Medicaid Expansion Outlook in 2019

Bending the cost curve through improved access and quality

Earlier this month the newly-elected governor of Maine, Janet Mills, signed an executive order to begin the process for expanding the state’s Medicaid program. Maine voters had approved Medicaid expansion more than a year ago, but enacting the program had been blocked by then-governor Paul LePage.

Governor Mills’ action brings the count of states without expanded health coverage down to fourteen. Notable hold-outs for expansion include a block of states in the southeast and four that are among the U.S. Census Bureau’s top states with the highest rates of poverty.

While the typical lightning rod issue of the Affordable Care Act (ACA) is often the coverage mandate, Medicaid expansion is probably a close second. The expansion provision was designed to reduce the number of uninsured by offering coverage for low-income adults at up to 138% of the federal poverty level. Following the 2012 Supreme Court decision on the ACA, states were faced with making their own decisions about whether to adopt the expansion and when.

In addition to Maine four other states will be enacting Medicaid expansion in 2019. This includes Virginia, where the tide of voter opinion on healthcare issues made opposition to expansion an untenable position for several in the commonwealth’s legislature. A common rebuke in Virginia was similar to what former Maine governor LePage would claim - that of the “hidden costs” of expansion.

However some would counter that the costs of not expanding access to affordable healthcare are hidden in plain sight, and few would disagree that more can be done to create healthier communities.

As of this writing there are over 200 published works that have studied the effects of Medicaid expansion in the “early adopter” states (Antonisse, et al., 2018). For those still on the fence about Medicaid expansion, I would like to share what the research evidence tells us about the effects of increasing access to healthcare on cost and consumption through the experience of states that have been on the leading edge of this effort.

Myth #1: There is no evidence to support the claim that Medicaid expansion will improve health outcomes or lower costs.

Fact: In Medicaid expansion states, increased coverage rates have improved care access, resource utilization, and affordability for low-income populations, with a disproportionately positive effect in rural communities (Antonisse, et al.). Medicaid expansion has also increased coverage and access for care to pediatric and behavioral health populations (Hudson and Moriya, 2017, and U.S. GAO, 2017), two vulnerable populations in our communities that are commonly underserved (with sometimes disastrous effects in our communities). Need further proof that expanding coverage improves quality and cost? In Medicaid expansion states, infant mortality rates have dropped, while in non-expansion states they have risen (Bhatt and Beck-Sague, 2018).

Myth #2: Medicaid expansion will cause hospitals’ emergency departments to become overrun with non-emergent visits.

Fact: A research study in Maryland found there was no relationship between Medicaid expansion and changes in emergency department (ED) volume (Klein, 2017), and a separate single-facility study found that there were statistically significant reductions in ED visits for ambulatory sensitive conditions and high-utilizers (Gingold, et al., 2017).

Myth #3: There are so few providers that accept Medicaid, the newly-insured will wait months for primary care appointments (if they can find a provider at all).

Fact: Medicaid primary care appointment availability increased significantly in five expansion states, while there was no change in non-expansion states (Candon, 2017). Granted, I doubt anyone would dispute that we have an overall shortage of providers nationally, or that Medicaid is not the most sought-after payor. However, several nationally-recognized, innovative healthcare organizations are actually redesigning their care delivery models and system of services to increase access and efficiency for Medicaid patients... perhaps in some part due to the volume of customers on-hand and the reliability of the payment structure.

In close, the “hidden costs” of expansion are not hidden at all - they’ve always been in plain sight to healthcare providers who see the unfortunate sequelae of poor disease management that results from lack of access to quality, affordable care. What has been hidden, though, are the costs of not exploring and understanding the dynamics that drive care access, utilization, and ultimately cost, quality, and overall community health.

What do you see as hidden costs of current barriers to care access for vulnerable populations?

References

Antonisse, L., Garfield, R., and Rudowitz, R. (2018, March 28). The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. Henry J. Kaiser Family Foundation. Retrieved from: http://www.kff.org

Hudson, J., and Moriya, A. (2017). Medicaid Expansion for Adults Had Measureable ‘Welcome Mat’ Effects on Their Children. Health Affairs, 36(9). Retrieved from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0347

United States Government Accountability Office (2017). Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014. Washington, DC. Retrieved from: https://www.gao.gov/assets/690/685415.pdf

Bhatt, C., and Beck-Sague, C. (2018). Medicaid Expansion and Infant Mortality in the United States. American Journal of Public Health. Retrieved from: http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2017.304218

Klein, E. (2017). The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments. Annals of Emergency Medicine. Retrieved from: http://www.annemergmed.com/article/S0196-0644(17)30784-9/pdf

Gingold, D., Pierre-Mathieu, R., Cole, B., Miller, A., and Khaldun, J. (2017). Impact of the Affordable Care Act Medicaid Expansion on Emergency Department High Utilizers with Ambulatory Care Sensitive Conditions: A Cross-Sectional Study. The American Journal of Emergency Medicine. Retrieved from: http://www.sciencedirect.com/science/article/pii/S0735675717300141

Candon, M. (2017). Primary Care Appointment Availability and the ACA Insurance Expansions. University of Pennsylvania Leonard Davis Institute of Health Economics (Philadelphia, PA). Retrieved from: https://ldi.upenn.edu/brief/primary-care-appointment-availability-and-aca-insurance-expansions