The Battle over Medicaid

Over the last several weeks, a common debate on whether Medicaid improves health has reemerged in the context of the Republican health care proposals. Adding to this debate is a recent study of the experience of Medicaid beneficiaries in Kentucky, Arkansas, and Texas. The study found that previously uninsured low-income adults saw significant improvements in access to preventative health services and reported health. An often-overlooked result, Medicaid beneficiaries saw significant improvement to financial health and affordability of coverage. The study focused on people with chronic conditions, highlighting the importance of affordability when adhering to long-term treatment plans.

We’ve known for decades that an inability to afford care is detrimental to the health of low-income Americans, especially those with chronic disease, yet this is often forgotten in policy discussions. Access to a usual source of care is critical for people with chronic conditions because long-term treatment plans often involve medication adherence and changes to diet and exercise.

The primary purpose of Medicaid coverage and any health insurance, for that matter, is to reduce the financial burden that prevents people from accessing services. However, recent policy efforts have encouraged insurers to administer delivery system reforms, change benefit design, create behavioral incentives, and  prevent the spread of addictive opioid medications as well as  control health care costs. While a well-functioning insurance system would do all of these, affordability has a broader impact on improving health for beneficiaries.

Medicaid has been shown time and again to improve the financial health of beneficiaries and studies have consistently shown that reducing financial barriers to care improves health.  As Congress moves to reduce the number of people enrolled in Medicaid by limiting the growth of federal dollars to states, it’s important to remember that for many Americans, without Medicaid care will be inaccessible because of cost. For many, there are no alternatives for the treatment of diabetes, depression, heart disease, and other chronic conditions. Medicaid expansion has created conditions that improve access to care and continuity with a physician. The Senate’s now-abandoned Medicaid reforms would have created the conditions under which millions of Americans would again find health care unattainable.

This Policy Prescriptions® review is written by Emma Sandoe, MPH. Ms. Sandoe is a PhD candidate in Health Policy at Harvard University. She holds an MPH from George Washington University. Previously she was the spokeswoman for Medicaid and ACA policy analyst for the Department of Health and Human Services.

Abstract

Major policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of the ACA’s coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in “excellent” self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health. PMID: 28515140 

Sommers, BD, et al. Health Affairs. 2017; 36 (6): 1119-1128.