Study: Access to Care Improved Most Where Medicaid Expanded

March 16, 2017

For low-income Americans, health insurance coverage and access to care have improved more in states that expanded Medicaid eligibility under the Affordable Care Act (ACA) than in states that didn't, according to a new health system "scorecard" released on March 15 by the Commonwealth Fund.

The percentage of low-income, working-age adults without insurance decreased 14.1 points on average in Medicaid expansion states from 2013 to 2015 compared with 8.9 points in nonexpansion states. Likewise, expansion states outperformed nonexpansion states when it came to a drop in the percentage of adults who went without care because of cost (5.5 points vs 2.3 points) and who didn't have a regular healthcare provider (2.7 points vs 1 point).

Commonwealth Fund President David Blumenthal, MD, said lawmakers need to heed these and other findings as a Republican-controlled Congress crafts legislation to repeal and replace the ACA. A House bill would end Medicaid expansion in 31 states that implemented it and reduce federal contributions to state programs by $880 billion over 10 years, in part by capping them on a per-capita basis, according to an analysis by the Congressional Budget Office (CBO). The CBO said on March 13 that these rollbacks were major reasons why the bill, called the American Health Care Act, would add 24 million more Americans to the ranks of the uninsured by 2026.

"The bottom line is that that any [repeal and replace] plan must hold onto the gains we've made, and improve on them," Dr Blumenthal said during a news briefing yesterday. Dr Blumenthal served in the Obama administration as National Coordinator for Health Information Technology.

Howard Forman, MD, a lecturer in ethics, politics, and economics at Yale University, described the Commonwealth Fund report as convincing.

"I don't think Republicans would disagree with the fact that expanding Medicaid increases access and that people with insurance, even Medicaid, have better healthcare and better healthcare access and less cost incurred by them," Dr Forman, director of Yale's MD/MBA program, said in an interview with Medscape Medical News.

Forman said the people who want to repeal the ACA are asking whether this progress "is worth the cost, and are there other ways to use the money more efficiently."

Improvements in Patient Safety and Quality of Care

The Commonwealth Fund scorecard ranks each state and Washington, DC, using 44 measures of healthcare access, quality, cost, and outcomes. In the latest scorecard, the vast majority of states improved their overall performance between 2013 and 2015, when the ACA's major coverage provisions took effect. Vermont topped the list, followed by Minnesota, Hawaii, Rhode Island, and Massachusetts. The bottom five states were, in reverse order, Mississippi, Oklahoma, Louisiana, Arkansas, and Alabama.

There were significant advances in healthcare quality and patient safety over slightly different time frames. In 46 states, Medicare patients were less likely to be prescribed a high-risk medication in 2014 than in 2012. The incidence of central line–associated bloodstream infections declined in 20 states and Washington, DC; stayed the same in 21 states; and rose in nine others between 2013 and 2014. And hospital 30-day readmission rates among Medicare patients fell in 33 states and Washington, DC, between 2012 and 2014.

The Commonwealth Fund study was not entirely rosy. It reported that premature deaths before 75 years of age that could have been prevented with timely care rose slightly in 30 states and Washington, DC, between 2011-2012 and 2013-2014 after having fallen over the previous decade. And healthcare disparities persist for people with low income and for minorities. In Oklahoma, for example, 17% of adults went without needed care because of its cost in 2015, but the corresponding figure for African Americans there was 26%.

Follow Robert Lowes on Twitter @LowesRobert

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