The June 2012 decision by the Supreme Court upholding the Affordable Care Act (ACA) also allowed states to opt-out of the ACA-mandated expansion of Medicaid. In this way SCOTUS started an unintended (albeit non-randomized) experiment.
In this week’s New England Journal of Medicine, researchers compared health care access and self-reported health status in expansion and non-expansion states.
Who performed the study?
Researchers at the University of Michigan’s business school, UCLA’s medical school and the National Bureau of Economic Research, a private think tank.
Who were the experimental population?
Those eligible for Medicaid expansion: US citizens aged 19 to 64 with an income less than 138% of the federal poverty level.
What was the intervention?
As allowed by SCOTUS, US states chose to accept (29 states and DC) or decline (21 states) Medicaid expansion.
How was the data collected?
The researchers used data from an annual survey done by the National Center for Health Statistics. They compared pre-expansion data from 2010 to 2013 with post expansion data from 2014 and 2015. They used data from over 60,000 people.
What was measured and compared?
The researchers looked at three main classes of outcomes:
- Did the people have insurance coverage?
- Did the people access the healthcare system? How did they access the healthcare system? Did they have receive any preventative services? Could they afford to access the healthcare system? Did they have financial stress after using the healthcare system?
- How did the people feel about their health status? Were they diagnosed with diabetes, high blood pressure or high cholesterol?
What were the results?
In comparing accepting states versus declining states:
- After expansion, insurance coverage increased more in those states that accepted Medicaid expansion.
- After expansion, people in expansion states were less likely to report being unable to afford follow-up care, specialty care or medications.
- After expansion, people in expansion states had less reported financial strain due to medical bills.
- After expansion, people in expansion states were more likely to be diagnosed with diabetes, high cholesterol and depression in the first year after expansion. There was no difference in the second year after expansion.
- After expansion, people in expansion states were more likely to be hospitalized in the first year after expansion. There was no difference in the second year.
- After expansion, people in expansion states were more likely to report delays in obtaining appointments for follow-up care.
What are the limitations of this study?
This is not a true randomized, double-blind study, which would be unethical. This is likely the best study that could be done. The study population did not include everyone eligible for Medicaid expansion and only represents a subset of US citizens who completed the National Center for Health Statistics’ annual survey. Comparing characteristics of the people in the states accepting expansion versus the states declining expansion showed that they were roughly comparable. There is always a chance that they differed in some way that wasn’t measured.
What are the implications?
Here are my thoughts about the study.
First, Medicaid expansion lowers the uninsured rate. This may seem like a no-brainer, but some some states, like South Carolina, actually saw an increase in Medicaid enrollment despite turning down Medicaid expansion. This was because previously eligible but un-enrolled people sought Medicaid after all the publicity about the ACA.
Second, Medicaid expansion didn’t just increase access to health care, but actually resulted in people getting health care.
Third, the increase in diagnoses and hospitalizations in the first year of expansion, but not in the second, can be explained by people finally getting medical problems tended to when they obtain health care. I have seen this effect in my own clinical experience. Back in the 1990’s, the local medical community opened a free medical clinic for folks who “fell through the cracks;” having too much income for Medicaid, not enough to afford insurance. In the first year we had many people walk in with advanced breast cancer, colon cancer, undiagnosed diabetes, untreated heart failure, unstable angina among other maladies.
Fourth, the people in Medicaid expansion states perceived less financial stress due to medical problems. It will be interesting to see future studies about bankruptcy rates.
Fifth, the difficulty getting appointments in expansion states needs to be addressed. Increasing the low reimbursement rates and increasing the use of “physician extenders” like nurse practitioners and physicians assistants could help.
We should be seeing a lot more data and analysis coming out of the ACA experience. I am interested in seeing the effect of the ACA on things like mortality rates, neonatal mortality rates, re-hospitalization, etc.
Unfortunately, the Trump administration’s plan to cut domestic spending along with the GOP efforts to repeal the ACA will negatively impact the CDC and its National Center for Health Statistics.
The GOP might view that as a feature, not a bug. “No data. No problem.”