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Medicaid Expansion: An Improved Safety Net

Medicaid expansion reduces the insurance coverage gap between the rich and poor (Volume 10, Issue 17)

Nearly 50 million Americans lacked health insurance prior to the passage of the Affordable Care Act (ACA), with the bulk of the uninsured being low-income individuals. This combination of poverty and the uncertainty over health (or unexpected health care costs) contributed to significant health disparities.


Since the law’s passage, the ACA is commonly cited as one of the largest transfers of wealth between rich and poor Americans in modern history. After decades of research demonstrating that the wealth of a community significantly influences citizens’ health, the ACA demonstrates the potential to offset health barriers associated with poverty.

A recent study in Health Affairs specifically aims to assess this particular question. Specifically, the authors examined the extent to which the ACA’s Medicaid expansion closed gaps in insurance coverage due to economic hardship. Using a national sample from the Behavioral Risk Factor Surveillance System, researchers were able examine over 1 million respondents in 43 states. Using these data, they were able to compare individuals at similar income levels in Medicaid expansion vs non-expansion states.

The results were unsurprising. Between 2013 and 2015, the gap in percent insured from residents of lower-income households (earning <$25,000) and higher income (>$75,000) fell by 46% in expansions states, while it only fell 23% in non-expansion states. Similarly, patient-level effects on access to a primary care provider and avoiding care due to costs improved in similar proportions.

Importantly, these data are consistent with previous studies on the benefits of Medicaid expansion. As has been covered in previous posts, Medicaid expansion has been associated with improved medication compliance, decreased patient out-of-pocket spending, and high levels of overall patient satisfaction. Additionally, these benefits accrue both to the patients and the hospitals who care for them.

Although Congress may still return to debating the future of the Affordable Care Act, the effects of the law on American citizens are clear. From a social justice lens, Medicaid expansion has consistently been shown to counteract economic disparities from both a financial and health perspective. Any attempt to repeal this coverage would surely reverse these gains.

commentary by Kyle Fischer


The United States has the largest socioeconomic disparities in health care access of any wealthy country. We assessed changes in these disparities in the United States under the Affordable Care Act (ACA). We used survey data for the period 2011-15 from the Behavioral Risk Factor Surveillance System to assess trends in insurance coverage, having a personal doctor, and avoiding medical care due to cost. All analyses were stratified by household income, education level, employment status, and home ownership status. Health care access for people in lower socioeconomic strata improved in both states that did expand eligibility for Medicaid under the ACA and states that did not. However, gains were larger in expansion states. The absolute gap in insurance coverage between people in households with annual incomes below $25,000 and those in households with incomes above $75,000 fell from 31 percent to 17 percent (a relative reduction of 46 percent) in expansion states and from 36 percent to 28 percent in nonexpansion states (a 23 percent reduction). This serves as evidence that socioeconomic disparities in health care access narrowed significantly under the ACA. 

PMID: 28747321

Griffith, K, et al. Health Affairs. 2017; 36 (8):1503-1510.

Kyle Fischer, MD, MPH
About Kyle Fischer, MD, MPH

Kyle Fischer is a practicing emergency physician in Maryland. He received a combined MD/MPH from the University of Wisconsin School of Medicine and subsequently completed an emergency medicine residency at Drexel University. Dr. Fischer possesses legislative health policy experience in both the Wisconsin and Maryland state legislatures and the United States House of Representatives. Broadly, his interests lie in health system and payment reform, integration of public health measures into emergency care as well as targeted interventions of high-risk populations, particularly victims of violent injury. Of note, he participates as the policy liaison for the National Network of Hospital-Based Violence Intervention Programs. He is currently a health policy fellow in the University of Maryland Department of Emergency Medicine and tweets at @KBFischer. Contact: Website | Facebook | Twitter | Google+ | More Posts