|Ausmita Ghosh, Kosali Simon, and Benjamin Sommers, The Effect of State Medicaid Expansions on Prescription Drug Use: Evidence from the Affordable Care Act (Working Paper No. 23044, National Bureau of Economic Research, January 2017).
||Nationwide: Analyzed how the ACA Medicaid expansions have affected aggregate prescription drug utilization. Used a differences-in-differences regression framework and data from a large, nationally representative database of prescriptions dispensed from January 2013 through March 2015 at both retail and mail-order pharmacies.
- Within the first 15 months of expansion, Medicaid-paid prescription utilization increased by 19% in expansion states relative to states that did not expand.
- The greatest increases in Medicaid prescriptions occurred among diabetes medications, which increased by 24% in expansion states relative to non-expansion states.
- Other classes of medication that experienced relatively large increases in expansion relative to non-expansion states include contraceptives (22%) and cardiovascular drugs (21%), while several classes more consistent with acute conditions such as allergies and infections experienced significantly smaller increases.
- Authors suggested that the pattern of results described above indicates that Medicaid expansion was particularly effective at increasing prescription drug utilization for common and potentially costly chronic medical conditions such as diabetes and heart disease.
- Did not observe reductions in uninsured or privately insured prescriptions, suggesting that increased utilization under Medicaid did not substitute for other forms of payment.
- Within expansion states, increases in prescription drug utilization were larger in geographical areas with higher uninsured rates prior to the ACA.
|Anne DiGiulio et al., “State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage – United States, 2016,” Morbidity and Mortality Weekly Report 65, no. 48 (December 2016).
||Nationwide: Assessed smoking cessation coverage available to the Medicaid expansion population as of July 1, 2016. Used data collected by the American Lung Association on coverage of, and barriers to accessing, all evidence-based cessation treatments except telephone counseling for expansion populations.
- As of December 2015, approximately 3.3 million adult cigarette smokers were enrolled in Medicaid expansion coverage, including approximately 2.3 million adults who were newly eligible for Medicaid expansion coverage.
- As of July 1, 2016, nine of the 32 expansion states covered all nine cessation treatments for all Medicaid expansion enrollees.
- Of the 32 states, 17 states covered individual counseling for all Medicaid expansion enrollees, 11 covered group counseling for all enrollees, and 19 covered all seven FDA-approved cessation medications for all enrollees.
- All 32 states imposed at least one barrier (e.g., copayments or prior authorization) on at least one treatment for at least some enrollees.
- Several states that currently require copayments for some cessation treatments for expansion enrollees have indicated that they are planning to remove that requirement.
|Tyler Winkelman, Edith Kieffer, Susan Goold, Jeffrey Morenoff, Kristen Cross, and John Ayanian, “Health Insurance Trends and Access to Behavioral Health Care Among Justice-Involved Individuals,” Journal of General Internal Medicine 31, no. 12 (December 2016): 1523-1529.
||Nationwide: Assessed health insurance trends among justice-involved individuals before and after implementation of the ACA coverage provisions and examined the relationship between insurance and treatment for behavioral health conditions. Used 2008-2014 data from the National Survey of Drug Use and Health.
- Though Medicaid is associated with higher levels of treatment over the 2008-2014 period, overall substance use disorder treatment rates for justice-involved individuals remained low even after implementation of the ACA coverage provisions. This suggests that justice-involved individuals gaining insurance coverage under the ACA may still face barriers to care for some behavioral health conditions.
- The decline in the uninsured rate among justice-involved individuals between 2013 and 2014 was due mostly to a statistically significant increase in Medicaid enrollment between 2013 and 2014.
|Kamyar Nasseh and Marko Vujicic, Early Impact of the Affordable Care Act’s Medicaid Expansion on Dental Care Use (Health Services Research, November 2016).
||Nationwide: Compared trends in dental care use among adults ages 21-64 with incomes at or below 138% FPL across four categories of states (expansion states that do and do not provide adult dental benefits and non-expansion states that do and do not provide adult dental benefits). Used 2010-2014 data from the Gallup-Healthways Wellbeing Index survey and a differences-in-differences analysis.
- Dental care use among low-income adults in expansion states with dental benefits increased by 6.2 percentage points in the second half of 2014 relative to the pre-reform period and non-expansion states with adult dental benefits.
- Over the same period, the increases in dental care use among expansion states with adult dental benefits were not statistically significant relative to either expansion states or non-expansion states without adult dental benefits.
|James Kirby and Jessica Vistnes, “Access to Care Improved for People Who Gained Medicaid or Marketplace Coverage in 2014,” Health Affairs 35 no. 10 (October 2016): 1830-1834.
||Nationwide: Explored the extent to which people who obtained coverage through the Marketplaces or Medicaid under the ACA experienced improved access to care between 2013 and 2014, relative to those who remained uninsured. Used longitudinal data from the Medical Expenditure Panel Survey-Household Component (MEPS-HC).
- Compared to people who were uninsured throughout both 2013 and 2014, more of those who gained Medicaid coverage in 2014 went from not having preventive care or a usual source of care in 2013 to having such care in 2014.
- 26% of people who gained Medicaid coverage went from not having an annual checkup in 2013 to having one in 2014, compared to 14% of those who remained uninsured.
- 22% of people who gained Medicaid coverage went from not having a blood pressure screening in 2013 to having one in 2014, compared to 13% of those who remained uninsured.
- 17% of people who gained Medicaid coverage went from not having a flu shot in 2013 to having one in 2014, compared to 6% of those who remained uninsured.
- Conversely, across most measures (aside from the percentage obtaining flu shots), fewer individuals who gained Medicaid coverage went from having preventive care or a usual source of care in 2013 to not having such care in 2014, compared to those who remained uninsured.
- Improvements in access associated with gaining Marketplace coverage were not significantly different from those associated with gaining Medicaid coverage.
||Nationwide: Studied changes in health insurance status for nonelderly adults using data from the Medical Expenditure Panel Survey-Household Component for the 2012-2014 period. Examined gains in Medicaid coverage among those who were uninsured for the previous calendar year.
