Expanding access to healthcare insurance is intended to protect more people from crushing medical debt, but does making it easier to see a doctor improve their health?
Researchers have been comparing early data from states that expanded Medicaid, set up their own healthcare exchanges or defaulted to federal exchanges, to states that declined to expand Medicaid coverage under the Patient Protection and Affordable Care Act (ACA, âObamacareâ).
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Since the passage of the ACA in 2010, 32 statesâincluding the District of Columbiaâhave expanded Medicaid coverage for low-income adults. Nineteen states have not.
Clues are emerging from recent data as more people start seeing a doctor more often.
Short-term window, but signs of change
An Annals of Internal Medicine study, based on National Health Survey data of 44,427 adults with family income below 138% of the poverty line, compared outcomes from the states that expanded Medicaid between 2010 and 2014 to the states that didnât. By the second half of 2014, low-income adults in the Medicaid expansion states reported increased insurance coverage, visits to general physicians and specialists, more overnight hospital stays, and better quality of coverage compared with the states that didnât expand coverage.
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âThere was more diagnosis of chronic health conditions such as diabetes and high cholesterol, suggesting that increased insurance coverage enables people to get screened for chronic diseases.â says study coauthor Sarah Miller, PhD, assistant professor of business economics and public policy at the University of Michigan.
âFifty-eight percent of people queried said that they had visited a general physician in the past year. That jumped to 68%, after the ACA, a significant increase,â says Miller. âThis was really only the very early first-year effect. I see this as the first step in having actual health improvements.â
According to Jesse Cross-Call, a policy analyst with the Center on Budget and Policy Priorities, people are using the healthcare that they are getting in an âappropriate way.â âEmergency rooms were not flooded,â says Cross-Call.
In studies comparing Arkansas and Kentuckyâwhich expanded Medicaidâto Texas, which didnât, Arkansas and Kentucky saw greater increases in the share of residents with a personal doctor.
âEven though Texas didnât expand Medicaid, there was marketplace coverage that people were accessing, but the growth was much greater in Arkansas and Kentucky,â Cross-Call says.
Healthcare use rose in all three states between 2013 and 2014. People were having an easier time paying for care and hospitals were experiencing less uninsured stays.
From the consumer side, costs in the private exchanges will have to be addressed.
According to Jeffrey Kullgren, MD, MS, MPH, 85% of people in Healthcare.gov exchanges are choosing high-deductible plans.
âMany people are feeling that their insurance coverage is not as generous as they want it to be.â says Kullgren, assistant professor in the department of internal medicine at the University of Michigan Medical School. âBut the fundamental goal of health insurance is to protect people from catastrophic, unexpected health shocks.
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âAs more years pass, people have more opportunity to use their coverage,â says Benjamin Sommers, MD, PhD, assistant professor of policy and economics in the Harvard School of Public Health.
According to Sommers, under Massachusettsâs 2006 healthcare reformâwhich was the model for the ACAâearly evidence showed that people were getting health insurance and had better access to care.
But it wasnât until 2014 that researchers had enough data to determine that people were living longer as a result of the law. Massachusetts had more doctors per capita than any other state and high-quality health plans, so the biggest benefit of expanding coverage will probably be seen in states with large numbers of uninsured people.
While every stateâs Medicaid program is different, according to Sommers, it didnât seem to matter if people had Medicaid or private insurance, as long as they had some form of coverage, compared to the states that didnât expand coverage.
Another factor driving coverage expansion is if states facilitated or hampered their obtaining coverage through the ACA.
According to Sommers, some states have conducted aggressive outreach to enroll people in the ACA, while others made it difficult to obtain information on eligibility, or even enacted restrictions on community groups signing people up for coverage. âThat turns out to make a big difference in whether people know about the law and sign up for it.â says Sommers.
While studies showed people living longer based on expanding coverage, health insurance can only narrow health disparities based on poverty, race and ethnicity, not erase them.
âIt might close 20 to 30% of the survival gap by giving health insurance.â Sommers says. âHealthcare is a relatively small part of that puzzle. That said, it is really important to address that part, because we can.â