Effect of expansions in state Medicaid eligibility on access to care and the use of emergency department services for adult Medicaid enrollees

Chima D Ndumele, Vincent Mor, Susan Allen, James F Burgess, Amal N Trivedi
JAMA Internal Medicine 2014, 174 (6): 920-6

IMPORTANCE: Medicaid enrollees typically report worse access to care than other insured populations. Expansions in Medicaid through less restrictive income eligibility requirements and the resulting influx of new enrollees may further erode access to care for those already enrolled in Medicaid.

OBJECTIVE: To assess the effect of previous Medicaid expansions on self-reported access to care and the use of emergency department services by Medicaid enrollees.

DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental difference-in-differences design among 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 1, 2000, and October 1, 2009, and 5097 Medicaid enrollees in 14 bordering control states that did not expand Medicaid.

MAIN OUTCOMES AND MEASURES: Self-reported access to care and annualized emergency department use.

RESULTS: Among states expanding their Medicaid program for adults, the mean income eligibility level increased from 82.6% to 144.2% of the federal poverty level. Income eligibility in matched control states remained constant at 77.1% of the federal poverty level. The proportion of adults reporting being enrolled in Medicaid increased from 7.2% to 8.8% in expansion states and from 6.1% to 6.4% in matched control states. In Medicaid program expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion to 7.3% after the expansion. In matched control states, the proportion of Medicaid enrollees reporting poor access to care remained constant at 5.3%. The proportion of enrollees reporting any emergency department use decreased from 41.2% to 40.1% in expansion states and from 37.3% to 36.1% in matched control states. In the period following expansions, newly eligible enrollees reported poorer access to care than previously enrolled beneficiaries, although the overall difference between groups did not reach statistical significance.

CONCLUSIONS AND RELEVANCE: We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees.

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