- Uninsured adults in expansion states who enrolled in Medicaid in 2014 were more likely to report being in fair or poor health and were about twice as likely to have at least one chronic condition, compared to those who remained uninsured.
- Previously uninsured adults in expansion states who enrolled in Medicaid were more likely to have had at least one office visit, a usual source of care, or both in 2013, and a previous source of coverage in 2011 or 2012.
||Nationwide: Used IMS Health prescription transaction data from 2012-2014 to measure number of prescription drug users who changed their source of coverage during the expansion period. Also tracked changes in individual prescription drug use, total drug spending, and out-of-pocket drug spending for prescription drug users following ACA expansion implementation.
- Previously uninsured prescription drug users who gained Medicaid coverage had, on average, 13.3 more prescription fills compared to when they were uninsured, a 79% increase.
- Previously uninsured prescription drug users who gained Medicaid coverage saw, on average, a $205 reduction in annual out-of-pocket spending in 2014.
- People with one of the chronic conditions included in the study who gained Medicaid coverage benefited from larger reductions in out-of-pocket spending ($279) compared to those without a study chronic condition who gained coverage ($152). Reductions in out-of-pocket spending among people with chronic conditions were larger for those who gained Medicaid than those who gained private coverage.
- Previously uninsured individuals who gained Medicaid coverage paid 58% less out-of-pocket per prescription in 2014 compared to 2013.
|Hefei Wen, Tyrone Borders, and Benjamin Druss, ”Number of Medicaid Prescriptions Grew, Drug Spending was Steady in Medicaid Expansion States,” Health Affairs 35, no. 12 (September 2016): 1604-1607.
||Nationwide: Explored changes in Medicaid drug spending and numbers of prescriptions between the pre-expansion period (2011-2013) and the post-expansion period (2014), comparing expansion and non-expansion states. Used sixteen waves of quarterly state-aggregate data from the Medicaid State Drug Utilization Data files of the Centers for Medicare and Medicaid Services (CMS).
- There were significant increases in 2014 compared to the pre-expansion 2011-2013 period in the amount of Medicaid drug spending per resident in the 23 non- or late-expansion states ($3.21 per quarter) and in the 26 expansion states ($4.75 per quarter).
- The difference between the two groups of states in the spending increases was not significant, indicating that implementation of the Medicaid expansions did not affect total Medicaid drug spending.
- There was no discernible change over time in the number of Medicaid prescriptions per resident in the non- or late-expansion states; a significant increase in prescriptions (0.06 per resident per quarter) in the expansion states was observed.
- Additional findings suggest that, on average, Medicaid enrollees in expansion states may have been prescribed drugs at a rate no different from those in the non- or late-expansion states, but the drugs prescribed for enrollees in the expansion states may have been less expensive than those prescribed for enrollees in the other states.
|Jesse M. Pines, Mark Zocchi, Ali Moghtaderi, Bernard Black, Steven A. Farmer, Greg Hufstetler, Kevin Klauer and Randy Pilgrim, “Medicaid Expansion In 2014 Did Not Increase Emergency Department Use But Did Change Insurance Payer Mix,” Health Affairs 35, no. 8 (August 2016).
||Nationwide: Examined Medicaid expansion’s impact on overall emergency department (ED) visits and the mix of payers during the first year of expansion. Collected data from 478 hospital-based EDs in 36 states from 2012-2014. The EDs included in the sample were located in 344 counties that together contain 35% of the US population.
- Medicaid expansion changed the insurance payer mix of ED visits.
- Compared to those in non-expansion states, EDs in expansion states experienced a larger increase in Medicaid-paid visits (27.1%), a larger decrease in uninsured visits (−31.4%), and a bigger drop in privately insured visits (−6.7%) during the first year of expansion.
- Overall, total ED visits grew by less than 3% in 2014 compared to 2012-2013, with no significant difference between expansion and non-expansion states.
||Nationwide: Examined the ACA’s effects on insurance coverage and how people are using their coverage to get health care. Reported data from the fourth wave of the Commonwealth Fund Affordable Care Act Tracking Survey, February-April 2016.
- 72% of adults enrolled in a marketplace plan or newly enrolled in Medicaid said they had used their coverage to go to a doctor, hospital, or other health care provider or to fill a prescription. 70% of adults enrolled in Medicaid said they would not have been able to access or afford this care prior to getting their new coverage.
- 93% of Medicaid enrollees who have had coverage for two months or less said their ability to get health care had improved or stayed the same since getting their insurance. 4% of those with new Medicaid coverage said their ability to obtain care had gotten worse.
- 56% of Medicaid enrollees who had Medicaid for less than three years and needed to see a specialist were able to secure a specialist appointment within two weeks.
- Over the three years of the ACA coverage expansions, the experience of marketplace and Medicaid enrollees in finding doctors and getting appointments is similar to that reported by insured Americans as a whole.
- In each of the three years since the ACA’s major coverage expansions, majorities of new Medicaid enrollees have reported that they are satisfied with their new health insurance overall. In 2016, 88% of those newly enrolled in Medicaid were very or somewhat satisfied with their health insurance. When asked to rate their insurance, 77% of new Medicaid enrollees said their coverage was good, very good, or excellent.
|Kosali Simon, Aparna Soni, and John Cawley, The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the 2014 ACA Medicaid Expansions (Working Paper 22265, National Bureau of Economic Research, May 2016).
||Nationwide: Examined the impact of 2014 ACA Medicaid expansions on preventative care (e.g. dental visits, immunizations, mammograms, cancer screenings) and risky health behaviors (e.g. smoking, heavy drinking, lack of exercise, obesity) among low-income (<100% FPL), childless, nonelderly adults. Used 2012-2014 data from the Behavioral Risk Factor Surveillance System and a difference-in-difference model.
- Expansions increased certain types of preventative care among low-income, childless adults, particularly dental visits (20% increase compared to 2012-2013 period), breast exams (14% increase), and mammograms (16% increase). Expansion had no detectable effect on flu shots, HIV tests, or Pap tests.
- Despite the fact that the number of preventive services and routine doctor visits were decreasing in the treatment states prior to the expansions, results indicate that the expansions increased those significantly (e.g. the probability of a routine checkup rose by 10% compared to the 2012-2013).
