Medicaid Expansion Shrinks Distance to Care, Improves Equity

Medicaid expansion may have an impact on transportation for healthcare access among underserved groups, according to an article published in Health Affairs.

“As expected, nonmetropolitan areas were those registering the strongest policy effect because distances to the closest health care provider are, on average, longer than those in metropolitan areas, where the population density is higher,” the study explained. 

“In contrast, the fact that the policy had a stronger effect on the Black population has important public health implications, given that members of racial and ethnic minority groups are consistently found to face longer travel times to obtain health care services. Medicaid expansion increased access, in particular, for these most vulnerable populations.”

Researchers assessed how Louisiana’s Medicaid expansion impacted the distance that Louisianans had to travel for access to care.

Across multiple lines of business, from specialty to general practice, minority and rural Louisiana residents saw the distance to their appointments shrink after the Affordable Care Act expanded coverage.

Researchers leveraged Louisiana Medicaid claims from the start of 2015 through the end of 2017 in order to examine the change in distance traveled for care before and after Medicaid expansion. The study evaluated eight lines of business: outpatient care, primary care, specialty care, general practice, family practice, internal medicine, obstetrics-gynecology, and pediatrics.

In urban areas, Black beneficiaries made up over half of the Louisianans in the sample (51.2 percent) while White beneficiaries made up 34.2 percent and in rural regions the split was fairly even: 45.1 percent were Black beneficiaries and 45.5 percent were White beneficiaries. Nearly six in ten of the beneficiaries were female in the rural and urban environments.

On average, urban beneficiaries took a little over 16 trips to the provider and rural beneficiaries took slightly more than 17 trips to see their providers between 2015 and 2017.

The researchers saw a surge in physicians accepting Medicaid the month after Medicaid expansion. Five hundred providers started accepting Medicaid beneficiaries a month after the expansion went into effect.

The impact was greatest in rural areas, particularly for Black beneficiaries suggesting that there are both overall access to care benefits and health equity benefits to expansion. 

Black beneficiaries traveled 9.25 fewer miles for general practice care. Additionally, Black enrollees traveled 2.95 fewer miles for primary care, while their White counterparts traveled 3.32 fewer miles for this line of business.

Black Iowans in urban settings also saw improvements across all lines of business. White beneficiaries in urban areas saw significant changes in distance traveled for five types of care.

Obstetrics services saw the biggest mean decline in distance traveled, dropping 3.18 miles. Specialty care services saw the smallest mean decline (0.63 fewer miles).

Even the ninety-fifth percentile of beneficiaries who traveled for care saw a decline across all lines of business. This group was important because they had the biggest travel distances pre-expansion. After expansion, though, the mean distance to see general practitioner dropped by 1.76 miles and the mean distance to an obstetrician declined by a mean of 25.83 miles.

Using regression discontinuity, the researchers found that individuals traveling to a general care provider saw the greatest benefit from the Medicaid expansion on their distance to care. The distance to a general practice dropped on average 3.46 miles. 

The distance to primary care also dropped significantly, with beneficiaries traveling on average 1.78 fewer miles after the expansion to their primary care visits.

The researchers noted one problem with the study’s design: they only had each beneficiary’s most recent address, which may not be where the beneficiary lived before the Affordable Care Act’s expansion. 

To account for this, the researchers looked at data form a 2018 snapshot—after the study’s timeframe—and found that only 8.3 percent of beneficiaries had changed addresses. The method that the study employed to make this analysis also controlled for trends in distances, potentially lessening the impact of this challenge.

Payers are well aware that travel time can pose a significant barrier to care, particularly among rural and minority communities.

“Long-distance travel is commonly cited as one of the biggest barriers to health care for our members,” Karen Amezcua, senior director of provider partnerships at Blue Cross and Blue Shield of Minnesota (Blue Cross), said in a recent press release detailing the payer’s attempts to support access to rural maternity healthcare.

The payer offered technology and training support to a rural provider partner in order to better equip the hospital’s obstetrics and other maternal clinical care functions.

The distance that a beneficiary has to travel to access care have played a key role in assigning network adequacy standards, though some experts question whether this is an effective measurement.

The study’s results are particularly interesting when set alongside additional research showing that Medicaid expansion has demonstrated mixed results in reducing care disparities.