The study examines the effects of Medicaid expansion in states that have embraced it versus those that have not, shedding light on the “coverage gap” faced by individuals with low incomes. It finds that expansion leads to increased health insurance coverage, reduced avoidance of medical care due to cost, and greater utilization of preventive healthcare services. The study recommends that nonexpansion states consider adopting Medicaid expansion to improve healthcare access for low-income populations.
It has been nine years since the Medicaid coverage expansions of the Affordable Care Act (ACA) came into effect, yet ten states still have not expanded eligibility for their Medicaid programs. This has resulted in a “coverage gap,” where individuals with low incomes find themselves earning too much to qualify for Medicaid but too little to receive subsidies for marketplace health plans, effectively limiting their access to healthcare services.
The main objective of this study is to evaluate the impact of being in the Medicaid coverage gap on insurance coverage and healthcare utilization.
Methods
The analysis draws from the Behavioral Risk Factor Surveillance System (BRFSS) data, spanning two periods: 2011-2013 and 2017-2019. The study compares outcomes for individuals who potentially fall into the coverage gap, specifically those with incomes between the eligibility thresholds before and after the ACA, across states that did and did not expand Medicaid.
Key Findings and Conclusion
In states that expanded Medicaid, individuals who would otherwise fall into the Medicaid coverage gap experienced increased health insurance coverage, lower rates of avoiding medical care due to cost, and a higher utilization of preventive healthcare measures.
Key Points
1. Medicaid Expansion and Its Impact:
The ACA mandated states to expand Medicaid eligibility to people with incomes up to 138 percent of the federal poverty level. While 26 states and the District of Columbia initially expanded Medicaid, 15 more followed suit, leaving ten states yet to expand as of September 2023. The impact of expansion varied because states had the autonomy to set their own Medicaid income eligibility thresholds for nondisabled adults.
2. Coverage Gap and its Characteristics:
The coverage gap primarily affects those with incomes above their state’s Medicaid eligibility threshold but below 100 percent of the federal poverty level. This gap is estimated to include about 2.2 million Americans, mostly people of color and those residing in the South.
3. Existing Research:
Existing research indicates that Medicaid expansion improved health insurance coverage, access to care, and healthcare utilization among low-income Americans. While evidence on health outcomes is limited, one study showed that ACA Medicaid expansions reduced disease-related mortality among older adults.
4. Impact of Nonexpansion:
However, there is limited research on the impact of nonexpansion on individuals in the Medicaid coverage gap, and the available evidence is often outdated and state-specific. Studies in North Carolina, Texas, and other areas found that people in the coverage gap were less likely to have a regular source of care, routine checkups, and were more likely to forgo doctor visits and skip medication due to cost concerns.
5. Study Approach:
In this study, we examine the experiences of the Medicaid coverage gap population before the COVID-19 pandemic across multiple states. The analysis focuses on individuals with incomes between their state’s pre-ACA eligibility level for their population group and 100 percent of the federal poverty level, comparing nonexpansion states with comparable expansion states.
6. Key Findings:
a. Medicaid expansion significantly increased health insurance coverage for the potential gap population.
b. The increase in coverage led to reduced avoidance of doctor visits due to cost concerns.
c. Improved connections to care were observed, with more individuals reporting routine checkups and having a personal doctor.
d. Preventive healthcare service utilization increased in expansion states.
7. Case Studies:
The study also presents in-depth case studies of four states (Alabama, Arkansas, Tennessee, and Illinois) to highlight the impact of Medicaid expansion on coverage and access to care in specific scenarios.
– Alabama (nonexpansion) and Arkansas (expansion): Expansion in Arkansas led to a substantial increase in coverage rates for both parents and nonparents compared to Alabama.
– Tennessee (nonexpansion) and Illinois (expansion): Illinois experienced a significantly greater increase in coverage and access to care for nonparents following expansion.
8. Potential Gains:
The study estimates the potential benefits of Medicaid expansion for states that have not expanded, indicating significant increases in coverage, access to care, and preventive healthcare service utilization if they were to expand Medicaid.
In conclusion, the findings of this study underscore the positive impact of Medicaid expansion on increasing health insurance coverage and improving access to healthcare services, particularly for individuals in the Medicaid coverage gap. Expanding Medicaid in the remaining nonexpansion states could have substantial benefits for low-income populations.