- Expansion reduced the proportion of adults who reported cost as a barrier to care by 2.7 percentage points (or 7%) from pre-expansion level. The effect varied significantly by sex: among men, the probability of reporting cost as a barrier to care fell by 5.2 percentage points but for women, the point estimate is small and positive (0.1 percentage points) and not statistically significant.
- Medicaid did not affect the probability of having a personal doctor for either men, women, or the pooled sample.
- Found little evidence that the expansions affected risky health behaviors such as smoking, lack of exercise, or obesity. There is some evidence that expansion may have reduced the probability of heavy drinking, but the magnitude of the reduction (31%) may be too large to be plausible.
- Expansions resulted in modest improvements in self-rated health (3%) and decreases in the number of work days missed due to poor health (8%).
|Luojia Hu, Robert Kaestner, Bhashkar Mazumder, Sarah Miller, and Ashley Wong, The Effect of the Patient Protection and Affordable Care Act Medicaid Expansions on Financial Well-Being (Working Paper No. 22170, National Bureau of Economic Research, April 2016).
||Nationwide: Examined the effect of the ACA Medicaid expansions on financial outcomes using the synthetic control approach of Abadie et al. (2010). Used credit report data for all quarters from 2010 through 2015 from the Federal Reserve Bank of New York Consumer Credit Panel/Equifax.
- Medicaid expansions significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies among individuals living in the top quartile of zip codes ranked by the proportion of poor and uninsured persons.
- Estimates indicated that the 2014 Medicaid expansions were associated with a reduction in the amount of collections of between $51 and $85, with a mean estimate of $69.
- Estimates implied a reduction in collection balances of around $600 to $1,000 among those who gain Medicaid coverage due to the ACA.
- Did not find evidence that the ACA Medicaid expansions had any effect on other measures of debt and debt past due.
|Laura Wherry and Sarah Miller, “Early Coverage, Access, Utilization, and Health Effects Associated with the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study,” Annals of Internal Medicine, Epub ahead of print (April 2016).
||Nationwide: Evaluated whether state Medicaid expansions were associated with changes in insurance coverage, access and utilization of health care, and self-reported health. Used National Health Interview Survey data and a quasi-experimental difference-in-differences design that compared changes in outcomes for residents of expansion and non-expansion states before (during the 2010 to 2013 period) and after (through the end of 2014) the expansions became effective.
- There were larger increases in visits with a general physician and overnight hospital stays in the previous 12 months in the expansion states versus the non-expansion states.
- Found that no significant changes in other utilization measures (such as visits with a specialist or visits to a hospital emergency department) were associated with the expansions.
- Did estimate a significant increase in ED visits when sample was restricted to adults aged 26 years or older who did not benefit from changes in rules on dependent coverage during the study period.
- Found no significant differences between expansion and non-expansion states in changes in measures related to access (including delaying care, forgoing care, or not having a usual source of care because of cost), health status (self-reporting being in excellent or very good health and self-reporting that health is better than 12 months before), or mental health (mentioning depression as a health problem) in the expansion states compared with the non-expansion states.
- Found significant increases in respondents reporting diagnoses of diabetes (5.2 percentage points) and high cholesterol (5.7 percentage points) associated with the expansions but no significant change in hypertension diagnoses.
||Nationwide: Analyzed how the experiences of patients in three categories (Medicaid, commercially insured, and uninsured patients), as well as the economics of primary care practice, changed following implementation of the ACA’s coverage expansions. Used ACAView data (which tracks provider activity among practice locations on athenahealth’s network) through the end of 2015.
- In states that expanded Medicaid, primary care physicians (PCPs) are seeing substantially more Medicaid patients.
- Study found a 12 percent increase in the total number of primary care visits by Medicaid-covered patients.
- Among Medicaid patients who visited a PCP for the first time in the first half of 2014, 67% returned to the practice within 18 months for a second visit. This rate exceeds the comparable rate for commercial patients (60%).
- Return rates are even higher for patients diagnosed with chronic diseases during the first primary care visit.
- Average visit times for Medicaid patients is the same as for patients with commercial insurance or Medicare.
- Divided physician practices into four groups: those that saw small, modest, significant, and large shares of Medicaid patients in 2013. Found that the four practice groups increased their Medicaid volume significantly in 2014 by 42, 26, 20, and 4%, respectively.
|Adele Shartzer, Sharon Long, and Nathaniel Anderson, “Access To Care and Affordability have Improved Following Affordable Care Act Implementation; Problems Remain,” Health Affairs (December 2015).
||Nationwide: Used data from the Health Reform Monitoring Survey to describe changes in access and affordability for nonelderly adults from September 2013 to March 2015. Study is focused on broad effects of the ACA but includes comparisons of results in expansion vs. non-expansion states.
- Overall, health care access and affordability improved for adults at all income levels and for adults in both Medicaid expansion and non-expansion states during the study period (Sept. 2013-March 2015).
- There was a 4.9 percentage point increase in the share of adults in expansion states with a usual source of care; the small increase among adults in non-expansion states was not statistically significant.
- The share of nonelderly adults who had a routine checkup in the past 12 months increased in both expansion and non-expansion states, although the increase in non-expansion states was not statistically significant (p<.05).
- The decreases in unmet need for care because of cost seen in both expansion and non-expansion states were not statistically significant.
- Reports of problems paying family medical bills declined by 4.8 percentage points in expansion states and 2.8 percentage points in non-expansion states.
||Nationwide: Examined change between 2013 and 2014 in the volume and health coverage profile of health center patients, as well as health center enrollment activities and service capacity, comparing states that did and did not expand Medicaid in 2014. Based on 2013 and 2014 data from the federal Uniform Data System and a 2014 national survey of health centers.
- Health centers in expansion states were significantly more likely than those in non-expansion states to report having expanded their capacity for dental services (37% vs 31%) and mental health services (42% vs 35%) since the start of 2014.
