential impact of national insurance expansion for a large segment of urological care.
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor ; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor ; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.
authors.forename: Chandy
authors.initials: C
authors.lastname: Ellimoottil
authors.affiliation: Robert Wood Johnson Foundation Scholar in Health Policy Research.
authors.forename: Sarah
authors.initials: S
authors.lastname: Miller
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor ; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor ; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.
authors.forename: John T
authors.initials: JT
authors.lastname: Wei
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor ; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor ; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.
authors.forename: David C
authors.initials: DC
authors.lastname: Miller