Hospitals in states where Medicaid does not pay for routine male circumcision are only about half as likely to perform the procedure, and this disparity could lead to an increased risk of HIV infection among lower-income children later in life, according to a UCLA AIDS Institute study.
Researchers found that at hospitals in the 16 states where the procedure is not covered, circumcision rates were 24 percentage points lower than at hospitals in other states, with lower rates particularly prevalent among Hispanics. The mean male circumcision rate for all states was 55.9 percent.
The findings are important because they document the effect of state Medicaid reimbursement policies on the medical services that are actually delivered, said the study's lead author, Arleen A. Leibowitz, a professor of public policy and a researcher with both the UCLA Center for HIV Identification, Prevention and Treatment Services and the UCLA AIDS Institute. These services include male circumcision, which has been shown to lead to substantial health benefits in later life.
"Since children whose childbirth expenses are paid for by Medicaid are, by definition, lower income, the Medicaid policy in 16 states of not reimbursing for male circumcision is generating future disparities in health between children born to rich and poor families," Leibowitz said.
In 1999, the American Academy of Pediatrics (AAP) stated that the medical benefits of male circumcision were not enough for the group to recommend that the procedure be made routine at all hospitals. As a result, some states began withdrawing Medicaid coverage for circumcision.
But recent clinical trials in South Africa, Kenya and Uganda have revealed that male circumcision can reduce a man's risk of becoming infected with HIV from a female partner by 55 to 76 percent. In June 2007, the AAP began reviewing its stance on the procedure.
The UCLA researchers relied on data from the 2004 Nationwide Inpatient Sample (NIS), collected as part of the Healthcare Cost and Utilization Project of the federal Agency for Healthcare Research and Quality. They studied information on about 417,000 routine discharges of newborn males from 683 U.S. hospitals.
In addition to the overall lower circumcision rates, the researchers found that the more Hispanics a hospital served, the fewer circumcisions the hospital performed. For Hispanic parents, the circumcision decision was about more than simply cost, since male Hispanic infants were unlikely to receive the procedure even in states in which it was fully covered by Medicaid.
The 16 states without Medicaid coverage for male circumcision are California, Oregon, North Dakota, Mississippi, Nevada, Washington, Missouri, Arizona, North Carolina, Montana, Utah, Florida, Maine, Louisiana, Idaho and Minnesota.
The study authors estimate that if all states' Medicaid plans paid for male circumcision, the national rates for the procedure would increase to 62.6 percent. If all states dropped the coverage, the rate would fall to about 38.5 percent.
"State Medicaid plans that attempt to reduce costs in the short run by not covering the cost of infant male circumcision may be generating higher health care costs for HIV/AIDS and other sexually transmitted infections in the future," Leibowitz said.
Study co-authors were Katherine Desmond, M.S., and Thomas Belin, Ph.D, both with UCLA.
A National Institute of Mental Health grant to UCLA's Center for HIV Identification, Prevention and Treatment Services funded the study.
- Leibowitz et al. Determinants and Policy Implications of Male Circumcision in the United States. American Journal of Public Health, 2008; 99 (1): 138 DOI: 10.2105/AJPH.2008.134403
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