Implications of the Affordable Care Act: Medicaid Expansion for Health Care Access Among Uninsured Adults- Heather Dahlen

Implications of the Affordable Care Act's Medicaid Expansion for Health Care Access

among Uninsured Adults

Estimates from the National Health Interview Survey

Heather M. Dahlen

Acknowledgements

Coauthors: Donna Spencer, Sharon Long, and Kathleen T. Call

Funding: This project was supported by a grant from the Robert Wood Johnson Foundation. The content of the presentation is solely the responsibility of the authors and does not represent the views of the funding institute.

Introduction Data Analysis Results Discussion

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Medicaid Expansion

States


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In the expansion states, many uninsured adults may be accessing health coverage

for the first time.


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22%

5%

March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER

Increase in Total Medicaid and CHIP enrollment in August, 2014 (compared to the summer of 2013)

Source: CMS, Medicaid & CHIP: Monthly Application and Eligibility Reports

Expansion States

Non-Expansion States


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Expansion States


For state Medicaid program administrators and Medicaid health care providers, two important questions arise:

1. What are the health care needs of the population who are obtaining Medicaid coverage under the ACA?

2. How well will Medicaid coverage meet these needs?


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Expansion States


Sample

Nonelderly sample adults (aged 19-64) with incomes at or below 138% of FPG

– Medicaid coverage for the entire prior year

– No insurance for the entire prior year


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Expansion States


Sample

Excluded

– Individuals collecting SSI due to disability or blindness

– Individuals with both Medicare and Medicaid (dual eligibles)

Final analytic sample

– 2,211 low-income adults with Medicaid

– 5,608 low-income uninsured adults


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Expansion States


Data: 2011-2012 Integrated Health Interview Survey (IHIS)

Harmonized version of the National Health Interview Survey (NHIS), an annual household survey conducted by the National Center for Health Statistics (NCHS)


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Expansion States




IHIS accessed through the Minnesota Population Center


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Expansion States




IHIS accessed through the Minnesota Population Center and the State Health Access Data Assistance Center

Provides information on health insurance coverage and health care access and use for a representative sample of the civilian, non-institutionalized population in the United States


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Expansion States



Questions on health insurance coverage are asked of all individuals in a sampled household

Detailed health care access and use questions are asked only of one randomly selected person within each household (sample adult or child)


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Expansion States


Data: 2013 Medicaid eligibility levels (Kaiser State Health Facts)

Captures the variation in state Medicaid eligibility levels prior to the ACA


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Expansion States


Data: 2013 Medicaid eligibility levels (Kaiser State Health Facts)

Captures the variation in state Medicaid eligibility levels prior to the ACA

Eligibility levels for employed and jobless parents and childless adults were assigned to each member of our sample:

– their state of residence,

– employment status,

– and whether children under the age of 18 years resided in their household


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Expansion States


Data: 2011 Area Health Resource File (AHRF)

County-level economic and health care market characteristics, including:

– Unemployment rate

– # of primary care providers/capita

– # of hospital beds/capita

– # of Federally Qualified Healthcare Centers/capita


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Expansion States


Data: 2011-2012 Restricted National Health Interview Survey

State and county identifiers

Continuous family income

Urban/rural


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Expansion States


IHIS Medicaid Rules

AHRF

Restricted NHIS


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IHIS Medicaid Rules

AHRF

Restricted NHIS


Minnesota Census

RDC

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Expansion States


Outcomes

Problems with access to health care


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Expansion States


Outcomes


– Lacking a usual place for health care


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Expansion States


Outcomes



– Having trouble finding a general doctor or provider


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Expansion States


Outcomes




– Being told by a doctor’s office or clinic that they were not taking new patients


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Expansion States


Outcomes





– Having any unmet need for medical care (doctor, specialist, or follow-up care) as a result of cost


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Expansion States


Outcomes






New measures!


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Expansion States


Outcomes






– Created an overall health care access indicator

New measures!


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Outcomes

Emergency department (ED) use

– Any visit to the ED

– Multiple ED visits

– Whether the most recent ED visit did not result in a hospital admission


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Outcomes

Emergency department (ED) use

– Any visit to the ED

– Multiple ED visits

– Whether the most recent ED visit did not result in a hospital admission

New measure!


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Research Question #1

Bivariate analyses of health status and health care access and use by insurance status


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– Help understand the health care needs of the population potentially eligible for expanded Medicaid coverage


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Expansion States




– Help understand the health care needs of the population potentially eligible for expanded Medicaid coverage

– Health status measured by: Self-reported health status, presence of a chronic physical health

condition, presence of a functional limitation, and presence of a severe mental illness


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Multivariate models to examine the association between Medicaid coverage and health care access and use


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– Recycled prediction models

– Estimated the predicted changes in health care access and use for low-income uninsured individuals should they gain Medicaid coverage


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– Models controlled for the following: Demographic characteristics (age, race/ethnicity, sex, marital

status, highest education level, employment status, income, and urban/rural location)

Medicaid eligibility levels State fixed effects (unmeasured state characteristics) Provider capacity measures County-level economic characteristics

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Expansion States


Question 1: What are the health care needs of the population who are obtaining Medicaid

coverage under the ACA?


