State-Level Public Insurance Coverage and Neonatal Circumcision Rates

A retrospective cohort study of neonates born at hospitals in 4 US states in the years 2001, 2006, 2011, and 2016 was conducted. State-specific neonatal circumcision rates were calculated for each study year and compared to previously established national estimates. The impact of state-level changes in Medicaid coverage for neonatal circumcision was evaluated. The study was deemed exempt (analysis of de-identified, previously collected data) by the Ann & Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board.

The State Inpatient Databases (SID) are a subset of the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality. Each individual database contains data from an estimated 97% of inpatient hospitalizations for a given state and year. Study states were selected to optimize diversity in region of the United States, population demographics, and population density. Medicaid funding for neonatal circumcision during the study time period (continuous versus discontinued) was also taken into consideration for selection of study states. The final study cohort was constructed by using combined data from 4 states (CO, FL, NY, and MI) at 4 time points (2001, 2006, 2011, and 2016). Neonatal circumcision was covered by Medicaid in all 4 states in 2001. Medicaid funding for neonatal circumcision was discontinued in Florida (2003) and Colorado (2011) during the study period (Table 1).

Male neonates who were discharged from an inpatient stay were included in the cohort. Neonates were identified on the basis of admission type (neonatal). Neonates with coagulopathies, genitourinary anomalies, or prematurity were identified by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision diagnosis codes and excluded. The primary study outcome was inpatient neonatal circumcision, as determined by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision procedure coding. Because the SID only include inpatient events, outpatient circumcision and related encounters are not observed in the SID.

Descriptive statistics were used to characterize the study population. Logistic regression models were created to assess the association between patient characteristics, state characteristics, and the predicted odds of neonatal circumcision. Variables in the model included year, state, race and/or ethnicity, insurance status, and Medicaid coverage of neonatal circumcision. Univariable and multivariable analyses were performed. Neonates in the collapsed “other” race category included the following groups: Asian or Pacific Islander, American Indian, and other. None of these individual racial groups accounted for >8% of the population at any given time. A difference-in-differences estimation was used to assess the effect of discontinuation of Medicaid coverage for neonatal circumcision on the odds of neonatal circumcision in the population insured by Medicaid. An indicator variable for discontinuation of Medicaid coverage for neonatal circumcision (defined as the time after which circumcision was not covered by Medicaid) and an indicator variable for being covered by Medicaid were created. An interaction term between the 2 indicator variables was included in a logistic regression model (controlling for state, race and/or ethnicity, and year) to assess for the impact of policy change in the publicly insured population. A separate interaction term was included in the multivariable model to assess whether the effect of discontinuation of Medicaid coverage for neonatal circumcision on the odds of neonatal circumcision was different for different racial and/or ethnic groups. All statistical analyses were performed by using Stata 15.1 statistical software (Stata Corp, College Station, TX), and a P value of <.05 was considered statistically significant.

A total of 1 149 576 male neonates were included in the study (Table 2). The cohort included 278 000 to 294 000 neonates per study year. The number of eligible neonates varied widely by state, with Florida and New York accounting for three-quarters of the cohort (36.8% and 40.0%, respectively) and Colorado accounting for only 8.4%. The cohort was 52.8% white, 45.3% covered by Medicaid, and 47.6% covered by private insurance over all study years combined.

Overall, 54.5% of neonates underwent neonatal circumcision. Neonatal circumcision rates were highest in Michigan (84.5%) and lowest in Florida (37.8%). In states where Medicaid coverage for neonatal circumcision was discontinued during the study period, there was a decrease in circumcision rates in the years after discontinuation (from 47.4% to 37.5% in FL [2001–2006] and from 61.9% to 52.0% in CO [2011–2016]; Fig 1). In the 2 states where Medicaid coverage for neonatal circumcision was discontinued, the largest changes in neonatal circumcision rates were seen among neonates covered by Medicaid in the years after discontinuation of Medicaid coverage for the procedure (from 34.9% to 19.6% in FL [2001–2006] and from 48.1% to 36.7% in CO [2011–2016]; Fig 2).

