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Medicaid expansion under ACA increased health care access

Medicaid expansion under the Affordable Care Act led to increased access to care and insurance coverage, but was also associated with longer wait times for appointments, according to study results recently published in The New England Journal of Medicine.

Some of the findings contradict longstanding cornerstone arguments made by Republicans for replacing the Affordable Care Act (ACA).

“Our study provides new evidence regarding the effect of ACA Medicaid expansions on the use of health care, access to care, health status, and diagnosis of chronic conditions beyond the first year of implementation and offers important insights into how this policy has shaped experiences and outcomes for low-income adults,” Sarah Miller, PhD, Ross School of Business, University of Michigan, and Laura R. Wherry, PhD, David School of Medicine, University of California, Los Angeles wrote.

The researchers used a quasi-experimental difference-in-differences design to analyze outcomes among patients in expansion states compared with nonexpansion states, specifically the 4 years before the expansion and 2 years after it. They considered expansion states those that implemented the ACA Medicaid expansion during 2014 or 2015, and defined the postexpansion period on the basis of the implementation date in each state. Five states that already provided Medicaid or similar coverage to low-income adults during 2010 through 2013 were not included. They used data from the National Health Interview Survey to analyze a sample of 60,766 patients, aged between 19 and 64 years, with incomes 138% below the federal poverty level.

Miller and Wherry found that uninsurance rates were reduced in expansion states relative to nonexpansion states (difference-in-differences estimate, –8.2 percentage points; P < .001) and rates of Medicaid coverage were increased (difference-in-differences estimate, 15.6 percentage points; P < .001) in year 2 after expansion onset. Further, these expansions were not associated with significant changes in the likelihood of a doctor visit or overnight hospital stay or health status as reported by the respondent. However, compared with nonexpansion states, expansion states had a decrease in reports of inability to afford needed follow-up care (difference-in-differences estimate, –3.4 percentage points; P= .002) and in reports of worry about paying medical bills (difference-in-differences estimate, –7.9 percentage points; P = 0.002) and an increase in reports of medical care being delayed because of wait times for appointments (difference-in-differences estimate, 2.6 percentage points; P = 0.02).

The researchers wrote that no significant change was observed in hypertension diagnoses or health status in either year. While year 1 of the expansion saw significant increases in reported diagnoses of high cholesterol, diabetes and mentioning depression as a health problem, the difference-in-differences estimates for these outcomes were not significant in year 2.

Miller and Wherry stated that other factors besides the Medicaid expansion may have contributed to their results.

“We measured changes associated with the Medicaid expansion that took place during a period when other changes were occurring under the ACA. We cannot definitively exclude the possibility that a contemporaneous change that was unrelated to the ACA Medicaid expansions was confounding the results,” they wrote. “In addition, the survey data that we use are based on participants’ recall of their use of health services and their subjective health status, and these data may be less accurate than administrative or clinical data.”

From the start of ACA’s implementation, many Republicans have claimed the law would limit access to health care and have tried to increase that access ever since.

Current HHS Secretary Tom R. Price, MD, while still a U.S. Representative, stated at an event hosted by The Heritage Foundation that accessibility, along with affordability, quality, responsiveness, innovation and choices, were six principles that the country should adhere to in health care.

“Current law of the land, violates every one of those principles,” he added. “We’re moving away from, not even on the right trajectory, to get to patient-centered health care.”

A Better Way: Our Plan for a Confident America, which was published last year by House Republicans, asserts that the ACA failed on many fronts, including access.

"Nonpartisan analysts warned that the law’s new mandates and regulations would lead to higher premiums and reduced access to care."

According to the report, House Republicans introduced more than 400 individual bills between January 2015 and June 2016, with the intent of improving the nation’s health care system.

As of January 2017, 19 states have still not implemented Medicaid expansions.

Earlier this week, the House unveiled a plan to replace ACA, the American Health Care Act, which faces criticism from both Republicans and Democrats, as well as the ACP and AMA. The proposed legislation was approved by the House Ways and Means and the Energy and Commerce committees committees on Thursday. – by Janel Miller

Disclosure: Healio Family Medicine was unable to determine the researchers’ relevant financial disclosures prior to publication.