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Multiple studies have found improvements in measures of self-reported health following Medicaid expansions, and additional research has documented provider reports of newly eligible adults receiving life-saving or life-changing treatments that they could not obtain prior to expansion. One 2017 study found that Medicaid expansion was associated with improved health outcomes for cardiac surgery patients, including a significant decrease in predicted preoperative risk of morbidity or mortality and a decreased risk-adjusted rate of postoperative major morbidity. A january 2018 study suggests that expansion may contribute to infant mortality rate reductions. While the mean infant mortality rate rose slightly in non-expansion states between 20, it declined in expansion states over that period. This effect was particularly pronounced among the African-American population. A 2018 study found no evidence of expansion affecting drug-related overdoses or fatal alcohol poisonings. Four analyses did not find significant changes in self-reported health status. Given that it may take additional time for measureable changes in health to occur, researchers suggest that further work is needed to provide longer-term insight into expansions effects on self-reported health and health outcomes.

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Several studies show that expansion states have experienced greater reductions in unmet medical need because of cost than non-expansion states. Although a few studies did not identify statistically significant differences in changes in unmet medical need due to cost between expansion and non-expansion states, some of these findings may have been affected by study design or data limitations. research suggests that Medicaid expansion results in significant reductions in out-of-pocket medical spending. One study found that previously uninsured prescription drug users who gained Medicaid coverage in 2014 saw, on average, a 205 reduction in annual out-of-pocket spending in 2014. The january 2018 study noted above that focused on the 100-138 fpl population in expansion and non-expansion states also found that Medicaid expansion coverage produced far greater reductions than subsidized Marketplace food coverage in average total out-of-pocket spending, average out-of-pocket premium spending, and average cost-sharing spending. multiple studies found larger declines in trouble paying as well as worry about paying future medical bills in expansion states relative to non-expansion states. for example: One study found that, among those residing in areas with high shares of low-income, uninsured individuals, medicaid expansion significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies. Similarly, other studies have found that Medicaid expansion has significantly reduced the percentage of people with medical debt, reduced the average size of medical debt, reduced the average number of collections, improved credit scores, reduced the probability of having one or more medical bills. a study of Ohios Medicaid expansion found that the percentage of expansion enrollees with medical debt fell by nearly half since enrolling in Medicaid (55.8 had debt prior to enrollment,.8 had debt at the time of the study). Self-Reported health and health Outcomes Continually emerging research has documented improvements in self-reported health and certain health outcomes measures following Medicaid expansion.

a few studies did not find significant positive effects of expansion on certain measures of access or utilization. For several of the earlier studies in this group, these results may reflect the additional time needed for persons to enroll in Medicaid and establish care following initial expansion implementation. Authors of early studies using 2014 data note how that changes in utilization may take more than one year to materialize. Consistent with this premise, a longer-term study found improvements in measures of access to care and financial strain in year two of the expansion that were not observed in the first year. While some research indicates that provider shortages are a challenge in certain contexts, many studies show that providers have expanded capacity and are meeting increased demands for care. for example: One study found that Medicaid expansion was associated with longer wait times for appointments, suggesting remaining access challenges despite improvements in coverage and access measures. In contrast, another study found that Medicaid primary care appointment availability increased significantly in the five expansion states included in the analysis, whereas there were no significant changes in appointment availability in the non-expansion states studied. An additional study found improvements in receipt of checkups, care for chronic conditions, and quality of care even in areas with primary care shortages, suggesting that insurance expansions can have a positive impact even in areas with relative shortages. Affordability and Financial Security, research suggests that Medicaid expansion improves the affordability of care and financial security among the low-income population.

