Where low-income insurance options improved, so did results

By Kathryn Doyle

(Reuters Health) – In states that expanded either their Medicaid programs or private insurance options for low-income Americans, beneficiaries used more outpatient and preventive care and less emergency care, and they had better subjective overall health, compared to low-income residents of states with no expanded coverage.

All states participate in Medicaid, a partnership with the federal government to provide some insurance coverage to low-income people. The Affordable Care Act would have expanded Medicaid coverage to all Americans under age 65 whose family income is at or below 133 percent of federal poverty guidelines, but only 32 states accepted this plan.

Nineteen states did not expand Medicaid coverage. Six of those – Arkansas, Indiana, Iowa, Michigan, Montana, and New Hampshire – instead approved alternative plans to make use of the federal funds for Medicaid expansion.

“There’s really a huge difference for healthcare of low income adults,” said lead author Dr. Benjamin D. Sommers of the Harvard T.H. Chan School of Public Health and Harvard Medical School in Boston.

For the new study, the researchers tracked how health and healthcare changed for low-income residents of three states taking different approaches between 2013 and 2015.

Low-income adults in Texas, Kentucky and Arkansas reported their access to primary care, specialty care, medications, use of the emergency department and outpatient care, blood sugar and cholesterol testing, annual checkups, depression and overall health.

Kentucky expanded Medicaid, Arkansas used Medicaid funds to purchase insurance for low-income residents on the private market, and Texas did not expand coverage at all.

By 2015, the uninsured rate in Kentucky and Arkansas was 22 percent lower than in Texas. Residents with expanded coverage reported fewer skipped medications due to cost, less out of pocket spending and less emergency department use. Those residents also had improvements in diabetes screening, chronic disease care, quality of care and likelihood of reporting overall “excellent health.”

There was more private coverage in Arkansas and more Medicaid coverage in Kentucky, but no other notable differences in healthcare between the two states, the researchers reported in JAMA Internal Medicine online August 8.

“It didn’t turn out to matter much whether you expanded or used a ‘private option,’ as long as coverage increased,” Sommers told Reuters Health by phone.

“Some of it is related to the politics of the state, how people feel about public vs. private plans,” he said. Private insurance pays doctors higher rates than Medicaid, which may be attractive to some states.

“It’s still not clear if alternative expansion plans will work in the long run, said Joel C. Cantor of Rutgers University in New Brunswick, New Jersey, who coauthored a commentary on the new findings.

“The unanswered question is whether it’s going to cost the government more, which ultimately would mean they couldn’t be continued,” Cantor told Reuters Health by phone.

But it is worth testing different approaches to see what works, he said.

Other studies have found that expanding Medicaid has a positive impact on a state’s economy and employment numbers, he said.

“From the patient’s perspective there doesn’t seem to be a big difference,” Sommers said. “The message here really is for state policy makers and advocates in states that have not expanded coverage.”

“People who have insurance feel better,” Sommers said. “Any kind of expansion of coverage is a major improvement regardless of method.”