Better Access, Longer Waits Under Medicaid Expansion

Bridget M. Kuehn

March 09, 2017

Health insurance coverage and access to care continued to improve in the second year of Medicaid expansion under the Affordable Care Act (ACA), according to a study published in the March 9 issue of the New England Journal of Medicine. Those covered under the expansion did, however, report longer wait times for care.

Starting in 2014, the ACA expanded Medicaid eligibility for people who earn up to 138% of the federal poverty level, which would have been about $16,000 for a single adult in 2014. Some states chose to opt out of expansion, as the Supreme Court made expansion optional in 2012. By 2015, 29 states and the District of Columbia had expanded Medicaid to residents meeting this threshold. Several studies to date have shown that in the first year, Medicaid expansion increased insurance coverage, healthcare access, and the health of those who benefited from expansion. But data on the longer-term effects of the expansion are only beginning to emerge.

Sarah Miller, PhD, an assistant professor of business economics and public policy at the University of Michigan, Ann Arbor, and Laura Wherry, PhD, an assistant professor of medicine at the University of California, Los Angeles, analyzed the effects of the first 2 years of Medicaid expansion. They compared insurance coverage, healthcare access, and self-reported health status for 60,766 expansion-eligible individuals during the 4 years before the expansion and the first 2 years after.

The analysis found an 8.2 percentage point decrease in the number of uninsured individuals after expansion and a 15.6 percentage point increase in Medicaid coverage in 2015, the second year after expansion, compared with the years before expansion. There was no change in self-reported health status, physician visits, or hospital stays, but there were decreased reports of individuals being unable to access necessary follow-up care (−3.4 percentage points) and worry about paying medical bills (−7.9 percentage points), and an increase in reports that long wait times delayed care (+2.6 percentage points).

"We found evidence that low-income adults are better off after Medicaid expansion," Dr Wherry told Medscape Medical News. But improvements in access to care, reductions in people foregoing care, and reduced financial strain "only showed up during the second year of expansion. We didn't see them during the first year. This indicates it will take some time to realize the effects of expanding Medicaid for low-income adults."

The lag time to seeing a benefit may reflect the time it takes for newly covered individuals to find a physician or establish care, Dr Wherry suggested.

Other studies looking at the second year of the Medicaid expansion have found improvements in self-reported health status. For example, a study of the ACA Medicaid expansion in Arkansas and Kentucky found that the number of low-income adults reporting excellent health increased by 4.8 percentage points (Sommers BD et al. JAMA Intern Med. 2016;176(10):1501-1509). Benjamin Sommers, MD, an associate professor of health policy and economics at the Harvard School of Public Health, Boston, Massachusetts, told Medscape Medical News that the states examined in the respective studies or the way patients were asked about their health status may have explained the difference.

The longer wait times experienced after the expansion may be an early sign that physicians are having a difficult time keeping up with the increased demand or the reluctance of providers to accept Medicaid's lower reimbursements, Dr Wherry told Medscape Medical News. She and Dr Miller write that efforts to boost the number of primary care physicians or to incentivize care for underserved patients may be needed.

"Fewer patients are going without the care they need, but they may be waiting longer for care than they would like," Dr Wherry said.

Studies that look at the longer-term effects of the Medicaid expansion are needed, Dr Sommers said, because many longer-term health improvements may take years to emerge.

Overall, the study adds to a growing body of evidence that suggests Medicaid expansion has beneficial effects on low-income adults, Dr Sommers explained. This evidence also has important implications for the current Republican ACA repeal and replace plan, which is expected to reduce the number of individuals covered by Medicaid.

"It's another brick in the wall of this base of evidence that giving low-income adults access to Medicaid makes a real difference in terms of people being able to get the care they need," Dr Sommers said. "Taking it away, limiting the numbers of people who get it or, or cutting federal funding for it is likely to have a negative effect on the very people we are talking about here.

"Rolling back Medicaid expansion will likely cause low-income adults to lose coverage and roll back some of the improvements we've seen," Dr Wherry said.

The authors and Dr Sommers have disclosed no relevant financial relationships.

N Engl J Med. 2017;376:947-956. Abstract

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