摘要：Objectives. We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision. Methods. Hospital discharge data from the 2000–2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence. Results. Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses ( P for trend = .008), but not in analyses adjusted for insurance status ( P for trend = .46) and other predictors ( P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall ( P for trend = .007) and among hospitalizations with Medicaid ( P for trend = .005) but not those with private insurance ( P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend < .001), suggesting 390 000 additional circumcisions might have occurred nationwide had insurance coverage remained constant. Conclusions. Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure. There is renewed interest in circumcision in the United States because of the increasing evidence for reduced risks of sexually transmitted infections, including human papillomavirus (HPV), genital herpes, and HIV; urinary tract infections in infancy; balanoposthitis; and penile cancer for males and cervical cancer in their female partners. 1,2 The procedure is not completely without risk, however, as circumcision may result in minor complications (most commonly bleeding and infection) and, albeit rarely, serious complications that require surgery. 3,4 Recent recognition of the benefits of circumcision has rekindled discussion about the need for updated recommendations for newborn circumcision in the United States. 5 Because the health benefits outweigh the risks and therefore warrant reimbursement, the American Academy of Pediatrics (AAP) issued guidance in 2012 that explicitly recommended access to newborn circumcision for families who desired the procedure. 3 In addition, the Centers for Disease Control and Prevention (CDC) recently issued the agency’s first-ever draft guidelines on circumcision, which state that parents of newborn males should be informed of the medical benefits of the procedure as well as the risks involved. 6 Circumcision incidence has decreased in the United States from around 60% in 2000 to 56% in 2008 7,8 after increasing during the late 1980s and 1990s. 9,10 The decrease in circumcision nationwide since 2000 coincides with the release of an earlier, more neutral position statement regarding the risk–benefit ratio for neonatal circumcision issued by AAP 5 that was reaffirmed in 2005. 11 The previous AAP statement, although acknowledging the potential medical benefits of circumcision, indicated that the procedure was not essential to the child’s well-being and that the decision was best left to parents. After the earlier guidance was released, many states ceased Medicaid coverage for circumcision procedures. Overall, at the time of this writing, 18 states have discontinued Medicaid coverage, including 12 that have ceased such coverage since 1999 ( Figure 1 ). 12,13 Whereas states that discontinued coverage were initially concentrated in the West, in recent years states across all regions have discontinued Medicaid coverage, particularly in the South, where 5 states have ceased coverage. This change in Medicaid coverage may be in response to earlier recommendations regarding newborn circumcision from AAP 5 and other professional organizations. 12,14–17 Open in a separate window FIGURE 1— Medicaid coverage of newborn circumcision procedures by state: United States. Because little research to date has explored factors that could explain this decline, we examined trends in circumcision during the period between issuance of the previous and current AAP guidance and assessed how shifts in insurance coverage (from private insurance to Medicaid) may have contributed to the recent nationwide decrease in newborn circumcision.
