Affordable Care Act Medicaid Expansion Research Articles

Association of state Medicaid expansion with timeliness of cancer care delivery.

e18126 Background: The Affordable Care Act (ACA) expanded Medicaid eligibility to nonelderly adults with incomes at or below 138% of the federal poverty level in participating states. Medicaid expansion has been associated with earlier cancer stage at diagnosis; however, its impact on cancer treatment is unknown. Methods: We assembled retrospective cohorts of adult nonelderly patients (ages 40-64) with newly diagnosed breast, colon and lung cancer from January 2011 to December 2015, using data from the National Cancer Database (NCDB). We conducted a quasi-experimental, difference-in-differences analysis to compare Medicaid expansion and non-expansion states on timeliness of cancer therapy, stage at diagnosis, and insurance status for the years before (2011-2013) and after ACA Medicaid expansion (2014-2015). Results: There were 466,314 patients in expansion states (mean age, 54.7 years; 81.5% women) and 487,958 patients in non-expansion states (mean age, 54.9 years; 78.5% women). In expansion states relative to non-expansion states, there was no significant difference in the proportion of patients initiating cancer therapy within 30 days (adjusted difference-in-difference (DID) estimate -0.1%; 95% CI -0.8 to +0.7%, p = 0.868) or within 90 days of diagnosis (adjusted DID estimate -0.1%; 95% CI -0.3 to +0.1%, p = 0.501), before and after expansion. Among those with early-stage cancers undergoing definitive therapy, there was similarly no significant difference in time to treatment. Relative to non-expansion states, the proportion of early stage cancer diagnoses increased more (adjusted DID estimate +0.7%; 95% CI +0.3 to +1.2%, p = 0.002), and the proportion of advanced stage cancers decreased more (adjusted DID estimate -0.4%; 95% CI -0.7 to -0.1%, p = 0.008) in expansion states. The proportion uninsured at diagnosis decreased more in expansion states (adjusted DID estimate -0.8%; 95% CI -1.2 to -0.4%, p < 0.001). Conclusions: Among nonelderly patients with common cancers, ACA Medicaid expansion was associated with an increase in the proportion of cancers diagnosed at early stage, a decrease in the proportion of cancers diagnosed at advanced stage, and a decrease in the proportion of uninsured. There was no significant effect on the timeliness of treatment.

Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion

Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs.Electronic health record data on 624,601 non-pregnant patients aged 21–64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology.Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09–1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05–1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16–1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11–1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states.Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.

Four Years Later: Insurance Coverage and Access to Care Continue to Diverge between ACA Medicaid Expansion and Non-Expansion States

This paper evaluates the impact of the Affordable Care Act Medicaid expansions four years after implementation using data from the 2010-2017 National Health Interview Survey. We find that low-income adults in states that implemented the Medicaid expansions experienced increases in insurance and Medicaid coverage and improvements in access to health care across several measures.

Examining Medicaid Expansion and the Treatment of Substance Use Disorders

As the drug epidemic continues to cripple communities and disrupt our country, identifying and understanding state and federal policies which have helped alleviate the burden of substance use disorders (SUDs) is imperative. In 2010, the passage of the Patient Protection and Affordable Care Act (ACA) expanded health coverage and services offered to millions of Americans. Prior to the ACA, treatment for substance use disorders was not included in all medical coverage. We examine the brief literature on ACA Medicaid Expansion and SUDs and complement this literature by including the effects on measures of supply and efficacy of SUD treatment.

Changes in State Technical Assistance Priorities and Block Grant Funds for Addiction After ACA Implementation.

Objectives. To assess states' provision of technical assistance and allocation of block grants for treatment, prevention, and outreach after the expansion of health insurance coverage for addiction treatment in the United States under the Affordable Care Act (ACA). Methods. We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. Results. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. Public Health Implications. The ACA's infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA's Medicaid expansion.

Lung transplantation and Affordable Care Act Medicaid expansion in the era of lung allocation score - a retrospective study.

This study evaluated the impact of Medicaid eligibility expansion (ME) on lung transplant (LT) listings and Medicaid coverage. Data on LT candidates aged 18-64 were obtained from the Scientific Registry of Transplant Recipients (N=9153). The impact of ME was evaluated by comparing LT listings in 2011-2013 with listings in 2014-2016, as well as comparing states that had and had not adopted ME in 2014. LT listings increased by 7.7% nationally post-ME. In ME states, LT listings increased by 15.2%, whereas nonexpansion states decreased by 1.5%. LT candidates with Medicaid increased after ME nationally (8.3% vs. 9.9%, P=0.006) and in ME states (9.7% vs. 11.5%, P=0.036), but not in nonexpansion states (6.6% vs. 7.7%, P=0.170). Following multivariable adjustment, LT listings in ME states had 58% greater odds for Medicaid compared to nonexpansion states (P<0.001). Expansion of Medicaid provided greater healthcare access and increased LT listings, but only within states that adopted eligibility expansion.

