Give the people what they want

Under the , eligibility for Medicaid benefits was expanded to include low-income childless adults. This provision has proven to be immensely controversial, however, and 23 states have refused to accept it*.

A survey published in Health Affairs asked low-income adult citizens (household income less than 138% of the federal poverty level) in Texas, Arkansas, and Kentucky about their perceptions of Medicaid services. These states were chosen because of their very different responses to Medicaid expansion: Texas has refused to expand Medicaid coverage, Kentucky has chosen to accept the Medicaid expansion, and Arkansas has chosen to accept federal money for Medicaid expansion and use it to purchase private insurance for its eligible constituents. A large proportion of respondents (40%) in each of the three states were uninsured and 22-25% reported health coverage through Medicaid.

Source: U.S. Army Corps of Engineers Europe District (Flickr/CC)

Source: U.S. Army Corps of Engineers Europe District (Flickr/CC)

In all three states, approximately 80% of respondents favored Medicaid expansion. About 60% in Arkansas and Kentucky believed that they would be subjected to a fine if they did not have health insurance in 2014 (only 49% believed this in Texas, a significant difference).

In general, those most likely to support Medicaid expansion were women, African Americans, people with less than a high school education, the uninsured, those currently covered by Medicaid, sicker individuals, and Democrats.

In terms of quality, less than 5% of respondents in all three states agreed with the statement “Medicaid or subsidized private coverage was not good insurance.” In fact, most rated the quality of care with Medicaid to be similar to or better than private insurance. Most respondents ranked Medicaid to be no different from or better than being uninsured in terms of wait time, being treated with care and respect by physicians, and .

The results of this survey show that low-income Americans believe being covered by and that the quality of care by health care providers received through Medicaid is not significantly different from care given when or with .

Are elected officials in these states representing their constituents by choosing not to expand Medicaid? There was no significant difference in responses between Texas and Kentucky in perceptions of Medicaid. Why are Texans going without?

commentary by Vidya Eswaran

(*as of December 17, 2014)

Abstract

Expansion of Medicaid under the Affordable Care Act to millions of low-income adults has been controversial, yet little is known about what these Americans themselves think about Medicaid. We conducted a telephone survey in late 2013 of nearly 3,000 low-income adults in three Southern states–Arkansas, Kentucky, and Texas–that have adopted different approaches to the options for expansion. Nearly 80 percent of our sample in all three states favored Medicaid expansion, and approximately two-thirds of uninsured respondents said that they planned to apply for either Medicaid or subsidized private coverage in 2014. Yet awareness of their state’s actual expansion plans was low. Most viewed having Medicaid as better than being uninsured and at least as good as private insurance in overall quality and affordability. While the debate over Medicaid expansion continues, support for expansion is strong among low-income adults, and the perceived quality of Medicaid coverage is high. PMID: 25298540

Epstein AM, et al. Health Affairs. 2014; 33 (11): 2041-7.

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