States See Patient Experience Shifts in the First Year After Medicaid Expansion

Medicaid expansion can alter the characteristics of states’ Medicaid populations, which is a factor that policymakers need to consider when formulating standards for quality of care and patient experience, according to a study published in the American Journal of Managed Care.

“More states are developing reporting systems to hold Medicaid managed care plans accountable for enrollee experience of care, but measured performance may be affected by shifts in the composition of Medicaid enrollees following coverage expansions to previously ineligible adults,” the study explained.

Researchers leveraged data from the 2012-2018 National Committee on Quality Assurance (NCQA) Adult Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS). The analysis was restricted to nonelderly adults who were not dual eligible and who were in comprehensive managed care plans. The study represents results from 324,435 Medicaid managed care enrollees.

The study analyzed four metrics of enrollee experience to assess changes after Medicaid expansion. First, it considered access to a personal doctor. In adjusted analyses, enrollees in expansion states were less likely to have a personal doctor. Access to a personal doctor dropped 1.6 percentage points when states expanded their Medicaid programs in the first year after the expansion.

Second, it considered timely access to specialty care. Expanding Medicaid programs was associated with beneficiaries being 2.1 percent less likely to be able to access specialty care in a timely manner in the first year after expansion.

Out of the four enrollee experience metrics, these two metrics—having a personal doctor and timely access to specialty care—produced the most significant results. Both measures saw decreases in the first year after expansion. However, in both cases, the differences shrank by the second year of Medicaid expansion.

The study also tested whether respondents “always or usually” had easy access to needed care and easy access to a checkup or routine care.

In addition to these four metrics, the researchers looked at socioeconomic and demographic changes that occurred in the Medicaid population when states expanded eligibility.

After expansion, the new Medicaid enrollees tended to be college-educated, non-Hispanic White males who were less frequent utilizers of care and in better health compared to Medicaid beneficiaries who were eligible for Medicaid before the expansion.

The researchers found that the Hispanic/Latino Medicaid beneficiary population shrank after Medicaid expansion.

“Prior work indicated that uninsurance disparities narrowed for Hispanic/Latino adults, but there were substantially larger coverage gains among non-Hispanic White adults,” the researchers noted.

“Failure to recognize that MCO case mix changed may lead to spurious conclusions about the effects of Medicaid expansion on enrollee experience of care, as our findings indicate that MCOs’ enrollee compositions were fundamentally different in 2014 than they would have been in the absence of Medicaid expansion.”

Policymakers should let these expected shifts in demographics and patient experience inform their decision-making when establishing quality measures for Medicaid managed care organizations. These results are particularly important for policymakers in states that have not yet adopted Medicaid expansion.

“There may be value to collecting and using pathway-to-eligibility data for risk adjustment or stratification, which may allow states to more accurately compare whether MCOs are meeting their enrollees’ needs and to identify targeted quality improvement interventions,” the researchers suggested.

A separate study of Medicaid expansion in Arkansas found that Medicaid expansion might increase access to care for homeless individuals, who tend to be white, middle-aged, and male.

Medicaid expansion has been seen as an antidote to uninsurance. During the initial phases of the coronavirus pandemic, declines in employer-sponsored coverage corresponded with increases in public healthcare coverage. However, nonexpansion states saw higher uninsurance rates.