The Impact of the Affordable Care Act Medicaid Expansion on Type 2 Diabetes Diagnosis and Treatment: A National Survey of Physicians.

In 2014, the Affordable Care Act (ACA) provided funding for states to expand Medicaid coverage to include citizens who earned up to 138% of the federal poverty line. We sought to ascertain whether physicians practicing in Medicaid expansion states reported an increase in Medicaid or newly insured patients with type 2 diabetes in their panels, compared to physicians practicing in non-expansion states. We conducted a 55-question cross-sectional survey of 356 physicians providing outpatient care for adults with type 2 diabetes. We used adjusted multivariate logistic regression analyses to compare responses from physicians who practiced in expansion versus non-expansion states regarding whether they observed an increase since 2014 in (1) the number of Medicaid or newly insured patients with diabetes and (2) the number of additional newly or previously diagnosed patients who were newly receiving care, in their panels, adjusting for physician, practice, and patient-level characteristics, weighted for the U.S. physician population. 41% of eligible recipients responded. 64.2% of physicians who practice in an expansion state report an increase in Medicaid or newly insured patients with diabetes compared with 46.1% who practice in non-expansion states (p = 0.05; Table2). Compared with physicians who practice in non-expansion states, physicians who practice in Medicaid expansion states are more likely to report an increase in the number of Medicaid or newly insured patients with diabetes in their practice since 2014. The increased access associated with the Medicaid expansion may improve long-term outcomes for patients with type 2 diabetes.

The Impacts of the ACA Medicaid Expansions on Cancer Screening Use by Primary Care Provider Supply.

Recent studies of the impacts of the Affordable Care Act (ACA) Medicaid expansions on cancer screening use have mostly found insignificant effects. We posit that these findings mask meaningful heterogeneity in impacts depending on availability of primary care providers. This study examined the impacts of the ACA Medicaid expansions on cancer screening use separately by state-level supply of primary care providers. We used data from the 2012 and 2016 Behavioral Risk Factor Surveillance System surveys to measure use of mammograms, Pap smear tests, blood stool tests, and sigmoidoscopy/colonoscopy for age groups recommended receiving these tests. The main analytical sample included 24,878-31,890 individuals with household income below 138% Federal Poverty Line. We used a difference-in-differences design comparing pre-post expansion changes in cancer screening use between expanding and nonexpanding states separately for 2 state groups defined by the median proportion of the state population residing in primary health professional shortage areas: low primary care provider supply (above median) and high supply (below median). Medicaid expansions were associated with significant increases in mammograms (11.4 percentage-points), Pap smear tests (6.9 percentage-points), and sigmoidoscopy/colonoscopy use (8.3 percentage-points) in states with high supply of primary care providers. In contrast, effects were small and insignificant in low supply states. ACA Medicaid expansions were associated with increased cancer screening use only in states with high supply of primary care providers. Improving access for Medicaid beneficiaries in provider shortage areas may require coupling coverage expansions with supply-side interventions to increase provider availability.

Medicaid Expansion and Breast Cancer Screening in Appalachia and Non-Appalachia, United States, BRFSS 2003 to 2015.

Background:Prior data suggests that breast cancer screening rates are lower among women in the Appalachian region of the United States. This study examined the changes in breast cancer screening before and after the implementation of the Affordable Care Act Medicaid expansion, in Appalachia and non-Appalachia states.Methods:Data from the Behavioral Risk Factor Surveillance System between 2003 and 2015 were analyzed to evaluate changes in breast cancer screening in the past 2 years among US women aged 50-74 years. Multivariable adjusted logistic regression and generalized estimating equation models were utilized, adjusting for sociodemographic, socioeconomic, and health-care characteristics. Data were analyzed for 2 periods: 2003 to 2009 (pre-expansion) and 2011 to 2015 (post-expansion) comparing Appalachia and non-Appalachia states.Results:The prevalence for of self-reported breast cancer screening in Appalachia and non-Appalachia states were 83% and 82% (P < .001), respectively. In Appalachian states, breast cancer screening was marginally higher in non-expanded versus expanded states in both the pre-expansion (relative risk [RR]: 1.002, 95% confidence interval [CI]: 1.002-1.003) and post-expansion period (RR: 1.001, 95% CI: 1.001-1.002). In non-Appalachian states, screening was lower in non-expanded states versus expanded states in both the pre-expansion (RR: 0.98, 95% CI: 0.97-0.98) and post-expansion period (RR: 0.95, 95% CI: 0.95-0.96). There were modest 3% to 4% declines in breast cancer screening rates in the pos-texpansion period regardless of expansion and Appalachia status.Conclusions:Breast cancer screening rates were higher in Appalachia versus non-Appalachia US states and higher in expanded versus nonexpanded non-Appalachia states. There were modest declines in breast cancer screening rates in the post-expansion period regardless of expansion and Appalachia status, suggesting that more work may be needed to reduce administrative, logistical, and structural barriers to breast cancer screening services.