Unadjusted analyses revealed higher odds of neonatal circumcision among neonates from Michigan compared with Colorado, among neonates with private insurance compared with public insurance, and among non-Hispanic white neonates compared with those of all other racial and/or ethnic groups (Table 3). Further exploration of interaction terms and difference-in-differences analyses indicated that associations between race and/or ethnicity and insurance status and odds of neonatal circumcision also depended Medicaid coverage for the procedure. The difference-in-differences estimation revealed that the discontinuation of Medicaid coverage for neonatal circumcision had a statistically significant negative effect on the odds of neonatal circumcision in the population covered by Medicaid versus those covered by private insurance (adjusted odds ratio [aOR] 0.43; 95% confidence interval [CI] 0.43–0.44). In the multivariable regression model with interaction terms, neonates covered by private insurance had higher odds of neonatal circumcision than neonates covered by Medicaid (aOR 2.23; 95% CI 2.21–2.25) when controlling for other factors (Table 4). The interaction term revealed an association between race and/or ethnicity and Medicaid coverage of neonatal circumcision, suggesting that the effect of discontinuation of Medicaid coverage for neonatal circumcision on the odds of neonatal circumcision varied by racial and/or ethnic group. When Medicaid coverage for the procedure was available, Black neonates had significantly higher odds of neonatal circumcision than white neonates (aOR 1.44; 95% CI 1.42–1.46). When Medicaid coverage for neonatal circumcision was not available, Black neonates had significantly lower odds of neonatal circumcision than white neonates (aOR 0.40; 95% CI 0.39–0.41). In contrast, Medicaid funding for neonatal circumcision was not associated with substantive differences in the comparative rates of neonatal circumcision for Hispanic and non-Hispanic other race neonates compared with non-Hispanic white neonates (Table 4).

Neonatal circumcision rates in the current study closely mirror previously established regional and national estimates,^2,7  indicating differences by US region and a modest overall decline in neonatal circumcision rates over time. In Colorado and Florida, Medicaid coverage for neonatal circumcision was discontinued during the study period, and rates declined more significantly in those states versus with Michigan and New York, where Medicaid coverage for the procedure was continuous. A decrease in neonatal circumcisions among neonates covered by Medicaid appears to be contributing to the overall decline in rates of neonatal circumcision, and non-Hispanic Black neonates were the group most significantly impacted by discontinuation of Medicaid coverage for neonatal circumcision.

Researchers of previous studies have sought to estimate rates of neonatal circumcision at state and national levels using large databases. However, most studies to date rely on sampled data intended to be used as a national or regional sample, limiting the ability to evaluate state-level changes in access to the procedure. Additionally, given the sampled nature of the data, doubts have been raised about the accuracy of previous estimates. In this study, we use population-level data to investigate rates of circumcision at the state level, allowing for conclusions about state-level changes in Medicaid coverage for neonatal circumcision to be drawn. The rates of circumcision from this study trend closely with previously established regional estimates,^2,7  validating previous analyses.

Several organizations, including the American Academy of Pediatrics, have determined that the benefits of neonatal circumcision are sufficient to justify access to the procedure for families who choose it. Although many factors may influence whether families pursue neonatal circumcision, affordability of the procedure has been identified as a main factor in the decision-making process. By discontinuing Medicaid coverage for the procedure, states are ultimately influencing the decision-making process in a manner that is inconsistent with current evidence-based clinical guidance. Given the demographic distribution of the population covered by Medicaid, certain groups are disproportionately affected. A lifetime cost simulation model published by Kacker et al²⁵  in 2012 estimated a high likelihood of increased Medicaid expenditures if rates of male circumcision in the United States were to decrease, suggesting that the long-term financial benefits of the procedure far outweigh the initial cost. This financial benefit was predominantly linked to higher rates of urinary tract and sexually transmitted infections in a population with lower rates of male circumcision. Although this does not justify recommending that all boys undergo the procedure, it does support the position that families who choose for their child to undergo the procedure should have access to circumcision in the neonatal period. In 2013, Introcaso et al¹  suggested that low-income populations, including those covered by Medicaid, stand to gain the most from the medical benefits of the procedure. This raises concern that discontinuation of Medicaid coverage for neonatal circumcision may be a key contributor to health disparities, such as transmission of HIV or prevalence of HPV. Combined with the findings in our study, one can conclude that discontinuing coverage of neonatal circumcision under Medicaid is creating access barriers for the population who will benefit the most from the procedure.