- Health centers in expansion states were more likely to report increased wait times for appointments compared to non-expansion states (35% vs. 20%), possibly reflecting greater increases in demand for services associated with larger gains in coverage among health center patients in these states.
|Benjamin Sommers, Munira Gunja, Kenneth Finegold, and Thomas Musco, “Changes in Self-Reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act,” The Journal of the American Medical Association 314 no. 4 (July 2015): 366-374.
||Nationwide: Analyzed the 2012-2015 Gallup-Healthways Well-Being Index to estimate national changes in self-reported coverage, access to care, and health during the ACA’s first two open enrollment periods, as well as to assess differences between low-income adults in states that did and did not expand Medicaid under the ACA.
- Pre-ACA trends for study outcomes did not differ significantly by expansion status, except for difficulty affording care, which was slightly worsening in expansion states relative to non-expansion states prior to 2014.
- The share of low-income adults lacking a personal physician and lacking easy access to medicine both declined significantly more in expansion states than in non-expansion states.
- Inability to afford care declined among low-income adults from 35.5% to 33.1% in expansion states, but this decline was not significantly different from the decline in non-expansion states.
- Did not find statistically significant differences in changes in self-reported health (fair/poor health or activity limitations due to health) between Medicaid expansion and non-expansion states.
||Nationwide: Examined the impact of Medicaid expansion on the number of Medicaid patients with newly identified diabetes among enrollees (19-64 years of age) who had laboratory testing through Quest Diagnostics. Used the first half of 2014 as the study period and the first half of 2013 as the control period.
- Overall (among the total population), observed a 1.6% increase in newly identified diabetes in the first half of 2014 compared to the first half of 2013.
- A total of 26,237 Medicaid-enrolled patients were newly identified with diabetes in the control period vs. 29,673 Medicaid-enrolled patients in the study period, an increase of 13%. In comparison, the number of non-Medicaid patients with newly identified diabetes increased by only .03%.
- The number of Medicaid patients with newly identified diabetes increased by 23% in expansion states between the control and study periods, compared to an increase of only 0.4% in non-expansion states.
||Nationwide: Reviewed the use of Medicines in the US in 2014 with the goal of bringing context and perspective to the complex interplay of factors that determine the level of spending on medicines and their role in the US healthcare system. Findings were based on data from on a range of IMS Health services sources.
- Medicaid was the leading driver of retail prescription growth in the first year of expanded coverage under the ACA. Total retail prescriptions rose 2.4% while overall Medicaid prescriptions increased 16.8% in 2014. Medicaid prescriptions accounted for 70% of the growth in retail prescription demand.
- Medicaid prescriptions increased 25.4% in 2014 in states that expanded Medicaid coverage and 2.8% in states that did not expand Medicaid.
- Cash prescriptions, typically filled by uninsured patients, declined 5.5% overall in 2014.
- Although Medicaid expansion increased enrollment by 10-15% in 2014, nearly a quarter of Medicaid prescriptions in 2014 were filled by newly enrolled patients, suggesting that many of them were carrying significantly higher disease burdens than existing patients.
||Nationwide: Based on a sample of nearly 16,000 health care providers, explores changes that occurred in 2014 (compared to before implementation of ACA coverage expansions) in areas such as insurance rates, patient health needs, and new patient rates in physician practices.
- In expansion states, the proportion of visits with Medicaid patients increased quickly, from 12.2% in December 2013 to 15% in March 2014, and hit a 2014 peak in September when Medicaid patients made up 16.7% of all visits.
- The number of Medicaid-covered PCP visits in expansion states increased from 12.8% of visits to 15.6% between 2013 and 2014.
- Despite a 1.5 million increase in the number of individuals enrolled in Medicaid in non-expansion states (largely due to increased media attention on health insurance surrounding the ACA), the number of Medicaid enrollees seen in physicians’ offices in non-expansion states decreased by 10.8% in 2014.
|Multi-State Studies (back to top)
||Michigan and Indiana: Explored the key components of and early implementation experiences with the Section 1115 Medicaid expansion waivers used in MI and IN. Findings were based on 22 in-person and telephone interviews conducted in July and August, 2016 with state officials, providers, health plans, beneficiary advocates, and enrollment assistors in MI and IN; data and reports from the state Medicaid agencies and other publically available sources; and four focus groups (two in each state) with beneficiaries enrolled in waiver coverage.
- Beneficiaries were able to access needed health care services with their new Medicaid coverage, although challenges remain in certain areas.
- Medicaid expansion design, whether through state plan authority or waivers, is highly dependent on the features of a state’s underlying Medicaid program.
- Implementation of complex programs involves collaboration with a variety of stakeholders, sophisticated IT systems, and administrative costs.
- Premium costs and complex enrollment policies can deter eligible people from enrolling in coverage.
- Health accounts can be confusing for beneficiaries.
- Beneficiary and provider education and tangible incentives appear central to implementing healthy behavior incentive programs.
|Megan Hoopes, Heather Angier, Rachel Gold, Steffani Bailey, Nathalie Huguet, Miguel Marino, and Jennifer DeVoe, “Utilization of Community Health Centers in Medicaid Expansion and Nonexpansion States, 2013-2014,” Journal of Ambulatory Care Management 39 no. 4 (October 2016): 290-298.
||Nine states (five expansion and four non-expansion): Examined longitudinal changes in community health center (CHC) visit rates from 2013 through 2014 in Medicaid expansion (CA, MN, OH, OR, WA) vs. non-expansion (AK, IN, MT, NC) states. Included visits from 219 CHCs across the nine states. Used electronic health record data.
- Rates of Medicaid-insured visits increased 46% for total expansion state CHCs post-expansion and 12% in non-expansion state CHCs.
- Uninsured visit rates were 47% lower in 2014 compared to 2013 in combined expansion state CHCs. Uninsured rates also dropped in non-expansion state CHCs, but to a lesser degree.
- Overall CHC visit rates increased by 6% in 2014 compared with 2013 in expansion states; visit rates remained unchanged across the entire group of CHCs in non-expansion states.