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Low-Income Uninsured

Low-Income Medicaid

Any health problem (%) 88.3 88.3

In fair or poor health 18.7 23.0**

Has a chronic condition 74.2 77.8**

Has a functional limitation 28.2 33.0**

Severe mental illness 6.9 7.5

No. of obs 5,608 2,211

*p<0.05, **p<0.01, *** p<0.001

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Low-Income Medicaid

Any access problem (%) 87.3 46.4***

Does not have a usual source of care 53.3 12.1***

Did not have a visit to a general doctor 64.7 34.0***

Had trouble finding a new doctor 9.2 4.7***

Was told the doctor was not taking new patients

5.0 5.2

Had unmet need for medical care due to cost (doctor, specialist, or follow-up)

42.0 10.4***

No. of obs 5,608 2,211

*p<0.05, **p<0.01, *** p<0.001

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Low-Income Medicaid

Had a visit to the emergency department (ED)

23.2 36.1***

Had more than one visit to the ED 10.9 18.8***

Most recent ED visit did not lead to a hospital admission

17.7 27.3***

No. of obs 5,608 2,211

*p<0.05, **p<0.01, *** p<0.001

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Expansion States


Question 2: How well will Medicaid coverage meet of the population who could obtain

Medicaid coverage under the ACA?


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Expansion States


How well Medicaid will meet the needs of low-income uninsured adults: Access

Results from the recycled predictions models suggest strong gains in health care access, with a 39 percentage point reduction in the probability of any access problem


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Expansion States


Regression-Adjusted Estimates of Health Care Access and Use Among Low-Income Uninsured Adults

-39pp***

-28pp***

-5pp***

-33pp***

Lacking a usual sourceof care

Not having a doctorvisit

Trouble finding a doctor

Unmet need for medicalcare due to cost*p<0.05, **p<0.01,***p<0.001


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Expansion States


How well Medicaid will meet the needs of low-income uninsured adults: ED use

Despite the gains in access and use, we predict newly enrolled Medicaid beneficiaries, like current Medicaid enrollees, will face barriers to care under Medicaid


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Expansion States


How well Medicaid will meet the needs of low-income uninsured adults: ED use

Despite the gains in access and use, we predict newly enrolled Medicaid beneficiaries, like current Medicaid enrollees, will face barriers to care under Medicaid

– Increase in ED use

Consistent with other studies (Taubman et al. 2014, DeLiere et al. 2012, and Gandhi et al. 2014)


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Expansion States


Regression-Adjusted Estimates of ED Use Among Low-Income Uninsured Adults

*p<0.05, **p<0.01,***p<0.001

6pp***

3pp**

4pp**

Visit to the ED

More than one visitto the ED

Most recent ED visitdid not lead to ahospital admission

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Expansion States


Limitations

1. We predict access to and use of health care for potential Medicaid enrollees based on the experiences of similar adults currently enrolled in Medicaid

– Despite controlling for observable differences between the two groups, unmeasured differences could confound estimates


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Expansion States


Limitations

2. Adults with health insurance coverage are more likely to use care (Davis 2012) possibly overestimating new access and use for those who were uninsured


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Expansion States


Limitations

2. Adults with health insurance coverage are more likely to use care (Davis 2012) possibly overestimating new access and use for those who were uninsured

– Restricted the sample to individuals who reported a chronic health problem (and therefore may be more likely to use health care)

No substantive differences in the findings


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Expansion States


Medicaid offers significant gains in health care access for low-income uninsured adults

Low-income uninsured adults have health problems and lack a connection to the health care system


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Expansion States




The expansion of health insurance coverage through Medicaid offers the possibility of significant gains in health care access


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Expansion States




The expansion of health insurance coverage through Medicaid offers the possibility of significant gains in health care access

We predict that the share of uninsured individuals with a health care access problem would drop considerably


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Expansion States


Despite the gains in access to care, barriers remain

As is the case with current Medicaid enrollees, health care access barriers will remain

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Expansion States


Despite the gains in access to care, barriers remain

As is the case with current Medicaid enrollees, health care access barriers will remain

Our findings reinforce the importance of current Medicaid policy discussions that have implications for health care access to and use, such as: – provider participation

– appropriate settings for care

– access standards and enforcement

– program provisions

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Questions? Contact:Heather Dahlen

[email protected]

Support for this work was provided through a grant from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network