A second potential impact of changes in Medicaid coverage of neonatal circumcision not directly addressed in this study is the potential for increased incidence of delayed elective circumcision among the population covered under Medicaid. In 2013, Gutwein et al²³  published an analysis of outpatient data in Florida, comparing boys covered by Medicaid with those covered by private insurance, and demonstrated a significant sixfold increase in nonneonatal (delayed) circumcision rates after discontinuation of Medicaid coverage for neonatal circumcision in the state. A racial difference was also seen, with a 77.3% increase in outpatient circumcision among Black boys compared with a 28.7% increase among white boys in the same time period.²³  The concern is that removing coverage for neonatal circumcision under Medicaid may decrease the rates of the safer, less costly procedure in exchange for a concurrent increase in the more expensive one, which will expose boys to higher risk and the increased potential for complications.

The Colorado Department of Health Care Policy and Financing reinstated funding for neonatal circumcision in September 2017, 6 years after initial discontinuation of Medicaid funding for neonatal circumcision.²²  To the best of the authors’ knowledge, there is no publicly available statement justifying the decision to reinstate coverage for the procedure. Follow-up studies on how reinstatement of neonatal circumcision coverage affects circumcision rates within a population could provide valuable information to support the development of future policies.

This study is limited by use of multiple individual databases from relatively few states and years to assess the impact of Medicaid coverage changes. In particular, we were unable to include more recent data because 2016 was the most recent year available for all states. Our 4-state approach also limits generalizability to all states, or the United States as a whole, given the many factors that impact decision-making regarding neonatal circumcision. However, we note that the inclusion of 3 of the 10 most populous states with a wide range of demographics is likely illustrative of broad national trends and echoes rates of neonatal circumcision reported in other studies. Additionally, the differences in variable availability between databases limited inclusion of some variables of interest in the final analysis. Finally, use of population-level databases does not allow for a thorough assessment of all factors that contribute to an individual family’s decision to pursue neonatal circumcision. However, the use of a difference-in-differences analysis can mitigate this problem of unobserved data by assuming that such factors are unlikely to change as substantially over time within each state as the major policy change in Medicaid that was observed.

Within the context of its limitations, this population-level study provides essential insight about neonatal circumcision rates in 4 US states with different demographic profiles. The study design allowed for a detailed analysis of state-level changes in Medicaid coverage of neonatal circumcision. The impact of the change is apparent in the study, and follow-up studies are underway to assess the long-term impact on individual boys and society. One such potential impact could be the increase in rates of elective operative outpatient circumcision in the same population, a procedure with higher complication rates and cost when compared to neonatal circumcision. Such unintended consequences of Medicaid policy may have long-standing health implications that merit reconsideration of the policy as a way to safeguard lifelong health while also reducing the cost burden for Medicaid. Although this study expands our understanding of how policy affects neonatal circumcision rates, many questions remain. Further studies on how reinstating Medicaid coverage for neonatal circumcision affects rates of the procedure and how demographic shifts are expected to affect rates of neonatal circumcision would help guide future policy decisions.

State-specific data reveal trends in neonatal circumcision rates and racial distributions that mirror previous national and regional estimates. Colorado and Florida revealed reductions in neonatal circumcision in the years after defunding, which appear unlikely to be due to secular trends alone. Black neonates appear to be disproportionately affected by changes in Medicaid coverage of neonatal circumcision.

aOR

adjusted odds ratio

CI

confidence interval

HPV

human papillomavirus

SID

State Inpatient Databases