Public, private health insurance expansion improves care for low-income adults

Kentucky’s Medicaid program and Arkansas’ private option resulted in significant improvements in health care quality during their second year of expansion, as well as increases in preventive care, outpatient utilization and self-reported health, according to recent data.

“The Medicaid expansion under the Affordable Care Act (ACA) has led to gains in coverage for millions of low-income adults in more than 30 states. But in several states, policymakers continue to debate whether to expand Medicaid and are weighing alternative approaches, such as using private insurance, increased cost-sharing, or work requirements for beneficiaries,” Benjamin D. Sommers, MD, PhD, from the department of health policy and management at Harvard T.H. Chan School of Public Health, and colleagues wrote. “In this report, we assess changes in access, utilization, preventive care, and self-reported health among low-income adults after 2 full years of expansion in three Southern states that responded differently to the ACA’s optional Medicaid expansion.”

Of the three states evaluated in the study, Texas did not expand Medicaid, whereas Kentucky expanded it and Arkansas used Medicaid funds for private insurance for low-income adults.

The researchers evaluated survey data from 8,676 low-income adults aged 19 to 64 years. The participants were all U.S. citizens with incomes below 138% of the federal poverty level. The researchers conducted differences-in-differences analyses of survey data from November 2013 through December 2015 to compare changes before and after the ACA between the expansion states, Kentucky and Arkansas, and the nonexpansion state, Texas. They analyzed changes in self-reported access to primary care, specialty care, affordability of care, quality of care, outpatient and emergency utilization, and overall health.

There were no differences in sex, income, or marital status among the three states, although Texas residents were younger and more urban. In 2015, there were more apparent changes in coverage and access than in 2014. Expansion was associated with a reduction in the uninsured rate (–22.7 percentage points; P < .001), increased access to primary care (12.1 percentage points; P < .001), increased outpatient visits (0.69 visits per year; P = .04), reduced out-of-pocket spending (–29.5%; P = .02), fewer skipped medications due to cost (–11.6 percentage points; P < .001), and reduced likelihood of ED visits (–6 percentage points; P = .04). They also determined that quality of care ratings had a significant improvement (–7.1 percentage points with “fair/poor quality of care”; P = .03), and in the number of adults reporting excellent health (4.8 percentage points; P = .04).

“We find that significant impacts of Medicaid expansion may take several years to unfold. After 2 years of coverage expansion in Kentucky and Arkansas, compared with Texas’ nonexpansion, there were major improvements in access to primary care and medications, affordability of care, utilization of preventive services, care for chronic conditions, and self-reported quality of care and health,” Sommers and colleagues wrote. “As Kentucky and Arkansas reconsider the future of their expansions, our study (along with evidence on the financial benefits to these states of expansion) provides support for staying the course. For other states still considering whether to expand, our study suggests that coverage expansion under the ACA — whether via Medicaid or private coverage — can produce substantial benefits for low-income populations.” – by Rafi Naseer

Disclosure: The researchers report no relevant financial disclosures.

Kentucky’s Medicaid program and Arkansas’ private option resulted in significant improvements in health care quality during their second year of expansion, as well as increases in preventive care, outpatient utilization and self-reported health, according to recent data.

“The Medicaid expansion under the Affordable Care Act (ACA) has led to gains in coverage for millions of low-income adults in more than 30 states. But in several states, policymakers continue to debate whether to expand Medicaid and are weighing alternative approaches, such as using private insurance, increased cost-sharing, or work requirements for beneficiaries,” Benjamin D. Sommers, MD, PhD, from the department of health policy and management at Harvard T.H. Chan School of Public Health, and colleagues wrote. “In this report, we assess changes in access, utilization, preventive care, and self-reported health among low-income adults after 2 full years of expansion in three Southern states that responded differently to the ACA’s optional Medicaid expansion.”

Of the three states evaluated in the study, Texas did not expand Medicaid, whereas Kentucky expanded it and Arkansas used Medicaid funds for private insurance for low-income adults.

The researchers evaluated survey data from 8,676 low-income adults aged 19 to 64 years. The participants were all U.S. citizens with incomes below 138% of the federal poverty level. The researchers conducted differences-in-differences analyses of survey data from November 2013 through December 2015 to compare changes before and after the ACA between the expansion states, Kentucky and Arkansas, and the nonexpansion state, Texas. They analyzed changes in self-reported access to primary care, specialty care, affordability of care, quality of care, outpatient and emergency utilization, and overall health.

There were no differences in sex, income, or marital status among the three states, although Texas residents were younger and more urban. In 2015, there were more apparent changes in coverage and access than in 2014. Expansion was associated with a reduction in the uninsured rate (–22.7 percentage points; P < .001), increased access to primary care (12.1 percentage points; P < .001), increased outpatient visits (0.69 visits per year; P = .04), reduced out-of-pocket spending (–29.5%; P = .02), fewer skipped medications due to cost (–11.6 percentage points; P < .001), and reduced likelihood of ED visits (–6 percentage points; P = .04). They also determined that quality of care ratings had a significant improvement (–7.1 percentage points with “fair/poor quality of care”; P = .03), and in the number of adults reporting excellent health (4.8 percentage points; P = .04).

“We find that significant impacts of Medicaid expansion may take several years to unfold. After 2 years of coverage expansion in Kentucky and Arkansas, compared with Texas’ nonexpansion, there were major improvements in access to primary care and medications, affordability of care, utilization of preventive services, care for chronic conditions, and self-reported quality of care and health,” Sommers and colleagues wrote. “As Kentucky and Arkansas reconsider the future of their expansions, our study (along with evidence on the financial benefits to these states of expansion) provides support for staying the course. For other states still considering whether to expand, our study suggests that coverage expansion under the ACA — whether via Medicaid or private coverage — can produce substantial benefits for low-income populations.” – by Rafi Naseer

Disclosure: The researchers report no relevant financial disclosures.