Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study.

OBJECTIVE:To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). DESIGN:Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. SETTING:United States. PARTICIPANTS:A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. MAIN OUTCOMES AND MEASURES:Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. RESULTS:37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -442; adjusted P&lt;0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions. CONCLUSION:Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults

The Effects of the Affordable Care Act Medicaid Expansions on Out-Of-Pocket Spending, Healthcare Utilization, and Health Outcomes

It is well documented that lack of health insurance negatively affects access to care and health outcomes. Uninsured people are less likely, compared to those with health insurance, to have usual source of care and receive necessary care primarily due to the cost, leading to detrimental health consequences. The Medicaid expansions under the Patient Protection and Affordable Care Act (ACA) were intended to provide access to health insurance coverage for many of the more than 45 million uninsured Americans. This major policy change originally required all states to expand the eligibility of their Medicaid programs to those younger than 65 years with incomes up to 138% of the federal poverty level (FPL), based solely on income without regard to categorical eligibility status. To date, there is ample evidence that the percentage of the uninsured has been significantly reduced nationally despite the fact that 14 states have not adopted the ACA Medicaid expansions as of August 2019 due to the 2012 Supreme Court ruling making those expansions voluntary rather than mandatory. This dissertation assessed the further effects of the ACA Medicaid expansions on out-of-pocket spending, healthcare utilization, and health outcomes for chronic conditions using a nationally representative sample of the low-income non-elderly population from the 2010-2016 Medical Expenditure Panel Survey and 2005-2016 National Health and Nutrition Examination Survey. It took advantage of the natural experiment that allowed a comparison of changes in outcomes between the expansion and non-expansion states. The three studies found that the ACA Medicaid expansions were associated with reduced out-of-pocket spending and improved financial risk protection, a modest increase in primary care physician visits without any meaningful change in emergency department visits, and improved clinical measures for hypertension and diabetes (but no improvement in outcomes for hyperlipidemia and depression), during the three years after the policy implementation. The findings suggest that the ACA has been successful in achieving its goals of removing financial barriers, promoting access to primary care, and improving population health among low-income uninsured Americans. It has important implications for state decisions on adopting the ACA Medicaid expansions and for the ongoing national debate over the repeal of the ACA, including the Medicaid expansions

Association Between the ACA Medicaid Expansions and Primary Care and Emergency Department Use During the First 3 Years.

BackgroundEvidence is limited and mixed as to how the Patient Protection and Affordable Care Act (ACA) Medicaid expansions affected the utilization of primary care physicians (PCPs) and emergency departments (EDs) at the national level.ObjectiveTo examine the association between the ACA Medicaid expansions and changes in the utilization of PCP and ED visits at the national level during the first 3 years (2014-2016) of the implementation.DesignA difference-in-differences analysis to compare outcomes between individuals in 32 states that expanded Medicaid versus individuals in 19 non-expansion states.ParticipantsA nationally representative sample of US-born individuals 26-64 years old with family incomes lower than 138% of the federal poverty level from the 2010-2016 Medical Expenditure Panel Survey.InterventionACA Medicaid expansions MAIN MEASURES: We examined PCP-related outcomes ((i) whether a participant had any PCP visit during a year and (ii) the annual number of PCP visits per person) and ED-related outcomes ((i) whether a participant had any ED visit during a year and (ii) the annual number of ED visits per person).Key resultsA total of 17,803 participants were included in our analysis. We found that the proportion of individuals with any PCP visit during a year marginally increased (difference-in-differences estimate, + 3.6 percentage points [pp]; 95% CI, - 0.4 pp to + 7.6 pp; P = 0.08) following the Medicaid expansions, without any change in the annual number of PCP visits per person. We found no evidence that ED utilization (both the proportion of individuals with any ED visit during a year and the annual number of ED visits per person) changed meaningfully after the Medicaid expansions.ConclusionUsing the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a modest improvement in access to PCPs without an increase in ED use