Impact of State-Level Public Insurance Coverage on Neonatal Circumcision Rates
Mateo Zambrano Navia, BA, Deborah L. Jacobson, MD/MS, Lauren C. Balmert, PhD, Ilina Rosoklija, MPH, Jane L. Holl, MD/MPH, Matthew M. Davis, MD/MAPP, Emilie K. Johnson, MD/MPH.
Lurie Children's Hospital/Northwestern University, Chicago, IL, USA.
BACKGROUND: The 2012 AAP Circumcision Taskforce concluded that "health benefits of newborn male circumcision outweigh the risks⋯[and] the procedure's benefits justify access to this procedure for families who choose it." Despite these recommendations, eighteen states do not provide Medicaid coverage for neonatal circumcision (NC). While many factors may impact parents' choice of NC for their sons, previous research suggests that state-level differences in Medicaid coverage of the procedure may impact NC rates. The objectives of this study were to: (1) compare state-specific trends in NC rates to previously established estimates, and (2) assess the impact of changes in Medicaid coverage of NC at the state level.
METHODS: The Healthcare Cost Utilization Project State Inpatient Database was utilized to determine NC rates among male infants in four regionally diverse states (Colorado, Florida, Michigan, and New York) at four time points (2001, 2006, 2011, 2016). NC was defunded by Medicaid in Florida (2003) and Colorado (2011) during the study period. Male infants ≥1 year and those with coagulopathies, genitourinary anomalies, or prematurity were excluded. A multivariable logistic regression model was created to assess associations between patient and state characteristics and the odds of NC.
RESULTS: A total of 1,358,463 male infants were included. Overall, 52.5% underwent NC. Rates were highest in Michigan (74.1%) and lowest in Florida (32.5%) [Table 1, NC rates by state and year]. States where NC was defunded during the study period showed a decrease in NC rates in subsequent years (39.6% to 31.9% in Florida [2001-2006]; 55.3% to 46.2% in Colorado [2011-2016]). Figure 1 shows state-specific trends over time, stratified by insurance status, demonstrating a disproportionate decrease in NC rates for publicly-insured male infants in Florida and Colorado following defunding. In an adjusted analysis [Table 2], male infants with private insurance had higher odds of NC compared to male infants with public insurance (adjusted odds ratio [aOR] 2.25 [2.23-2.27]). In states and in years with Medicaid coverage for NC, black infants had significantly higher odds of NC compared to white infants (aOR 1.19 [1.18-1.21]). In states and in years without Medicaid coverage for NC, black infants had significantly lower odds of NC compared to white infants (aOR 0.60 [0.59-0.61]; Table 2).
CONCLUSIONS: State-specific data demonstrate trends in NC rates and racial distributions that are similar to previous national and regional estimates. Colorado and Florida showed 18% and 19.5% reductions in NC rates, respectively, in the years following defunding, which appear unlikely due to secular trends alone. Additionally, black infants appear to be disproportionately affected by changes in Medicaid coverage of NC. 
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