Medicaid Expansion Improves Access to Care, Population Health

States that did not opt into Medicaid expansion under the Affordable Care Act (ACA) experienced worse emergency access to acute care hospitals compared to states that did, according to recent study.

Overall, states that expanded Medicaid saw an increase in access to care. In 2007, 5.65 percent of the population did not have access to hospitals. By 2017, that number decreased to 5.35 percent in 2017. On the other hand, states that did not expand Medicaid saw an increase in the population without access to hospitals overall, rising from 6.76 percent in 2007 to 6.79 percent in 2017.

If access changes in non-expansion states were the same as expansion states, approximately 421,000 more people would have had access to acute care hospitals.

The ACA, signed into law in 2010, included conditions for states to receive federal funds to expand Medicaid eligibility up to 138 percent of the federal poverty level for adults. By December 2017, 19 states had not expanded Medicaid coverage. Research suggests that hospital closures in those states may have occurred due to the decision not to adopt Medicaid expansion.

The researchers noted that hospital closures do not necessarily mean decreased access to care, as closures may have occurred in areas with multiple healthcare facilities or declining populations. However, closures of safety-net hospitals may lead to a loss of access for some underinsured patients. These patients may be less likely to seek care at other hospitals due to the potential for high out-of-pocket expenses.

To understand the relationship between Medicaid expansion and access to care, the researchers evaluated the association of Medicaid expansion with changes in emergency access to acute care hospitals and safety-net hospitals in the overall population. Researchers also looked at the low-income population since this was the target group for the proposed Medicaid expansion changes.  

Access to care grew for low-income patients in all states, but the rate of growth was 0.06 percent greater in states with Medicaid expansion.

States with Medicaid expansion saw a decrease of 0.87 percent in the population without access to safety-net hospitals overall, while states that did not expand Medicaid saw a 0.79 percent increase. For low-income persons specifically, states with Medicaid expansion saw a 0.86 percent decrease in the population without access to safety-net hospitals compared to a increase of 0.77 percent in states that did not expand Medicaid.

If access changes to safety-net hospitals were the same in non-expansion as they were in expansion states, an estimated 2.2 million more persons overall and 364,000 more low-income persons would have retained access to care.

“Our analysis found a potential spillover effect from national health policy reform on changes in the local availability of services, with unanticipated and undesirable repercussions at patient, hospital, and regional levels,” the researchers noted. “Policy makers should factor these results into decision-making when considering payment reforms and changes to health care entitlements like Medicaid.”

Additionally, the researchers said the study’s results could encourage policymakers to develop other strategies to preserve population access to care that are independent of payment reform. For example, two Medicaid expansion states, Maryland and Pennsylvania, have taken on efforts to minimize financial strain and uncertainty for smaller, rural hospitals through versions of capitated payment models.

South Carolina, a state that did not expand Medicaid under the ACA, has taken a different approach to preserve population access to care by creating incentives for hospitals to expand service delivery. It is not known yet how well these programs maintain access to care and improve Population health.