In Republicans’ attempts to repeal and replace the Affordable Care Act, the ACA’s Medicaid expansions have drawn particular focus. While not all states accepted these expansions, those that did hoped the additional funding would increase coverage among their poor and medically underserved citizens. Now, as these expansions continue to face threats from Congress and the Administration, we must ask – did they achieve their goal?
To evaluate the expansions’ effectiveness, researchers compiled data from the American Community Survey from 2011 to 2015 and contrasted levels of insurance coverage between expansion and non-expansion states using a difference-in-differences regression model. Since the expansions were designed to benefit low-income individuals, the study focused specifically on individuals with a high school degree or less, due to education level’s close association with income. Income was rejected as a selection criterion due to its associations with Medicaid eligibility and employer sponsored insurance status. The researchers further divided these individuals by age and ethnicity to determine which demographic groups enjoyed the greatest increases in coverage.
The study found that while increases in Medicaid take-up and decreases in uninsured rates were comparable between expansion and non-expansion states prior to 2014, expansion states enjoyed significantly greater improvements in these measures after 2014. By ethnic group, the greatest increase in Medicaid take-up was seen in Hispanics; however, due to concurrent decreases in private insurance, blacks and non-Hispanic whites saw the greatest overall reductions in uninsured rate.
Overall, all demographic groups in expansion states enjoyed greater improvements in insurance coverage than their counterparts in non-expansion states. However, these improvements were comparably lower among Hispanics and individuals aged 19-45. Additionally, slight evidence of crowding out of private coverage was seen in Hispanic and young adult subgroups by gender, even though net declines suggested the Medicaid expansions were complementary rather than antagonistic to increases in private coverage.
The study suggests that while Medicaid expansions were significantly effective in addressing lack of insurance coverage among low-income individuals, further interventions are needed to target Hispanics and young adults who face internal and external barriers to coverage. Whether such interventions will be given the chance to occur in today’s political climate remains to be seen.
This Policy Prescriptions® review is written by Josè Dominguez. He is a medical student at Baylor College of Medicine.
OBJECTIVE: Examine the ACA Medicaid expansion effects on Medicaid take-up and private coverage through 2015 and coverage disparities by age, race/ethnicity, and gender.
DATA SOURCES: 2011-2015 American Community Survey for 3,137,989 low-educated adults aged 19-64 years.
STUDY DESIGN: Difference-in-differences regressions accounting for national coverage trends and state fixed effects.
PRINCIPAL FINDINGS: Expansion effects doubled in 2015 among low-educated adults, with a nearly 8 percentage-point increase in Medicaid take-up and 6 percentage-point decline in uninsured rate. Significant coverage gains were observed across virtually all examined groups by age, gender, and race/ethnicity. Take-up and insurance declines were strongest among younger adults and were generally close by gender and race/ethnicity. Despite the increased take-up however, coverage disparities remained sizeable, especially for young adults and Hispanics who had declining but still high uninsured rates in 2015. There was some evidence of private coverage crowd-out in certain subgroups, particularly among young adults aged 19-26 years and women, including in both individually purchased and employer-sponsored coverage.
CONCLUSIONS: The ACA Medicaid expansions have continued to increase coverage in 2015 across the entire population of low-educated adults and have reduced age disparities in coverage. However, there is still a need for interventions that target eligible young and Hispanic adults.