How Have State Medicaid Expansion Decisions Affected the Experiences of Low-Income Adults? Perspectives from Ohio, Arkansas, and Missouri
As of May 2015, 30 states have adopted the Affordable Care Act (ACA) Medicaid expansion to low-income adults, creating a new coverage option for millions of adults who were previously excluded from the program. In the remaining 21 states that have not adopted the expansion to date, many poor uninsured adults fall into a coverage gap—they do not qualify for Medicaid and earn too little to qualify for the tax credits to purchase Marketplace coverage, which begin at 100% of the federal poverty level for subsidized coverage.
This brief examines the experiences of low-income adults in three states that have made varied Medicaid expansion decisions: Ohio, which adopted the ACA Medicaid expansion, Arkansas which implemented the Medicaid expansion through a “Private Option” waiver, and Missouri, which has not adopted the expansion. Information was 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 the state expanded Medicaid. Although most of the adults were working, they were in part-time and/or low wage jobs and were all facing challenging financial situations. Many had ongoing physical and mental health needs. Following are key themes of their experiences:
In all three locations, participants sought coverage after the ACA was implemented. In Little Rock and Columbus, participants enrolled through varied methods. Many were aware of the new coverage options via news and media and enrolled on their own online or by phone. Others learned about the coverage after coming across enrollment events or outreach materials in the community and applied with an assister, and some were automatically enrolled based on their participation in another program. Most of the participants in St. Louis also tried to enroll in coverage after the ACA was implemented and were upset and disappointed to learn they did not qualify for Medicaid or tax credit subsidies to purchase a Marketplace plan.
“I did mine at the clinic…They had people… go through and sit there with the computer and do it with me.” Jimmie, Little Rock
“So I called that hotline and they said, well, you don’t make enough money for this, but then you make too much money for Medicaid. So, I’m in this donut hole where I don’t fit anywhere.” Christina, St. Louis
Participants in all three locations described how they delayed or went without needed care while uninsured, sometimes leading to worsening of conditions. All participants said that they tried to avoid obtaining care while uninsured because of the cost, which sometimes led to the worsening of conditions that ultimately resulted in higher-cost care, missed work, and disruptions to family relationships. They noted that they would put off seeking care until a condition becomes unbearable. They said when they did seek care they would try to use clinics and urgent care centers to minimize costs, but sometimes the only source of care they could turn to was the emergency room, often leaving them with large bills they could not afford.
After gaining coverage, adults in Little Rock and Columbus obtained needed care, leading to improvements in their health and quality of life. While Arkansas and Ohio implemented the Medicaid expansion in different ways, participants in both Little Rock and Columbus said that obtaining coverage enabled them to access needed care to address health problems as well as primary and preventive care. They described how obtaining coverage allowed them to better manage chronic conditions, led to the diagnosis of conditions, and contributed to significant improvements in their health and quality of life. Participants also said obtaining coverage and care provided them a huge feeling of relief and sense of security and enhanced their overall well-being, ability to work, and relationships. Participants indicated that they were grateful and proud that their states had expanded Medicaid, providing them access to coverage.
“I had a procedure that’s gotten me off all medications. I no longer take depression medication, high blood pressure medication. Now I am back to work, I feel healthy, and I interact with my kids.” Ann, Columbus
Participants in Little Rock and Columbus identified some remaining challenges even after gaining coverage. Some participants reported difficulty finding a primary care provider and certain types of specialists, particularly behavioral health providers, and noted that plan provider directories were not always up to date. In addition, many participants reported significant dental and vision needs. Although these benefits are covered in Ohio, adults in Columbus noted challenges finding an available dental provider. In Arkansas, enrollees currently are not covered for dental or vision care, which participants felt was a key gap in coverage.
Adults in St. Louis remained uninsured, leaving them unable to access needed care and with significant stress and anxiety. Adults in St. Louis described how remaining uninsured contributed to daily stress and anxiety and caused them to continue to delay or go without needed care. Participants described feeling defeated, angry, powerless, and frustrated that they remain ineligible for coverage without the Medicaid expansion.
In sum, these experiences illustrate the different experiences of low-income adults in states that have made varied Medicaid expansion decisions. While Arkansas and Ohio implemented the expansion in different ways, participants in both Little Rock and Columbus described how obtaining coverage improved their ability to access care, contributing to improvements in their ability to work and family relationships. In contrast, participants in St. Louis remained uninsured limiting their ability to obtain needed care, creating significant stress and anxiety in their lives, and interfering with their ability to work and care for their families.