Did the ACA Medicaid Expansion Save Lives?

We estimate the effect of the Affordable Care Act Medicaid expansion on county-level mortality in the first four years following expansion. We find a reduction in all-cause mortality in ages 20 to 64 equaling 11.36 deaths per 100,000 individuals, a 3.6 percent decrease. This estimate is largely driven by reductions in causes of death likely to be influenced by access to health care, and equates to one life saved per 310 newly covered individuals. A cost-benefit analysis shows that the improvement in welfare due to mortality responses may offset the entire net-of-transfers expenditure associated with the expansion.

Affordable Care Act Medicaid Expansion and Racial and Ethnic Disparities in Access to Primary Care.

The Affordable Care Act's (ACA) Medicaid expansions improved access to care for low-income populations, yet evidence is limited on how these gains differed by race/ethnicity. We examined how Medicaid expansions affected access to primary care, and how race/ethnicity moderated these effects. Using 2011-2016 Behavior Risk Factor Surveillance System data, we found that low-income adults in Medicaid expansion states were 13.9 percentage points more likely to have insurance, 5.6 percentage points more likely to have a usual source of care, and 5.0 percentage points less likely to delay care due to cost post-expansion versus in non-expansion states. Insurance gains were 6.4 percentage points lower for Hispanic adults than White adults in expansion states post-expansion; otherwise, gains were similar by race/ethnicity. Baseline access disparities between White and minority adults persisted post-expansion, especially between White and Hispanic adults. Access may decline comparably for White and minority adults if ACA Medicaid expansions are repealed.

The Effects of the Affordable Care Act Medicaid Expansion on Subjective Well-Being

This study analyzes the effects of the 2014 Affordable Care Act (ACA) Medicaid expansion on the subjective well-being of individuals in the United States. Using data from the Panel Study of Income Dynamics, we find that the expansion has significantly improved the overall life satisfaction of low-income non-elderly adults. Various sensitivity checks and falsification tests confirm the internal validity. Our findings imply that, without considering psychological benefits, the actual benefits of the ACA Medicaid expansion may be underemphasized.

The Effect of the ACA Medicaid Expansion on Marriage Behavior

paper investigates the impact of the 2014 Medicaid expansions on marital behavior. The Patient Protection and Affordable Care Act (ACA) encouraged states to expand Medicaid and thereby increase insurance options for low-income individuals. Contributing to earlier work showing evidence of a link between insurance coverage and incentives to marry, we test whether the Medicaid expansions affected marriage and divorce decisions. Using data from the American Community Survey from 2008 to 2018 and estimating difference-in-differences models, we test the impact of Medicaid expansion on both stock and flow marital outcomes. As a first-stage effect, we show that the expansions increased Medicaid coverage by 31.15 percent in first-time expansion states. When evaluating the effects of the policy on marriage behavior, we find that Medicaid expansions led to a 0.75 percent reduction in the stock of married people, a 4.15 percent reduction in the likelihood of having married in the past year, and a 3.61 percent increase in having had a recent divorce. We believe the underlying mechanism to be twofold. First, Medicaid expansion led to increased insurance options, which decreased reliance on spousal health insurance coverage. Second, by changing eligibility thresholds, Medicaid led to people choosing to forego marriage or get divorced to meet post-policy program eligibility restrictions.

The impact of ACA Medicaid expansion on socioeconomic inequality in health care services utilization.

