Expanding Medicaid increases rural health care access and use

A new study in Health Services Research reveals that expanding Medicaid to cover more adults boosts health care access and use in rural populations.

The nine study authors were all interested in what happens to use of health care services when public health insurance is expanded. "In particular, we find large increases in outpatient visits, no evidence of a change in ED visits, and a large increase in inpatient visits," wrote the authors. "We also estimate that public health insurance leads to increases in preventive care but no change in behavioral health care visits". Their estimates in this study were largely consistent with previous research, but also recognized potentially important differences.

Most previous studies have focused on urban populations, but more than 7 million uninsured people live in rural settings, the authors said, and the two health care profiles differ.

Her team looked specifically at adults without dependent children in a rural Wisconsin setting after the state expanded public health insurance to include that group under a Medicaid special waiver said co-author Laura Dague, Ph.D. and assistant professor at the Bush School of Government & Public Service at Texas A&M University. The researchers used data from claims filed at a large integrated health system, along with Medicaid enrollment files dated from January 2007 to September 2012.

The Wisconsin Medicaid expansion began July 1, 2009, but was closed after three months after more than 60,000 participants enrolled, leaving 100,000 hopeful applicants on a waitlist. "So many people signed up that there simply wasn't enough money to fund the program," she said.

The researchers compared people on the waitlist who wanted coverage but didn't get it, with people who were enrolled, in order to examine the effect of insurance status on health care utilization.

Insurance coverage expansion means health care costs less to the consumer, Dague said. "There's also an access dimension to this—maybe providers are more willing to serve patients with insurance."

Dague hopes future research will continue to study expansions and their effect on varied populations. "The effects of insurance really depend upon on underlying populations and the current level of access to care," she said.

The paper has important national implications, comments David Nash, M.D., M.B.A., Dean of the Jefferson School of Population Health. "In the bigger picture, conclusions are already pretty well known and not so surprising. For example, if you improve access for the rural poor, you've got to believe you improve outcomes."

In states that have expanded Medicaid, utilization will go up, he said. "The poor who are not on Medicaid who have no doctor and no access, have historically visited the emergency room. Once they have access, however, utilization of care increases, but whether outcomes improve is still unknown. Research published in the Annals of Internal Medicine in June this year did in fact show that when access improves, so does a measure of population health."