The 2010 Affordable Care Act (ACA) mandated expanding eligibility for Medicaid to any adult in a household with an income less than 138% of the federal poverty level; but in 2012, the U.S. Supreme Court made this expansion optional at the state level. Ultimately, 36 states and the District of Columbia opted to expand Medicaid eligibility, effective in 2014, while 14 did not. As a result, about 13.6 million adults gained health insurance coverage.
Selective state adoption of Medicaid expansion has allowed researchers to study the impact of broader insurance coverage for low-income adults by comparing data in expansion and nonexpansion states. A study by the National Bureau of Economic Research found that between 2014 and 2017, states that expanded Medicaid eligibility collectively had 19,200 fewer deaths than states that did not. Over the same period, the researchers attributed the deaths of an estimated 15,600 people in nonexpansion states to the failure to provide more people with Medicaid coverage.
Prior to 2014, mortality rates were comparable for those living in expansion states and nonexpansion states. But once expanded Medicaid eligibility kicked in, mortality rates in these states diverged sharply. Beginning in 2014 and each year thereafter, the mortality rate declined significantly for those in expansion states relative to nonexpansion states. In 2017, the mortality rate in expansion states was 0.208 percentage points lower than in nonexpansion states. The results point toward more lives saved should Medicaid be expanded nationwide.
In another study, researchers in Oregon examined the effect of Medicaid expansion on utilization of primary care and on continuity of care. Patients with Medicaid have historically overutilized the ED; however, among newly insured Oregon adults who benefited from Medicaid expansion, more visited primary care providers for their first outpatient visit than sought care in the ED or from specialists.
The researchers also found that while fewer than half of the newly insured patients had primary care providers at the start of 2014, some 92.7% did by the end of 2015, underscoring the importance of insurance coverage in continuity of care and reduced ED use.—Joan Zolot, PA
Holderness H, et al. Med Care
2019;57(10):788–94; Miller S, et al. Cambridge, MA: National Bureau of Economic Research; 2019 Jul. Working paper 26081; http://papers.nber.org/tmp/8183-w26081.pdf