Do Patients With Income-Based Insurance Have Access to Total Joint Arthroplasty? Ran Schwarzkopf, MD, MSc a , Duy L. Phan, MD a , Melinda Hoang, BSc a , Steven D.K. Ross, MD a , Dana Mukamel, PhD b a Department of Orthopaedic Surgery, University of California Irvine, Orange, California b Health Policy Research Institute, University of California Irvine, Irvine, California abstract article info Article history: Received 27 August 2013 Accepted 26 November 2013 Keywords: total hip arthroplasty Patient Protection and Affordable Care Act Medicaid income-based insurance health care access The Patient Protection and Affordable Care Act (PPACA) is expected to increase health care availability through Medicaid expansion. The objective of this study was to evaluate potential effects of the PPACA by examining access to total hip arthroplasty in Southern California. 39 orthopaedic surgeons were called to schedule a hip arthroplasty. Insurances used included a Preferred Provider Organization (PPO), Medicare, and three income-based insurances. There was a significant difference in acceptance rate when comparing PPO and Medicare patients with income-based insurances (P b 0.001). This study showed that in Southern California, patients with income-based insurances are limited in the number of surgeons from whom they can receive care. Thus, although the PPACA will increase the number of insured patients, it may not similarly increase access to providers. © 2014 Elsevier Inc. All rights reserved. Increasing patient access to health care has been a heavily studied topic, especially in the last half decade, culminating in the new Patient Protection and Affordable Care Act (PPACA) passed by Congress in 2010. The full implementation of the bill, expected in 2014, has been heralded by some as the solution to one of the most persistent problems of American health care – the lack of access for almost 50 million individuals [1] – and derided by others as both logistically and financially unfeasible. Older programs that were similarly intended to increase access, ranging from federal and state systems such as Medicare and Medicaid to programs at the local county or institution level, have decisively affected the role held by patients, physicians, and hospitals. That the PPACA will also change the way health care is maintained and delivered is undoubtedly true. The majority of the population is insured, either through private insurers if they are employed or by Medicare, if they are over 65 years of age and have been working (or have been married to someone who worked) during their earlier years. And while both access and quality may vary depending on the type of insurance or geographic location, by and large these patients have coverage and can readily receive medical care. Those with a low income or without employer-provided insurance might be eligible for Medicaid. Medicaid was created by an amendment to the Social Security Act of 1965 and is a federal entitlement program administered by the states. As of 2009, there were over 61.8 million beneficiaries enrolled with almost 308 million dollars in payments making Medicaid the single largest health insurance program in the United States [2,3]. In California, Medicaid services are disbursed by the Medi-Cal program, which had over 11.0 million beneficiaries in 2009 with over 35 million dollars in payments similarly making it the largest provider in the state [2–4]. Medicaid does not, however, cover all those who do not have private insurance. Many adults of low income do not qualify for Medicaid, resulting in over 40 million individuals who are uninsured. The PPACA is expected to change this lack of coverage through the Medicaid expansion provision of the law. Based on the recent Supreme Court ruling, individual states can choose to adopt or decline this provision; at last report a total of 27 states were planning to uphold the provision, 17 states were not, and 7 states were currently in debate [5]. Depending on the ultimate number of states accepting the provision, it is estimated that by 2016, another 21 million patients will potentially be enrolled, greatly reducing the overall number of the uninsured [2]. Insurance coverage, however, does not equate to access to care. Despite programs like Medicaid, there are still significant problems with access to elective services, especially when patients have insurances considered unattractive by providers. Iobst et al showed that in Florida, children requiring evaluation for fractures were less likely to be seen by an orthopaedic surgeon if they had Medicaid as opposed to private insurance [6]. Lavernia et al showed that in Florida, adults in need of lower extremity total joint arthroplasty had a lower likelihood of receiving a timely appointment if they had Medicaid [7]. A potential reason for this disparity may be due to the low rate of payment for Medicaid patients. In 2012, the national average The Journal of Arthroplasty 29 (2014) 1083–1086.e1 Supplementary material available at www.arthroplastyjournal.org. The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2013.11.022. Reprint requests: Ran Schwarzkopf, MD, MSc, 101 The City Drive South, Pavilion III, Building 29, Orange, CA 92868, USA. http://dx.doi.org/10.1016/j.arth.2013.11.022 0883-5403/© 2014 Elsevier Inc. All rights reserved. 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