- Despite some variation between states, utilization of several CHC visit types increased significantly post- vs. pre-expansion in expansion state CHCs: new patient (14%), primary care (6%), preventive care (41%), and limited service (23%) visits all increased in expansion states. None of these rates changed significantly in the group of non-expansion state CHCs.
|Benjamin Sommers, Robert Blendon, E. John Orav, Arnold Epstein, “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” The Journal of the American Medical Association 176 no. 10 (October 2016): 1501-1509.
||Arkansas, Kentucky, and Texas: Surveyed adults ages 19-64 with incomes below 138% of the FPL in November and December of 2013, 2014, and 2015 to track changes in insurance coverage, utilization, preventive care, and self-reported health. Performed a differences-in-differences analysis of the survey data to assess these changes before and after Medicaid expansion in two expansion states (KY, AR) and in one non-expansion state (TX).
- The increase in the number of people with primary physicians between 2013 and 2015 was 12 percentage points higher in AR and KY (pooled) compared to TX. Reliance on EDs decreased by 6.1 percentage points in the two expansion states compared to TX.
- The decrease in cost- related barriers to care in the expansion states was 18.2 percentage points larger than in TX. The expansion states also experienced decreases in skipping prescription medications, difficulty with medical bills and a reduction in out-of-pocket medical spending that were 11.6, 14.0 and 29.5 percentage points larger than TX, respectively.
- Compared to TX, the number of adults with office visits in expansion states increased by 0.69 more percentage points per individual and the likelihood of a checkup increased by 16.1 more percentage points overall.
- Expansion states experienced an increase in the number of adults receiving consistent care for a chronic condition following expansion that was 12 percentage points greater than TX.
- There were improvements in receipt of checkups, care for chronic conditions, and quality of care even in areas with primary care shortages, suggesting that insurance expansions can have a demonstrable positive impact even in areas with relative shortages.
- There were no significant differences in trouble obtaining a primary care or specialist appointment between private insurance (AR) and Medicaid (KY) expansions.
- In the expansion states compared with TX, the number of adults that reported excellent health increased significantly by 4.8 percentage points and the number of adults reporting fair or poor quality of care declined significantly by 7.1 percentage points.
- Expansion states saw significant increases in coverage among racial minorities as well as increases in affordability and number of check-ups following expansion. The number of ED visits among racial minorities also decreased.
||Colorado, Connecticut, Kentucky, and Washington: Conducted case studies and focus groups in four expansion states to provide an on-the-ground view of Medicaid delivery systems and enrollees’ experiences accessing care as of Spring 2016, three years after implementation of the Medicaid expansion.
- Stakeholders indicated that Medicaid expansion has significantly increased individuals’ access to specialty services. They noted that while individuals could access primary care through clinics while uninsured, it was very different for them to obtain specialty care.
- Findings suggested that some access challenges remain, including providers not accepting Medicaid patients, problems associated with managed care plan provider networks and formularies, and transportation issues in rural areas. However, these challenges were not unique to the expansion population—similar challenges were observed for Medicaid enrollees outside of the expansion group as well as Marketplace enrollees.
- CHCs in the study states reported they have made a variety of investments to expand access to care, in part, due to enhanced revenues from the Medicaid expansion. Examples of enhancements include adding clinical staff, including behavioral health providers; building dental clinics and expanding dental service capacity; providing intensive care management; addressing social determinants of health (e.g., housing); and adding case managers.
- Some health centers cited challenges to meeting increased demands for care and continued growth, including increasing competitive pressures for clinical staff.
||Arkansas and Iowa: Used audit methodology, or “secret shoppers” to assess the availability of primary care appointments under the premium assistance expansion models employed in AR and IA. Researchers examined whether the rate of appointment availability or appointment wait-times differed between Medicaid and Marketplace coverage.
- Callers with Marketplace plan coverage had higher appointment rates than Medicaid callers. In AR, Marketplace appointment rates were 27.7 percentage points higher than traditional Medicaid appointment rates (83.2% vs. 55.5%); in IA, Marketplace appointment rates were 12 percentage points higher (86.3% vs. 74.3%).
- Once an appointment was offered, the median wait-time was seven days for both groups.
||Kansas, Kentucky, and South Carolina: Through case studies of three rural hospital closures (one in an expansion and two in non-expansion states), analyzed the factors that contribute to rural hospital closures and the impact of closures on access to health care in rural communities. Each case study involved 6-8 interviews with a range of stakeholders and a review of publically-available materials related to the closures.
- Medicaid expansion increases access to care in rural communities. In Fulton, Kentucky (the location of Parkway Regional Hospital until it closed in March 2015), many uninsured adults gained coverage when KY implemented Medicaid expansion, giving them access to services they were previously unable to afford.
- Respondents reported that Medicaid coverage of non-emergency medical transportation is very important in rural communities and even more so in the event of a local hospital closure, because residents more often have to travel to get care.
- Respondents in Kansas and South Carolina reported that the tendency of uninsured residents in rural communities to forgo preventive care and to delay treatment until their health conditions worsen can be exacerbated by the loss of a local hospital, and they said that a decision by their state to expand Medicaid would have increased access to needed care for the low-income uninsured population.
|Adam Searing and Jack Hoadley, Beyond the Reduction in Uncompensated Care: Medicaid Expansion is Having a Positive Impact on Safety Net Hospitals and Clinics (Washington, DC: Georgetown University Center for Children and Families, June 2016).
||Seven states (four expansion and three non-expansion): Investigated impact of Medicaid expansion on safety net hospitals and clinics through interviews with leaders of hospital systems and federally qualified health centers (FQHCs) in seven states (AR, CO, KY, MO, NV, TN, UT). Selected states with common borders in order to better compare state experiences.
- Hospital and health center leaders in expansion states reported an increased ability to move toward integrating care through new systems and relationships due to expansion-driven financial security and increasing margins. Improvements cited included better integration of behavioral health and primary care, expanded access to dental services, and expanded access to prescription medications.
- Executives in both expansion and non-expansion states identified access to specialists as a particular problem for the low-income Medicaid populations they serve.