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One study in a single hospital in Maryland found that, in the year after expansion, there was a small but statistically significant reduction in the proportion of ed patients that were high utilizers and a reduction in visits to the ed for ambulatory care sensitive. However, high utilizers remained more likely than low utilizers to have ed visits for ambulatory care sensitive conditions before and after Medicaid expansion. Two studies found that Medicaid expansion was associated with declines in hospital length-of-stay for Medicaid patients. Another analysis found that, contrary to past studies associating Medicaid insurance with longer hospitalizations and higher in-hospital mortality, the shift in payer mix in expansion states (increase in Medicaid discharges and decrease in uninsured discharges) did not influence length of stay or in-hospital mortality for. evidence suggests that beneficiaries and other stakeholders lack understanding of some waiver provisions designed to change utilization or improve health outcomes. Multiple studies have demonstrated confusion among beneficiaries, providers, and advocates in expansion waiver states around the basic elements of the programs or requirements for participation, as well as beneficiary reports of barriers to completion of program activities (including internet access and transportation barriers). These challenges have resulted in increased costs to beneficiaries, beneficiaries being transitioned to more limited benefit packages, low program participation, or programs not operating as intended in other ways.

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A fourth study found that Medicaid expansion was correlated with increased heart transplant listing rates for African American patients (both overall and among Medicaid enrollees, specifically). recent position evidence demonstrates that compared to non-expansion states, medicaid expansion states have seen greater improvements in access to medications and services for the treatment of behavioral and mental health conditions. This evidence includes studies that have shown that Medicaid expansion is associated with increases in overall prescriptions page for, medicaid-covered prescriptions for, and Medicaid spending on medications to treat opioid use disorder and opioid overdose. Additional research found increased utilization and Medicaid coverage of evidence-based smoking cessation medications post-expansion in expansion states relative to non-expansion states. multiple recent studies have also found expansion to be associated with improvements in disparities by race and income, education level, and employment status in measures of access to and affordability of care. Studies conducted in 20 began to explore the effect of the medicaid expansion on quality of care. A january 2018 study found that for patients with one of five common surgical conditions admitted to an academic medical center or affiliated hospital, expansion was associated with a significantly greater probability of receiving optimal care.

Another study found that at federally funded community health centers, expansion was associated with improved quality on four of eight measures examined: asthma treatment, pap testing, body mass index assessment, and hypertension control. A third study found some improvement in perceived quality of care associated with expansion in 2015, but this result did not persist in 2016. some studies point to changes in patterns of use of emergency departments (EDs). Two recent single-state studies in Maryland and Illinois found declines in uninsured ed visits and increases in Medicaid-covered ed visits following expansion implementation. Some studies have explored expansions impact on total emergency department (ED) volume and utilization patterns. A single-state study in Maryland found no significant relationship between Medicaid expansion and changes in total ed volume by hospital. An Illinois study found an increase in total ed visits after aca implementation, but this included an increase in visits by individuals with private coverage.

Coverage Effects Under Section 1115 Medicaid Expansion waivers. States implementing the expansion through a waiver have seen similar gains in coverage, but some provisions in these waivers may present barriers to coverage. Studies show that states expanding Medicaid through Section 1115 waivers have experienced coverage gains that are similar to gains in states implementing traditional Medicaid expansions. Research comparing Arkansas (which expanded through a premium assistance model) and Kentucky (which expanded through a traditional, non-waiver model) showed no significant differences in uninsured rate declines between 20 in the two states. An analysis of expansion waiver programs in Michigan and Indiana showed that both states experienced uninsured rate reductions between 20 that were higher than the average decrease among expansion states as well as large gains in Medicaid enrollment. data from Indiana, which implemented the expansion through a section 1115 waiver, show that its required monthly contributions may have created an enrollment barrier for some adults.


In the healthy Indiana Plan (HIP).0 Medicaid expansion program, individuals above 100 fpl are either not enrolled or disenrolled from hip.0 coverage for unpaid monthly contributions. A report assessing the program showed that between February 1, 2015 and november 30, 2016, 57,189 members were disenrolled or not enrolled due do non-payment (representing 29 of those that could be affected by the policy)., evidence also suggests that beneficiaries and other stakeholders often. The march 2017 hip.0 evaluation found that 14 of all hip enrollees above 100 fpl, 33 of individuals who were disenrolled for not making a monthly contribution, and 40 of individuals who were not enrolled because they did not make a first monthly contribution. Impacts on Access to care, utilization, Affordability, and health Outcomes. Access to care and Utilization, most research demonstrates that Medicaid expansion positively impacts access to care and utilization of health care services among the low-income population, but some studies have not identified significant effects in these areas. Many expansion studies point to improvements across a wide range of measures of access to care as well as utilization of some medications and services. Some of this research also shows that improved access to care and utilization is leading to increases in diagnoses of a range of diseases and conditions and in the number of adults receiving consistent care for a chronic for example: Two studies found that expansion.

