Implications of the Affordable Care Act: Medicaid Expansion for Health Care Access Among Uninsured...
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Transcript of Implications of the Affordable Care Act: Medicaid Expansion for Health Care Access Among Uninsured...
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.
In the expansion states, many uninsured adults may be accessing health coverage
for the first time.
Introduction Data Analysis Results Discussion
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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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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?
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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)
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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)
IHIS accessed through the Minnesota Population Center
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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)
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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Data: 2011-2012 Integrated Health Interview Survey (IHIS)
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)
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Data: 2013 Medicaid eligibility levels (Kaiser State Health Facts)
Captures the variation in state Medicaid eligibility levels prior to the ACA
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Data: 2011-2012 Restricted National Health Interview Survey
State and county identifiers
Continuous family income
Urban/rural
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
IHIS Medicaid Rules
AHRF
Restricted NHIS
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
IHIS Medicaid Rules
AHRF
Restricted NHIS
Introduction Data Analysis Results Discussion
Minnesota Census
RDC
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Outcomes
Problems with access to health care
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Outcomes
Problems with access to health care
– Lacking a usual place for health care
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Outcomes
Problems with access to health care
– Lacking a usual place for health care
– Having trouble finding a general doctor or provider
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Outcomes
Problems with access to health care
– Lacking a usual place for health care
– Having trouble finding a general doctor or provider
– Being told by a doctor’s office or clinic that they were not taking new patients
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Outcomes
Problems with access to health care
– Lacking a usual place for health care
– Having trouble finding a general doctor or provider
– Being told by a doctor’s office or clinic that they were not taking new patients
– Having any unmet need for medical care (doctor, specialist, or follow-up care) as a result of cost
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Outcomes
Problems with access to health care
– Lacking a usual place for health care
– Having trouble finding a general doctor or provider
– Being told by a doctor’s office or clinic that they were not taking new patients
– Having any unmet need for medical care (doctor, specialist, or follow-up care) as a result of cost
New measures!
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Outcomes
Problems with access to health care
– Lacking a usual place for health care
– Having trouble finding a general doctor or provider
– Being told by a doctor’s office or clinic that they were not taking new patients
– Having any unmet need for medical care (doctor, specialist, or follow-up care) as a result of cost
– Created an overall health care access indicator
New measures!
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
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!
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Research Question #1
Bivariate analyses of health status and health care access and use by insurance status
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Research Question #1
Bivariate analyses of health status and health care access and use by insurance status
– Help understand the health care needs of the population potentially eligible for expanded Medicaid coverage
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Research Question #1
Bivariate analyses of health status and health care access and use by insurance status
– 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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Research Question #2
Multivariate models to examine the association between Medicaid coverage and health care access and use
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Non-Expansion States
Research Question #2
Multivariate models to examine the association between Medicaid coverage and health care access and use
– Recycled prediction models
– Estimated the predicted changes in health care access and use for low-income uninsured individuals should they gain Medicaid coverage
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Non-Expansion States
Research Question #2
Multivariate models to examine the association between Medicaid coverage and health care access and use
Introduction Data Analysis Results Discussion
– 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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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Question 1: What are the health care needs of the population who are obtaining Medicaid
coverage under the ACA?
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Introduction Data Analysis Results Discussion
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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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Introduction Data Analysis Results Discussion
Low-Income Uninsured
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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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Introduction Data Analysis Results Discussion
Low-Income Uninsured
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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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-Expansion States
Question 2: How well will Medicaid coverage meet of the population who could obtain
Medicaid coverage under the ACA?
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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)
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Introduction Data Analysis Results Discussion
Expansion States
Non-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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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
The expansion of health insurance coverage through Medicaid offers the possibility of significant gains in health care access
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Expansion States
Non-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
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
Introduction Data Analysis Results Discussion
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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Introduction Data Analysis Results Discussion
Expansion States
Non-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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March 2015 STATE HEALTH ACCESS DATA ASSISTANCE CENTER
Introduction Data Analysis Results Discussion
Expansion States
Non-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
Support for this work was provided through a grant from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network