ObjectiveWe examined whether the Affordable Care Act (ACA) Medicaid expansion reduced socioeconomic inequalities in health care utilization.MethodsWe used data from the Behavioral Risk Factor Surveillance System, covering the 50 U.S. states and the District of Columbia, between 2011 and 2016. We selected outcome indicators, viz. ability to afford needed health care, having a personal doctor, use of health services in the past year (routine check-up, flu shot and dental visits), and attending screenings for breast, cervical, and colon cancers. Socioeconomic status was measured by household income. We calculated two indices of inequality by household income for each outcome: Slope Index of Inequality (SII) and Relative Index of Inequality (RII). We estimated difference-in-differences models to examine the impact of ACA Medicaid expansion on socioeconomic inequality in use of health care services.ResultsThe ACA Medicaid expansion appeared to reduce the socioeconomic gap in individuals reporting financial ability in accessing health care (difference-in-differences estimators, -0.045 for SII and RII), having a personal doctor (-0.037 for SII and RII), and receiving routine check-ups (-0.027 for SII and -0.039 for RII). However, the expansion was not associated with reduction in the socioeconomic gap for preventive health care visits or dental care.ConclusionsThe ACA Medicaid expansion had mixed effects on socioeconomic disparities in health care utilization. Medicaid expansion may not be sufficient to address socioeconomic disparities in preventive services uptake.

The Impact of Affordable Care Act Medicaid Expansions on Applications to Federal Disability Programs.

In this paper, we estimate the impact of Medicaid expansions via the Patient Protection and Affordable Care Act (ACA) on applications to federal disability programs in 14 states that expanded Medicaid in January 2014. We use a difference-in-differences regression model to compare disability application rates in geographic areas within states that expanded Medicaid to rates in areas of non-expansion states that were carefully selected using a matching approach that accounts for state Medicaid policies pre-ACA as well as demographic and socioeconomic characteristics that might influence disability application rates. We find a slower decrease in Supplemental Security Income (SSI) application rates after Medicaid expansions in expansion states relative to non-expansion states, with application rates declining in both state groups from 2014 through 2016. Our analysis of the impact of the Medicaid expansions on Social Security Disability Insurance (SSDI) application rates was inconclusive for reasons we discuss in the paper.

Preconception Coverage Before and After the Affordable Care Act Medicaid Expansions

To estimate the effects of the Affordable Care Act Medicaid expansion provision that was largely implemented in 2014 on preconception insurance coverage among low-income women. We used a quasiexperimental, difference-in-difference design to compare changes in preconception insurance coverage among low-income women living in expansion compared with nonexpansion states before and after the Medicaid expansions. Women with family incomes 138% the federal poverty level or less who participated in the Pregnancy Risk Assessment Monitoring System from 2009 to 2015 from states that did or did not expand their Medicaid programs on January 1, 2014, were included. The exposure of interest was the state Medicaid expansion. The primary outcome was insurance status 1 month before conception. We conducted additional subgroup and sensitivity analyses to test the assumptions of the model and the robustness of the findings. The study sample included 30,495 women from eight states that expanded Medicaid under the Affordable Care Act and 26,561 patients from seven states in that did not. The rate of preconception Medicaid coverage was 30.8% prepolicy and 35.6% postpolicy in nonexpansion states and 43.2% prepolicy and 56.8% postpolicy in expansion states. There was a significantly greater increase in Medicaid coverage in expansion states after the policy implementation (adjusted difference-in-difference estimate +8.6% points, 95% CI 1.1-16.0). Rates of preconception uninsurance were 44.2% prepolicy and 34.3% postpolicy in nonexpansion states and 37.4% prepolicy and 23.5% postpolicy in expansion states. There was no significant difference in the changes in uninsurance between the two groups in the postpolicy period (adjusted difference-in-difference estimate -4.1, 95% CI -11.1 to 2.9). Non-Medicaid insurance coverage was 25.3% prepolicy and 30.5% postpolicy in nonexpansion states and 19.4% prepolicy and 19.7% postpolicy in expansion states. Relative to nonexpansion states, there was a significant decrease in non-Medicaid coverage in the expansion states in the postpolicy period (adjusted difference-in-difference estimate -4.7, 95% CI -8.3 to -1.1). The results were robust to alternate model specifications and study period definitions. Medicaid expansion was associated with increased enrollment in Medicaid before pregnancy among low-income women; however, there were no changes in the rates of uninsurance. Additional years of postpolicy data are needed to fully assess the effects of the policy change.

