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Expansion state enrollees more likely to pay medical bills


The Commonwealth Fund examined the effects of the ACA’s Medicaid expansion on low income adults in three states that took different approaches to the law. Here’s what they found.

Low-income adults in Kentucky and Arkansas, which both expanded Medicaid eligibility under the Affordable Care Act (ACA), were more likely to be insured and to report fewer problems paying medical bills or skipping prescriptions because of cost than adults in Texas, which did not expand coverage, according to a Commonwealth Fund-supported study released in Health Affairs.

The Commonwealth Fund examined the effects of the ACA’s Medicaid expansion on low income adults in three states that took different approaches to the law: Kentucky, which expanded Medicaid; Arkansas, which used Medicaid dollars to buy private health insurance for low-income adults (an approach called "the private option”); and Texas, which did not expand coverage.

The study, of more than 5,600 low-income adults, covers 2014, the first year of these programs. The researchers are completing a survey that assesses these policies after another year, and it’s possible that these results will continue to evolve as these programs have been effect for longer periods of time.


“We found that low-income adults in the two expansion states experienced significant improvements in coverage, access to medications, ability to pay medical bills, and regular care for chronic conditions, compared to those in Texas,” says lead study author Benjamin D. Sommers, MD, PhD, assistant professor of health policy and economics, Harvard T. H. Chan School of Public Health/Brigham & Women's Hospital, Boston.

“Meanwhile, instead of Medicaid managed care, Arkansas expanded coverage using commercial insurance purchased through the state’s marketplace,” Sommers says.  “Our findings are that both types of coverage expansion were beneficial for low-income adults.”

The uninsured rate in Kentucky and Arkansas dropped 14 percentage points more than it did in Texas between 2013, prior to full implementation of the ACA’s health insurance provisions, and 2014, after the expansion’s first full year. The uninsured rate for low-income adults was about 40% in all three states in 2013 but had dropped to 19% in Arkansas, 12% in Kentucky, and 27% in Texas in 2014.

In Kentucky and Arkansas the share of people who said they were struggling to pay medical bills fell by nearly 9 percentage points more than in Texas over 2013 to 2014. Adults reporting not filling a prescription because of the cost fell by nearly 10 percentage points more in Kentucky and Arkansas than in Texas. 

“While the expansion was very important, whether the expansion was done using Medicaid or private insurance did not matter as much. For Arkansas and Kentucky, most outcomes were similar, other than less trouble with medical bills in Kentucky,” Sommers says.   

Next: The role of Medicaid managed care



Managed care companies play a key role in many states’ Medicaid programs, and in the current study, Medicaid managed care was key to Kentucky’s expansion, he adds.

In Kentucky and Arkansas, the share of adults with chronic conditions (such as high blood pressure or diabetes) who reported receiving regular care for their condition rose by nearly 12 percentage points more than in Texas.

The share of adults reporting that the emergency room was their usual source of care fell by 5 percentage points in Kentucky and Arkansas compared to Texas.  But demand for outpatient visits overflowed to the emergency room in the expansion states: People reporting visiting the emergency room because they couldn’t get an outpatient appointment rose nearly 5 percentage points. 

Currently, 20 states have yet to expand Medicaid under the ACA, and many are debating whether to do so using traditional Medicaid or the private option, according to Sommers.  In addition, Kentucky’s new governor has suggested he would like to overhaul the state’s current approach to Medicaid expansion and shift to a private-market approach.

“Our study suggests that either option benefits low-income adults in terms of coverage, affordability, and access to care-whether you expand seems to matter much more than whether it is via public or private insurance,” he says.


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