- Executives in expansion states noted efforts to address the issue with new collaborative programs, new hiring, and new initiatives directed at increasing access to specialists for Medicaid enrollees. In cases where these programs and initiatives started before expansion, executives explained that efforts were bolstered by the expansion coverage.
|Stephen Berry et al., “Healthcare Coverage for HIV Provider Visits before and after Implementation of the Affordable Care Act,” Clinical Infectious Diseases, (May 2016).
||Ten adult HIV care sites in six states: Compared coverage pre (2011-2013) versus post (first half of 2014) ACA among a total of 28,374 persons living with HIV in 4 HIV provider sites in Medicaid expansion states (CA, OR, MD), 4 in a state (NY) that the study classified as expanding Medicaid in 2001, and 2 in non-expansion states (TX, FL).
- In expansion state sites, Ryan White HIV/AIDS Program support, local charities, or uncompensated care (RWHAP/Uncomp) decreased (from 28% pre-ACA to 13% post-ACA). Medicaid coverage increased (23% pre-ACA to 38% post-ACA) and private coverage was unchanged (21% pre-ACA to 19% post-ACA).
- In non-expansion state sites, RWHAP/Uncomp (57% pre-ACA and 52% post-ACA) and Medicaid (18% pre and 18% post-ACA) were unchanged, while private coverage increased (4% pre and 7% post-ACA).
|Benjamin Sommers, Robert Blendon, and E. John Orav, “Both the ‘Private Option’ And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults,” Health Affairs 35, no. 1 (January 2016): 96-105.
||Arkansas, Kentucky, and Texas: Conducted a telephone survey of two distinct waves of low-income adults in the three states in Nov.-Dec. 2013 and then 12 months later. Compared first year impacts of traditional Medicaid expansion (KY), the private option (AR), and non-expansion (TX) on coverage, access, affordability, and self-reported health status.
- Found a significantly greater decline in skipping medications because of cost and trouble paying medical bills in the two expansion states compared to the non-expansion state.
- Among adults with chronic conditions, found a significantly greater increase (11.6 percentage points) in the proportion of respondents in expansion states who had regularly received care for those conditions than the increase in TX.
- There was a greater reduction in trouble paying medical bills in KY than in AR. Otherwise, there were no significant differences in access measures between KY’s traditional expansion and AR’s private option, suggesting that both approaches improved access among low-income adults.
- Did not find significant impacts of expansion on numbers of office visits, emergency department visits, and overnight hospitalizations.
||Ohio, Arkansas, and Missouri: Examined the experiences of low-income adults in three states with varied Medicaid expansion decisions. Used information collected through 10 focus groups conducted with 85 adults in Columbus, Little Rock, and St. Louis. The groups in Columbus and Little Rock were conducted with previously uninsured adults who enrolled in the ACA Medicaid expansion or private option waiver, and the groups in St. Louis were conducted with uninsured low-income adults who would be eligible if Missouri expanded Medicaid.
- Participants in all three locations described how they delayed or went without needed care while uninsured, which sometimes led to worsening of conditions.
- After gaining coverage, adults in Little Rock and Columbus obtained needed care, leading to improvements in their health and quality of life.
- Some participants in Little Rock and Columbus identified remaining challenges after gaining coverage, including difficulty finding a primary care provider and certain types of specialists, as well as significant dental and vision needs.
- Adults in St. Louis described how remaining uninsured after implementation of the ACA contributed to daily stress and anxiety and caused them to continue to delay or go without needed care.
||Five states (three expansion and two non-expansion): Provides an on-the-ground view of ACA implementation in five states (CO, KY, WA, UT, and VA) following the completion of the second open enrollment period. Findings were based on 40 in-person interviews conducted with a range of stakeholders during April and May 2015.
- In the expansion states, enrollees are generally able to access needed care, although there are access challenges for certain services and providers.
- In CO, stakeholders commented that the increased demand for care has led to longer wait times in some cases, particularly for specialty services. Stakeholders in WA and KY similarly noted difficulty finding providers for certain specialties and behavioral health services.
|Government Accountability Office, Behavioral Health: Options for Low-Income Adults to Receive Treatment in Selected States (Washington, DC: Government Accountability Office, June 2015).
||Ten states (six expansion and four non-expansion): In six expansion (CT, KY, MD, MI, NV, WV) and four non-expansion (MO, MT, TX, WI) states, reviewed documents and interviewed state officials to understand how uninsured and Medicaid-enrolled adults receive behavioral health treatment.
- State officials in expansion states reported that Medicaid expansion increased the availability of behavioral health treatment, although some access concerns (mainly concerns related to behavioral health professional shortages and expansion-related budget reductions for state behavioral health agencies) continue.
- Expansion states generally managed behavioral health and physical health benefits separately for newly eligible Medicaid enrollees through carve-outs or separate contracts.
- Health plans for newly eligible Medicaid enrollees were generally aligned with Medicaid state plans, resulting in comparable behavioral health benefits for newly eligible and existing Medicaid enrollees.
- State BHAs in the non-expansion states offered various behavioral health treatment options for low-income, uninsured adults. Those states identified priority populations to focus care on adults with the most serious conditions and used waiting lists for those with more modest behavioral health needs.
||Five cities (in four expansion states and one non-expansion state): Provided an early look at the impact of the expansion for homeless providers and the patients they serve. Used data from focus groups conducted with administrators, providers, and enrollment workers at sites serving homeless individuals in Albuquerque, NM; Baltimore, MD; Chicago, IL; Portland, OR’ and Jacksonville, FL.
- Providers reported having access to a broader array of treatment options as a result of their patients’ coverage gains. Gains in Medicaid coverage have enabled patients to access many services that they could not obtain while uninsured, particularly specialty services, behavioral health services, medications, and medical supplies and equipment. Some providers described instances of individuals receiving life-saving or life-changing surgeries or treatments that they could not obtain while uninsured.
- Participants from the non-expansion site (in Jacksonville) indicated that without insurance, individuals continue to rely on limited pro bono services, have difficulty accessing needed treatments and specialty services, and utilize the emergency room for dental emergencies and acute mental health stabilization.
- Gains in Medicaid revenue (particularly in the expansion states) facilitated strategic and operational improvements focused on quality, care coordination, and information technology.
