July 5, 2018 at 9:26 am
Aaron Carroll
The following
originally appeared on The Upshot (copyright
2018, The New York Times Company).
The Medicaid logjam appears to be breaking.
When the Affordable Care Act first invited
states to make more low-income people eligible for Medicaid, pretty much all
the blue states said yes, but many red ones said no. Now, the Maine
Legislature seems poised to overcome Gov. Paul LePage’s opposition to
expanding the program. Just weeks ago, Virginia voted to expand Medicaid as well. They would
join 32 states that have already expanded the program, and three others
actively considering it.
But many are still arguing about whether the
expansion actually provides adequate care for more Americans. Some believe it
really doesn’t improve access to health care. Others believe that even if it
does, it doesn’t improve the quality of that care.
Dozens of studies are starting to answer those
questions, including a number in the June issue of
the journal Health Affairs. Such studies can be useful to states that may want
to jump into expansion, perhaps with their own conservative stamp. They may also
prove useful to others that want to tinker with already existing programs to
make things better in different areas.
Is Medicaid expansion
helping rural areas?
Community health centers have long provided primary care to millions of patients in
underserved areas across the United States, both urban and rural. Because most
of their patients are poor or uninsured, they were expected to benefit from the
Medicaid expansion. There was also hope that Obamacare’s increase in federal
funding for such centers would lead to improvements in rural areas that have
been difficult to reach.
Using data available each year from community
health centers that receive federal funding, researchers explored how access and quality changed from
2011 to 2015, before and after the Medicaid expansion. They compared centers in
states where expansion had taken place with those in states where it had not,
and found that in the expansion states, the percentage of uninsured patients
dropped more than 11 points. The percentage of patients covered by Medicaid
increased by more than 13 points.
Community health centers in urban areas where
Medicaid expanded saw no significant changes in quality compared with those in
urban areas in nonexpansion states. But rural health centers in states that
expanded experienced significant gains. More patients with asthma received
appropriate drug treatment (4 percent more), more patients received appropriate
weight screening and follow-up (7 percent more), and more patients with
hypertension gained control over their blood pressure (2 percent more). Gains
among rural Hispanic patients were even larger than those among white patients.
Some of these gains might be because
pharmaceutical treatment became much more affordable with Medicaid. More of
these gains, however, may be because insurance access makes visits to health
professionals easier. Extrapolated to the whole population, the Medicaid
expansion appears to have resulted in about 427,000 extra visits for depression
and 457,000 extra visits for high blood pressure in rural health centers alone.
These visits and improvements are occurring in
areas of the country that tend to be underserved and hard to affect. The visits
could also be substantially increased if holdout states expanded Medicaid.
Do more conservative
versions of Medicaid work?
Indiana expanded Medicaid through a waiver process,
creating the Healthy Indiana Plan 2.0. Enrollees must make contributions to a
health savings account, on a sliding scale based on income, to qualify for full
benefits. If enrollees miss a payment, they receive reduced benefits. If they
earn more than the poverty line and miss a payment, they can be locked out of
coverage for half a year.
Many experts (including me) feared that
Indiana would, consequently, see less benefit from the Medicaid expansion.
These concerns have national implications: Other states are trying to expand
Medicaid in novel ways, encouraged by Seema Verma, one of the architects of
Healthy Indiana Plan 2.0 and current head of the Centers for Medicare and
Medicaid Services.
Researchers from Indiana University’s School of Public and Environmental
Affairs published a paper to see how Indiana had fared compared
with other expansion states. They used data from the American Community Survey,
which gathers information on three million people across the United States each
year. Specifically, they looked at whether adults 18 to 64 (who might be
affected by the expansion) had Medicaid or other insurance from 2009 through
2016.
All states that expanded Medicaid saw greater
gains in coverage than those that did not. Indiana ranked in the middle, 13th
of 27 states. In general, states with higher uninsurance rates before expansion
saw larger gains, and Indiana ranked in the middle before and after expansion.
The good news is that even with these extra
requirements, Indiana saw significant gains in Medicaid coverage. But we don’t
know if gains would have been even larger without them. It’s possible that the
churn caused by cost-sharing requirements may be causing the state to
underperform. Neighboring states did see larger gains than Indiana itself. But
Indiana overperformed compared with other, more distant states, making this
unclear.
What’s the big
picture?
These are individual studies. Looking at all
the research together might provide a more accurate picture of how the Medicaid
expansion is performing. Another study in Health Affairs by Indiana University
health services researchers (I was one of them) systematically reviewed the
literature to gather all available peer-reviewed evidence.
Since the start of Medicaid expansion, 77
studies, most of them quasi-experimental in design, have been published. They
include 440 distinct analyses. More than 60 percent of them found a significant
effect of the Medicaid expansion that was consistent with the goals of the
Affordable Care Act.
Only 4 percent reported findings that showed
the Medicaid expansion had a negative effect, and 35 percent reported no
significant findings. Negative effects could include more uninsurance and
increased wait times, but none showed decreased quality. It should be noted,
moreover, that the few studies with negative outcomes were more likely to
employ methodologies that were less likely to be able to show that Medicaid was
causing these outcomes.
The majority of analyses looked at access to
care, and they showed that after the Medicaid expansion, insurance coverage
improved and the use of health services increased. It’s harder to study quality
than access, but 40 analyses in 16 studies did so. About half of these reported
improvements in quality measures like diabetes monitoring or preventive care
screenings.
It has only been a few years since the
Medicaid expansion, and clearly we need to follow these results over time. But
the evidence to date is — if anything — positive. As Olena Mazurenko, the lead
author of the systematic review, wrote to me, “With dozens of scientific
analyses spanning multiple years, the best evidence we currently have suggests
that Medicaid expansion greatly improved access to care, generally improved
quality of care, and to a lesser degree, positively affected people’s health.”
States should keep this in mind as they debate
whether and how to accept the A.C.A.’s invitation to expand Medicaid.
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