Expanding Coverage Does Not Guarantee a Benefit

Abstract

The Affordable Care Act (ACA) was designed to increase coverage and protect Americans from the financial risks associated with the receipt of health care. Studies estimate that approximately 20 million Americans gained coverage because of the ACA who otherwise would have been uninsured. This includes an estimated 1.9 million individuals with diabetes.1Myerson R. Romley J. Chiou T. et al.The Affordable Care Act and health insurance coverage among people with diagnosed and underdiagnosed diabetes: data from the National Health and Nutrition Examination Survey.Diabetes Care. 2019; 42: e179-e180Crossref PubMed Scopus (6) Google Scholar A major way in which the ACA expanded coverage was by creating a new eligibility category within state Medicaid programs for childless adults at less than 138% of the federal poverty level ($17 600 for an individual in 2020). When the ACA was enacted, it was intended to be nationwide, but the Supreme Court subsequently ruled that this provision should be optional for states. Fourteen states still have not expanded Medicaid to the newly eligible group under the ACA, and if they did, an additional 4.4 million individuals would gain coverage.2Kaiser Family FoundationWho could get covered under Medicaid expansion? State fact sheets January 23, 2020.https://www.kff.org/medicaid/fact-sheet/uninsured-adults-in-states-that-did-not-expand-who-would-become-eligible-for-medicaid-under-expansion/Google Scholar Proponents of the ACA assumed that expansions in coverage would facilitate access to care. The law also included provisions specifically designed to improve access to care for low-income patient populations. For example, the ACA provided federal funding to increase the availability of health centers and a temporary bump in payments to Medicare rates for all primary care physicians participating in the care of Medicaid patients. Several studies have evaluated the impact of Medicaid expansion on patient outcomes. In general, Medicaid expansion has been associated with improvements in access to primary care, self-reported physical and mental health, mortality, and disparities in outcomes by race and ethnicity.3Soni A. Wherry L.R. Simon K.I. How have ACA insurance expansions affected health outcomes? Findings from the literature.Health Affairs. 2020; 39: 371-378Crossref Scopus (6) Google Scholar For patients with diabetes, Medicaid expansion has been associated with improvements in access to care and the ability to afford the cost of care.4Luo H. Chen Z.A. Xu L. Bell R.A. Health care access and receipt of clinical diabetes preventive care for working-age adults with diabetes in states with and without Medicaid expansion: results from the 2013 and 2015 BRFSS.J Public Health Manag Pract. 2019; 25: E34-E43Crossref PubMed Scopus (8) Google Scholar In this issue of Ophthalmology, Chen et al5Chen E.M. Armstrong G.W. Cox J.T. et al.Association of the Affordable Care Act Medicaid expansion with dilated eye examinations among the United States population with diabetes.Ophthalmology. 2020; 127: 920-928Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar (see page 920) make use of an annual national survey to assess whether the expansion of Medicaid is associated with an increase in the receipt of dilated eye examinations among diabetic patients. They found that, although a significant increase in dilated eye examinations for patients with diabetes occurred in the first 2 years after Medicaid expansion, this improvement relative to what was observed in states that did not expand Medicaid was not sustained by the third year after expansion. Assuming these findings are accurate, they raise questions about how to improve eye care for diabetic patients. The ACA eliminated patient cost-sharing for preventive screening that has an A- or B-level recommendation from the United States Prevention Services Taskforce. Screening for diabetes is included in the list of services available without patient cost-sharing, but annual dilated eye examinations for patients with diabetes is not. Therefore, state Medicaid programs may not fully cover the cost of dilated eye examinations for the newly eligible or for traditional Medicaid beneficiaries. A difference in requirements for patient cost-sharing for dilated eye examinations as opposed to diabetic screening may explain why early detection of diabetes has increased after the ACA, but dilated eye examinations have not. In addition, it may be more challenging logistically for Medicaid beneficiaries to receive preventive services, such as dilated eye examinations, that require a referral to a specialist, than it is to obtain preventive services, such as diabetic screening, furnished in a primary care setting. The ACA has had a demonstrable impact on health insurance coverage and health outcomes, but health insurance coverage, including that provided by Medicaid, is insufficient for ensuring access to a specific health care service if that service is not included as a covered benefit. Achieving an A- or B-level recommendation for dilated eye examinations for diabetic patients from the United States Prevention Services Task Force would be one way to ensure the availability of this benefit for the newly eligible Medicaid population. An even better approach is to convince state Medicaid programs of the value of dilated eye examinations for diabetic patients. State Medicaid programs eager to find sources of cost savings could become allies in expanding access to preventive eye care services for diabetics if they can be convinced that an upfront investment in screening not only will improve patient outcomes, but also will result in downstream programmatic savings. Association of the Affordable Care Act Medicaid Expansion with Dilated Eye Examinations among the United States Population with DiabetesOphthalmologyVol. 127Issue 7PreviewTo evaluate the association between Medicaid expansion and diabetic dilated eye examinations. Full-Text PDF