- Some challenges were emerging as homeless patients gained Medicaid coverage and were enrolled in managed care (e.g. some patients were being auto-assigned to providers with whom they did not have an existing relationship and/or they may have difficulty accessing due to lack of transportation).
|Single State Studies (back to top)
|The Ohio Department of Medicaid, Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly (The Ohio Department of Medicaid, January 2017).
||Ohio: Examined the effects of OH’s 2014 Medicaid expansion on expansion (Group VIII) enrollees. When appropriate, compared Group VIII enrollees to those enrolled in OH Medicaid under pre-expansion eligibility rules. Used numerous data collection methods, including a detailed telephone survey of 7,508 expansion and pre-expansion enrollees, medical record reviews and biometric screenings of subsets of the survey sample, an analysis of administrative data for enrollees, focus groups of 27 enrollees, and interviews with 10 service providers and other key stakeholders.
- Expansion enrollees overwhelmingly reported that access to medical care had become easier since enrolling in Medicaid—these gains were largest for those who were previously uninsured.
- Nearly half of expansion enrollees (43.3%) reported a decline in unmet health care needs, while only 8.3% reported an increase, with the remainder reporting no unmet needs or no change in the level of unmet needs.
- Emergency department use decreased for expansion enrollees. Survey results and medical records analyses showed that expansion participants were better integrated into the health care system, increasingly connecting to a usual and appropriate source of health care.
- Nearly half of expansion enrollees (47.7%) reported improvement in their overall health status since enrolling in Medicaid, compared to 3.5% who said their health had worsened.
- A review of 430 expansion enrollees’ medical records showed that the individuals studied had lower levels of high blood pressure or high cholesterol since enrolling in Medicaid.
- Since enrollment in Medicaid, 44.0% of expansion enrollees reported better access to mental health services.
- Expansion enrollees with depression and anxiety reported greater improvement in access to care (68.5%) and prescriptions (71.2%) than those without depression or anxiety (62.4% and 62.5%, respectively).
- Expansion enrollees with opioid use disorders reported greater improvement in their access to care than other expansion enrollees (75.4% vs. 64.0% for overall access to care; 82.7% vs. 64.8% for access to prescription medications; and 59.3% vs. 32.2% for access to mental health care).
- A small percentage of expansion enrollees reported having unmet medical needs or challenges accessing certain services (e.g., dental care). Follow up interviews with providers and stakeholders confirmed challenges with the low Medicaid payment rates which limited the pool of providers, an issue that predates Medicaid expansion.
- More than half of expansion enrollees (58.6%) reported that it was now easier to buy food, 48.1% stated that it was easier to pay their rent or mortgage, and 43.6% said it was easier to pay off other debts than before they had Medicaid.
- The percentage of expansion enrollees with medical debt fell by nearly half since enrolling in Medicaid (55.8% had debt prior to enrollment, 30.8% had debt at the time of the study).
|Jeffrey Horn et al., “New Medicaid Enrollees See Health and Social Benefits in Pennsylvania’s Expansion,” INQUIRY: the Journal of Health Care Organization, Provision, and Financing 53 (October 2016): 1-8.
||Pennsylvania: Explored the health care experiences and expectations of new Medicaid expansion beneficiaries in the immediate post-enrollment period. Conducted semistructured, qualitative interviews with a random sample of 40 adults in Philadelphia who had completed an application for Medicaid through a comprehensive benefits organization after January 1, 2015, when the Medicaid expansion in Pennsylvania took effect. Conducted an inductive, applied thematic analysis of interview transcripts to understand their motivations for obtaining coverage, perceived health and health care needs, and early experiences navigating the health care system at a time of rapid health system change.
- While many participants spoke of having deferred a wide range of health care needs prior to gaining expansion coverage, including treatment for chronic medical conditions, filling prescriptions, or undergoing surgical procedures, they overwhelmingly described a need for dental care.
- 33 of 40 participants spontaneously discussed a need for dental care, without prompting from the interviewer, revealing a demand that had been building over years of inadequate dental coverage.
- Participants described how their new Medicaid coverage offered a reduction in stress and the hope of improved financial security.
- Participants described prior stigma and discrimination while uninsured as a negative influence on access, but they felt that new insurance would be a social equalizer and allow them to be treated similarly to other insured patients.
- Despite being recently enrolled in insurance, many participants described a persistent feeling of health care insecurity. Several participants feared that their new insurance would be taken away suddenly, particularly if their income increased.
||Indiana: Used data available as of June 2016 to evaluate the progress of the Healthy Indiana Plan (HIP) 2.0 in the first year of implementation. Report evaluates several unique features of Indiana’s HIP 2.0 expansion program, including the required (for members above poverty) or encouraged contributions to the HSA-like Personal Wellness and Responsibility (POWER) Accounts. Contributions determine member enrollment into HIP Plus (a plan that includes enhanced benefits) or HIP Basic (a more limited benefit plan that requires copayments for most services).
- 16% of HIP Plus members always worried about not being able to afford their PAC payment, 29% worried usually or sometimes, and 52% worried rarely or never.
- About 1% of Plus members and 2% of basic members reported missing appointments due to cost.
- A majority of HIP 2.0 members surveyed were unaware that preventive care is provided at no cost to the member.
- Utilization was higher for the Plus members below poverty compared to those above poverty, regardless of whether members had chronic physical or behavioral health conditions.
- Plus members were about 42% more likely to utilize preventive care services than Basic members. Chronic conditions are more prevalent in Plus than Basic members.
- Members with chronic conditions and medically frail members in either Plus or Basic were more likely to use preventive and primary care services than were healthier members.
- Basic members show higher rates of Emergency Department use overall and non-emergency use of the ED, compared to Plus members.
||Michigan: Follow-up to a July 2015 simulated patient study (using secret shoppers) assessing accessibility of routine new patient appointments in a random sample of Michigan primary care practices before versus four, eight, and 12 months after Medicaid expansion. Michigan’s expansion has a unique requirement that new Medicaid beneficiaries be seen by a primary care provider within 90 days of enrollment.
