JAMA study: Patients report better health, access in states with Medicaid expansion


CHICAGO — A new study in JAMA Internal Medicine is taking a look at how patients view the state of their health in states that chose to expand Medicaid access through the Affordable Care Act. The study surveyed nearly 3,000 low-income residents each in two states — Arkansas and Kentucky — whose governors opted into the Medicaid expansion and compared their responses to almost 3,000 people in Texas, a state that did not expand Medicaid under the ACA. 


The study found that, compared to an earlier survey asking the same questions in 2014, by 2015, Medicaid expansion meant patients in those states were more likely to have a personal physician (up 12.1 percentage points over 2014) and a decreased reliance on emergency rooms. The 2015 survey also recorded a reduction in reported cost-related barriers to care, skipped medications and difficulty with medical bills. And out-of-pocket spending in Kentucky and Arkansas dropped by 29.5% from a baseline average of $434.  


The results also showed that patients in states with Medicaid expansion reported a statistically significant lower likelihood of emergency room visits and more office visits per person compared to Texas, alongside an increased likelihood of patients receiving an annual checkup. Additionally, in Arkansas and Kentucky, the number of respondents with chronic conditions receiving regular care increased, and they saw a drop in the proportion of respondents who reported fair or poor quality of care. 


“Improvements in self-reported health in our study offer some of the earliest evidence that the ACA’s Medicaid expansion may be producing similar benefits detected in prior insurance expansions,” the study says. “While self-reported health has been shown to be a strong predictor of mortality, it remains to be seen whether the modest changes detected in our study will lead to subsequent improvements in objective measures of population health.”


Among the limitations of the study were response rate, though the authors note that studies with lower response rates have produced data that tracks with subsequent government-released data. The authors also note that the survey’s design prevents a clear causal interpretation, but the findings’ consistency with earlier, similar studies “makes alternative explanations less likely.” Moreover, though, the study notes that Arkansas and Kentucky may not generalize to the overall U.S. population, noting that Medicaid programs vary by states in terms of reimbursement and covered benefits, among other factors. But the study also has its strengths, according to the authors. 


“By targeting a sample of individuals most likely to gain coverage under the expansion—namely, poor adults in 2 states with the largest coverage gains under the ACA—we have greater statistical power to detect changes associated with this policy than many national analyses,” the study says. “Finally, by using a telephone survey with a short turnaround time, we offer timely evidence to inform policy decisions being made in these states and others.”


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