Spillover benefit of improved access to healthcare on reducing worry about housing and meal affordability

BackgroundThe Affordable Care Act Medicaid expansion improved access to health insurance among low-income populations. We sought to examine the spillover benefits of the ACA Medicaid expansion on ability to afford rent/mortgage and purchase of nutritious meals.MethodsUsing data from the Behavioral Risk Factor Surveillance System (BRFSS) we analyzed individuals aged 18–64 years residing in 12 U.S. states (including five ACA Medicaid expansion states) in 2015. Our treatment of interest was access to health insurance, instrumented by the ACA Medicaid expansion. Our outcome variables were: worry or stress about having sufficient money to pay the rent or mortgage and to purchase nutritious meals. We conducted a two-stage least squares instrumental variables regression.ResultsA 10%-point increase in the proportion of those who obtained health insurance following the ACA Medicaid expansion reduced the probability of being worried and stressed related to purchasing nutritious meals by 7.2% points (95% CI: 1.3–13.2) as well as paying the rent or mortgage by 8.6% points (95% CI: 2.5–14.7) among people living below 138% of the federal poverty level (FPL). The ACA Medicaid expansion was not associated with access to health insurance among those living over 138% of FPL, and obtaining health insurance did not influence stress or worry in relation to affording rent/mortgage or meals in this income group.ConclusionsImproved access to health insurance contributed to reducing worry and stress associated with paying rent/mortgage or purchasing meals among low-income people. Expanding health insurance access may have contributed to increasing the disposable income of low income groups.

Impacts of the ACA Medicaid expansion on health behaviors: Evidence from household panel data.

A motivation for increasing health insurance coverage is to improve health outcomes for impacted populations. However, health insurance coverage may alternatively increase risky health behaviors due to ex ante moral hazard, and past research on this issue has led to mixed conclusions. This paper uses a panel of household purchases to estimate the effects of the recent state-level Medicaid expansions resulting from the Affordable Care Act (ACA) on consumption goods that present adverse health risks. We utilize within-household variation to identify whether increases in Medicaid availability impacted household purchase patterns of alcohol, nicotine-related, snack food, and carbonated beverage products. Overall, we find little evidence that the ACA Medicaid expansion led to ex ante moral hazard across any of these products, but we find compelling evidence that the Medicaid expansions reduced cigarette consumption and increased smoking cessation product use among the Medicaid-eligible population.

Increased Cancer Screening for Low-income Adults Under the Affordable Care Act Medicaid Expansion.

We tested whether Medicaid expansion under the Affordable care Act was associated with increased screening for cervical, breast, and colorectal cancer among low-income adults. We analyzed Behavioral Risk Factor Surveillance System data, identifying 2012 as preexpansion and 2016 as postexpansion (2014 was treated as a wash-out, and 2013 and 2015 had missing screening data from most states). States (including District of Columbia) either expanded Medicaid in 2014 (n=28) or not (n=18); five states that expanded after 2014 were excluded. Participants included low-income adults aged 18-64 without dependent children. A difference-in-difference approach tested whether expansion was significantly associated with screening, controlling for time, state effects, age, sex, race/ethnicity, education, and urban/rural population. For comparison, we also conducted analyses among the low-income Medicare (aged 65 and above) population, and a higher income population. There was a significant expansion effect for women aged 18-64 for cervical cancer screening (N=29,059; odds ratio, 1.04; 95% confidence interval, 1.01-1.08), and for adults 50-64 for colorectal cancer screening (N=32,290; odds ratio, 1.12; 95% confidence interval, 1.03-1.22). Effects for mammography for women aged 40-64, or aged 50-64, were not significant. As expected, there were no significant improvements associated with expansion among the Medicare population, or among a population ineligible due to higher income. Medicaid expansion under the Affordable Care Act was associated with increased screening for cervical and colorectal cancer for low-income adults. It will be important to monitor possible adverse cancer outcomes in nonexpansion states among vulnerable populations over time.

The Effect of the Affordable Care Act Medicaid Expansion on Disparities in Access to Care and Health Status.

Before the Affordable Care Act Medicaid expansion, nonelderly childless adults were not generally eligible for Medicaid regardless of their income, and Hispanics had much higher uninsured rates than other racial/ethnic subgroups. We estimated difference-in-differences models on Behavioral Risk Factor Surveillance data (2011-2016) to estimate the impacts of Medicaid expansion on racial/ethnic disparities in insurance coverage, access to care, and health status in this vulnerable subpopulation. Uninsured rates among all poor childless adults declined by roughly 9 percentage points more in states that expanded Medicaid. While expansion also had favorable impacts on most access and health outcomes among Whites in expansion states, there were relatively few such impacts among Blacks and Hispanics. Through 2016, Affordable Care Act Medicaid expansion was more effective in improving access and health outcomes among White low-income childless adults than mitigating racial/ethnic disparities.