Alternative insurance expansions under ACA linked to better access, use of care

Two different approaches to insurance expansion under the Affordable Care Act (ACA) were associated with increased outpatient and preventive care, reduced emergency department use, and improved self-reported health compared to nonexpansion in another state, according to an article published online by JAMA Internal Medicine.

The Medicaid expansion under the ACA has resulted in gains in coverage for millions of low-income adults in 30 states. States have debated whether to expand Medicaid and considered alternative approaches such as using private insurance instead of Medicaid.

Benjamin D. Sommers, M.D., Ph.D., of the Harvard T.H. Chan School of Public Health and Harvard Medical School, Boston, and coauthors examined changes in access, utilization, preventive care and self-reported health among low-income adults. They focused on two full years after expansion in three states in the South that responded differently to the ACA's optional Medicaid expansion: Texas, which did not have an expansion; Kentucky, which expanded Medicaid with almost 90 percent of beneficiaries in Medicaid managed care; and Arkansas, which used the "private option" and used federal Medicaid funding to purchase private health insurance from the ACA marketplace.

The data from November 2013 through December 2015 included 8,676 adults (ages 19 to 64) with incomes below 138 percent of the federal poverty level in the three states.

The authors report that by 2015, both Medicaid expansions were associated with:

• Reduction in the rate of uninsured compared with no expansion
• Increased access to primary care
• Fewer medications skipped due to cost and reduced out-of-pocket spending
• Reduced likelihood of emergency department visits and increased outpatient visits
• Increases in screening for diabetes, glucose testing among patients with diabetes and regular care for chronic conditions
• Improved quality of care ratings and more adults reporting excellent health

The authors noted study limitations including that analysis from these three states may not be generalizable to the United States. Also, causal interpretations cannot be conclusively drawn from the study.

"As Kentucky and Arkansas reconsider the future of their expansions, our study (along with evidence on the financial benefits to these states of expansion) provides support for staying the course. For other states still considering whether to expand, our study suggests that coverage expansion under the ACA - whether via Medicaid or private coverage - can produce substantial benefits for low-income populations," the study concludes.

"We applaud the work of Sommers and colleagues in this issue to gauge the implications of different types of Medicaid expansions for pertinent measures of medical care access and quality as well as health. Their analysis clearly indicates that expanding Medicaid, whether through the Kentucky or Arkansas approaches, brings demonstrable benefits for previously uninsured low-income individuals. Their findings that outcomes in Arkansas, a private-option expansion state, did not differ appreciably from Kentucky, with a traditional Medicaid expansion, are also important. As the authors note, their results intersect with ongoing discussions as to whether federal flexibility in approving alternative state approaches to the expansion has positive or negative implications," write Frank J. Thompson, Ph.D., and Joel C. Cantor, Sc.D., of Rutgers University, New Brunswick, N.J.