Only Time Will Tell

Expanding Medicaid eligibility through the Affordable Care Act (ACA) was arguably one of the most powerful elements of recent healthcare reform. While the original nationwide expansion was struck down by the Supreme Court in 2012 as an unconstitutional overreach, the ACA has allowed states to voluntarily expand coverage to include nonelderly adults with income levels up to 138% of the federal poverty level. While most people agree that affordable healthcare is important, there continues to be great discussion about how Medicaid services are funded and utilized.

An article published in Health Affairs during the summer of 2018 sought to explore the effects of ACA Medicaid expansion on the major goals of the ACA – increasing insurance coverage, improving quality and access to care, and decreasing costs. The authors did a systemic review of 77 studies that examined various outcomes of ACA expansion. They found that ACA’s Medicaid expansion was associated with increases in coverage, health care utilization, and Medicaid spending. Expansion was associated with improved hospital financial performance, reduction in uncompensated care, and increases in positive financial margins and Medicaid revenue. Overall, they found no significant increase in the quality of care as quantified by various measures, like glucose monitoring, hypertension control, or prostate cancer screening. However, no studies reported any decline.   

The authors highlighted the significance of this study as the first peer-reviewed systematic review to holistically assess effects of Medicaid expansion and its relevance to ongoing policy reform. While analyses like these are critical to assess and refine health policy, the sheer scope of the paper introduced some limitations in interpretation due to the heterogeneity of included studies. However, one could argue that these limitations are inherent to any evaluation of the impact of large-scale health policies such as the ACA. As time passes, we should expect evolving data to continue driving thoughtful analysis and empower evidence-based policy reform to bolster President Obama’s signature achievement. 

This Policy Prescriptions® review is written by Andrea Jean Grimbergen as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where she is a medical student.

Abstract

Expanding eligibility for Medicaid was a central goal of the Affordable Care Act (ACA), which continues to be debated and discussed at the state and federal levels as further reforms are considered. In an effort to provide a synthesis of the available research, we systematically reviewed the peer-reviewed scientific literature on the effects of Medicaid expansion on the original goals of the ACA. After analyzing seventy-seven published studies, we found that expansion was associated with increases in coverage, service use, quality of care, and Medicaid spending. Furthermore, very few studies reported that Medicaid expansion was associated with negative consequences, such as increased wait times for appointments-and those studies tended to use study designs not suited for determining cause and effect. Thus, there is evidence to document improvements in several areas of health care delivery following the ACA Medicaid expansion. We outline areas for future research that can further reduce current knowledge gaps.

PMID: 29863941

Mazurenk, O, et al. Health Affairs. 2018; 37 (6): 944-950.?