Medicaid Expansion May Impact Patient Outcomes in Southern States

Medicaid expansion may impact patient outcomes and coverage in low-income populations in the southern states, according to a recent study published by Health Affairs.

The study surveyed and extracted data about over 15,000 nonelderly adults in the Southern Community Cohort Study (SCCS), which is comprised of 12 southern states. The study analyzed self-reported health outcomes in the five years before Medicaid expansion and the two years following Medicaid expansion.

The researchers found that expansion states saw higher coverage by 7.6 percentage points, fewer participants whose health declined, and more participants who maintained their baseline health condition.

“These findings suggest that access to safety net providers in southern states is an inadequate substitute for health insurance coverage,” the study stated. “Thus, nonexpanding southern states could improve the health of their low-income residents by accepting expansion funds or otherwise extending coverage to low- income residents.”

According to the researchers, 18.7 percent of the expansion state participants had Medicaid coverage in the post-expansion period of the study. Before expansion, the rate was 7.6 percent lower. 

Over this same period of time, the uninsurance rate declined 7.0 percent, possibly indicating that almost all of the 7.6 percent change in Medicaid coverage was due to the Medicaid expansion.

Over 36 percent experienced a health decline after Medicaid expansion. This is 1.8 percentage points less than what was expected. If translated to states’ rankings, the researchers said that such results could shift a state three or four places up in the states’ health rankings.

“This reduction in health status declines was explained by fewer transitions to health states with severe physical and mental health limitations as opposed to fewer transitions from health states with no limitations to health states with moderate limitations,” the researchers clarified.

The researchers found several possible reasons for this difference between expansion and non-expansion.

Expanded access to care with specialty providers through Medicaid coverage might make health declines more unlikely, they suggested.

As many as 25 percent of safety-net clinics may refer patients to specialty care. However, this often leads to high out-of-pocket expenses for uninsured individuals.

Under expanded Medicaid, specialty services are covered. With this benefit, newly eligible enrollees can access specialty care providers with little to no cost-sharing.

The availability of non-emergency medical transportation benefits under expanded Medicaid may improve health outcomes for expansion states. These benefits prevent patients from having to miss an appointment due to lack of transportation or resorting to expensive emergency services for simpler conditions. According to a 2017 paper by the American Hospitals Association, this social determinant of health restricted 3.6 million people from accessing care.

Despite these potential reasons for Medicaid expansion to be a driving force behind the improvement in health outcomes, there is reason to believe that to attribute the change entirely to expansion could be an exaggeration.

Medicaid expansion served two purposes: to provide insurance to the uninsured and to improve coverage continuity for those already on Medicaid. Thus, not all of the health outcomes represent new enrollees.

“Expressing the differential reduction in health declines in terms of state rankings pro- vides a more conservative and interpretable assessment of the population health benefits associated with expansion,” the researchers explained.

The demographic of this study—the south—was not incidental. The majority of remaining states that have not expanded their Medicaid programs are located in the south. These include some states with the lowest health rankings according to the 2019 America’s Health Rankings from UnitedHealthcare Foundation: Mississippi (50), Alabama (47), Oklahoma (46), Tennessee (44), and South Carolina (42).

“Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans,” the researchers pointed out. “Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits—even for those with established access to safety-net care.”