- The proportion of clinics with available appointments for new Medicaid patients increased from 49% before expansion to 55% by 12 months after expansion. Appointment availability for new privately insured patients decreased from 88% of clinics to 86% 12 months after expansion.
- Changes in appointment availability for both Medicaid and privately insured groups at 12 months post-expansion remained stable compared with the 4-month post-expansion findings.
- The percentage of appointments scheduled with non-physician providers (nurse practitioners or physician assistants) before expansion compared to 12 months post-expansion increased from 8% to 21% for Medicaid appointments and from 11% to 19% for private insurance appointments.
- In clinics that accepted patients with Medicaid, median wait times for new Medicaid patients remained stable over the 12-month period while median wait times for new privately insured patients in the same clinics increased slightly from 7-10 days. There was no significant difference between wait times for new Medicaid and new privately insured patients throughout the study period.
- Safety net clinics were much more likely than non–safety net clinics to accept new Medicaid patients at baseline; however, only non–safety net clinics had significantly increased appointment availability after expansion.
- Clinics in urban locations were less likely to accept new Medicaid patients than clinics in nonurban locations at baseline, but only urban clinics had increased Medicaid appointment availability post expansion.
|Joseph Benitez, Liza Creel, and J’Aime Jennings, “Kentucky’s Medicaid Expansion Showing Early Promise on Coverage and Access to Care,” Health Affairs (February 2016).
||Kentucky: Used BRFSS data on adults ages 25-64 reporting annual household income below $25,000 to study first-year impact of KY’s Medicaid expansion on insurance coverage and access to care. Low-income residents from the bordering non-expansion states Missouri, Tennessee, and Virginia served as controls.
- By the end of 2014, low-income Kentuckians experienced a 16 percentage point (40%) reduction in unmet medical need because of cost relative to the preexpansion period. Over the same period, there was a modest, statistically insignificant increase in the fraction experiencing financial barriers in the control states.
- The effect of the expansion on having a regular source of care was largely positive but more mixed, with the most substantial effects occurring in 2014’s second and third quarters.
||Arkansas: Preliminary report evaluated how efficiently Arkansas’ Medicaid program, and specifically the Private Option expansion model, was working and how well-prepared the program was to meet future trends. Findings were largely based on two reports from The Stephen Group, the consultant group hired by the Legislative Task Force, that were released earlier in 2015.
- Private Option participants have access to substantially more providers than through traditional Medicaid due to access to the private insurance company provider networks.
- Private Option beneficiaries utilized Emergency Department (ED) services at a rate greater than traditional Medicaid beneficiaries, despite being a healthier population. This is partially attributed to a lack of understanding of how to use the health care system by newly insured individuals and to a lack of incentives for using more appropriate care.
- Physician licensure rates appeared largely to not be impacted by the Private Option.
|Jocelyn Guyer, Naomi Shine, MaryBeth Musumeci, and Robin Rudowitz, A Look at the Private Option in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, August 2015).
||Arkansas: Provided an initial look at implementation of the private option in Arkansas. Findings came from a dozen interviews with state officials, providers, insurance carriers, and advocates, as well as early data on coverage, reductions in uncompensated care costs, and other topics.
- Stakeholders reported that Private Option enrollees were generally able to access services and that beneficiaries appreciate having the same commercial insurance card as other Marketplace enrollees and the access to doctors, hospitals, clinics, and specialists that these plans offer.
- The access to specialists was highlighted as a particularly important benefit of the private option coverage expansion, since traditional Medicaid beneficiaries can often secure primary and preventative care from community health centers but may encounter more challenges accessing specialists.
- Early reports indicated that Private Option beneficiaries were receiving wrap-around protections for premiums and cost-sharing that exceed Medicaid limits, while access to wrap-around benefits required by Medicaid but not covered in the Marketplace was more mixed.
|Michael McCue, “The Impact of Medicaid Expansion on Medicaid Focused Insurers in California,” Inquiry: The Journal of Health Care Organization, Provision, and Financing 52 (July 2015).
||California: Assessed the enrollment, utilization, and financial performance measures of California Medicaid focused health insurers. Compares these quarterly measures during the expansion period of 2014 to the same quarterly measures in 2013 and 2012.
- Medi-Cal members’ utilization patters changed in response to expansion. The first and fourth quarters’ ambulatory care encounters per member per month (PMPM) were reduced by more than .06 encounter PMPM from 2013 to 2014. Starting in the second quarter of 2014, inpatient days per thousand were substantially lower than their respective prior quarters of 2012 and 2013, with the greatest difference occurring in the fourth quarter with a reduction of 56 days from 279 days in 2013 to 223 days in 2014.
|Renuka Tipirneni et al. “Primary Care Appointment Availability For New Medicaid Patients Increased After Medicaid Expansion In Michigan,” Health Affairs (July 2015).
||Michigan: Conducted a simulated patient study to assess primary care appointment availability and wait times for new patients with Medicaid or private insurance before and after implementation of Michigan’s expansion in 2014 (Michigan’s expansion has a unique requirement that new Medicaid beneficiaries be seen by a primary care provider within 60-90 days of enrollment).
- Appointment availability for primary care increased by 6 percentage points (from 49% in the pre-expansion (March 2014) calls to 55% in the post-expansion (July-August 2014) calls) for new Medicaid patients and decreased by 2 percentage points for new privately insured patients over the same period. While the disparity between the two groups declined over time, appointments were still much more commonly available after expansion for new privately insured patients than for new Medicaid patients.
- Wait times remained stable, at 1-2 weeks for both groups.
|Deloitte Development LLC, Commonwealth of Kentucky Medicaid Expansion Report, (Deloitte Development LLC, February 2015).
||Kentucky: Examined progress toward the state’s initial goals for its Medicaid expansion during the first 12 months of expansion (Jan. 1-Dec. 31. 2014). Also updated initial estimates from the 2013 Medicaid Expansion Whitepaper based on the first year of experience.
- The KY expansion population accessed preventative services at a rate equal to, and in some instances greater than, the traditional Medicaid population during 2014.
- More than 300 new behavioral health providers enrolled in KY Medicaid and at least 13,000 individuals with a substance use disorder received related treatment services during the first year of expansion.