Effects of Medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for Medicaid

Abstract

Objective To estimate the effects of Affordable Care Act (ACA) Medicaid expansion on insurance and health services use for adults with disabilities who were newly eligible for Medicaid. Data Sources 2008–2018 Medical Expenditure Panel Survey data. Study Design We used the Agency for Healthcare Research and Quality (AHRQ) PUBSIM model to identify adults aged 26–64 years with disabilities who were newly Medicaid‐eligible in expansion states or would have been eligible in non‐expansion states had those states opted to expand. Outcomes included insurance coverage; access to care; receipt of primary care, outpatient specialty physician services, and preventive services; and out‐of‐pocket health care spending. To estimate the effects of Medicaid expansion, we used two‐way fixed effects models and a triple differences framework to compare pre‐post changes in each outcome in expansion and non‐expansion states for adults with and without disabilities. Extraction Methods We simulated Medicaid eligibility with the AHRQ PUBSIM model, which uses state‐specific Medicaid rules and MEPS data on family relationships, state of residence, and income. Principal Findings Among adults with disabilities who were newly eligible for Medicaid, Medicaid expansion was associated with significant increases in full‐year Medicaid coverage (35.9 percentage points [pp], p < 0.001), receipt of primary care (15.5 pp, p < 0.01), and receipt of flu shots (19.2 pp, p < 0.01), and a significant decrease in out‐of‐pocket spending (−$457, p < 0.01). There were larger improvements for adults with disabilities compared to those without disabilities in full‐year Medicaid coverage (11.0 pp, p < 0.01) and receipt of flu shots (18.0 pp, p < 0.05). Conclusions Medicaid expansion was associated with improvements in full‐year insurance coverage, receipt of primary and preventive care, and out‐of‐pocket spending for adults with disabilities who were newly eligible for Medicaid. For insurance coverage, preventive care, and some primary care measures, there were differentially larger improvements for adults with disabilities than for those without disabilities.

Medicaid can and should play an active role in advancing health equity

“…Through Medicaid expansion, the United States has robust, publicly financed coverage for low‐income families in 39 states and DC. Building on the evidence presented by Creedon, Zuvekas, Hill et al, 26 and Rivera‐González, Roby, Stimpson et al, 27 we argue that Medicaid can be a critical policy vehicle to redress the negative, reinforcing factors that perpetuate health care inequities. Specifically, Medicaid policy can improve health equity through several pathways, including (1) collecting member demographics and social determinants of health, (2) monitoring and evaluating health equity in Medicaid policy, and (3) incentivizing health equity.…”

“…14 Our commentary focuses on health equity in Medicaid policy as it relates to disability and citizenship status, as well as race/ethnicity, highlighting the merits of two contributions to this HSR special issue on health care equity. The papers by Creedon, Zuvekas, Hill et al, 26 and Rivera-González Roby, Stimpson et al, 27 provide evidence on understudied populations and extend our understanding of how different funding mechanisms of Medicaid programs can influence equity.…”

“…Early studies have shown greater improvements in outcomes after expansion for those with a disability, but this literature is limited 30 . Creedon, Zuvekas, Hill et al, 26 use data from the Medical Expenditures Panel Survey and the Agency for Health care Research and Quality's PUBSIM model to present a much‐needed analysis focused on the difference in coverage, access, and utilization among those with a disability and those without a disability following expansion.…”

“…In summary, Creedon, Zuvekas, Hill et al, 26 and Rivera‐González, Roby, Stimpson et al, 27 contribute to the Medicaid and health equity literature by focusing on common but understudied populations and distinct funding mechanisms. Importantly, as Creedon, Zuvekas, Hill et al, 26 note, expanded Medicaid eligibility is necessary but not sufficient to improve health equity, and additional policy interventions aligning improvements in social determinants of health with public coverage expansions are required.…”

“…Indeed, over half of those in the coverage gap in nonexpansion states are Black and/or Latino 12 . The papers by Creedon, Zuvekas, Hill et al, 26 and Rivera‐González, Roby, Stimpson et al, 27 add to the mounting evidence that helps us to understand the mechanisms that perpetuate health inequities as a step toward conceptualizing the tools and policies that are needed to effectively dismantle them.…”