The Effects of Medicaid Expansion under the aca: Updated

similar coverage gain patterns have occurred within specific vulnerable populations. While many studies focused on the low-income population broadly, several studies identified larger coverage gains in expansion versus non-expansion states for specific vulnerable populations, including young adults, prescription drug users, people with hiv, veterans, parents, mothers, women of reproductive age (with and without children children. multiple recent analyses demonstrate that same Medicaid expansion is having essay a disproportionately positive impact in rural areas in expansion states, where growth in Medicaid coverage and declines in uninsured rates have exceeded those in metropolitan areas in expansion states and both rural and metropolitan areas. One study found higher Medicaid growth rates in metropolitan counties compared to rural counties in both expansion and non-expansion states, but the geographic differential in growth rates was much less dramatic in expansion states and analysis at the state level showed much variability across the. multiple studies showed that this trend of larger uninsured rate reductions and Medicaid coverage gains in expansion states compared to non-expansion states occurred across the major racial/ethnic categories. Additional research also suggests that Medicaid expansion has helped to reduce disparities in coverage by income and age, and research shows improvements in disparities by race/ethnicity, with mixed outcomes for some specific racial and ethnic groups. One 2017 study demonstrated a clear welcome-mat effect of Medicaid expansion on enrollment in public coverage among children who were already eligible for Medicaid. Enrollment increases in 20mong children whose parents became newly eligible for Medicaid under the expansion outpaced coverage increases among children in families without newly eligible parents by more than double.

literature review in a report

Studies show that Medicaid expansion results in significant coverage gains and reductions in uninsured rates. States expanding their Medicaid programs under unity the aca have seen large increases in Medicaid enrollment, driven by enrollment of adults made newly eligible for Medicaid as well as enrollment growth among individuals who were previously eligible for but not enrolled in Medicaid (known as the. In comparison, non-expansion states have experienced slower enrollment growth. numerous analyses demonstrate that Medicaid expansion states experienced large reductions in uninsured rates and that these reductions significantly exceed those in non-expansion recent studies have shown that expansion-related enrollment growth in Medicaid and declines in uninsured rates in expansion states continued in 20, and that. One study found that the greater uninsured rate decline in expansion compared to non-expansion states was isolated among the population that is ineligible for aca coverage in non-expansion states (those below 100 fpl). The sharp declines in uninsured rates among the low-income population in expansion states are widely attributed to gains in Medicaid coverage. research does not support a relationship between states Medicaid expansion status and home and community-based services (hcbs) waiver waiting lists. One study found that most expansion states either had no hcbs waiver waiting list or had a decrease in their waiting list from 2014 to 2015, and more non-expansion states than expansion states experienced an hcbs waiver waiting list increase between 20Studies exploring the potential.

impacts of aca coverage expansions generally (not specific to medicaid expansion alone studies investigating potential effects of expansion in states that have not (or had not, at the time of the study) expanded Medicaid, and reports from advocacy organizations and media. Findings are separated into three broad categories: Medicaid expansions impact on coverage; access to care, utilization, affordability, and health outcomes; and economic outcomes for the expansion states. The Appendix at the end of the brief provides a list of citations for each of the included studies, grouped by the three categories of findings. Recently published studies from late 2017 and early 2018 have continued to support earlier findings while using the additional years of experience with expansion to deepen findings in many areas, including expansions effects on health outcomes, access to services and medications for behavioral health and. Among other findings, new studies in these areas show that expansion is associated with infant mortality rate reductions, increases in cancer diagnosis rates (especially early-stage diagnosis rates increases in prescriptions for and Medicaid coverage of medications to treat opioid use disorder and opioid overdose, and. We will continue to monitor and update these findings as additional studies and state experiences provide insight into how various factors shape coverage, access to care, and costs in Medicaid expansion states and as states continue to consider expansion and reshape medicaid coverage. While future research will be necessary to study the effects of new waiver provisions recently approved by or pending approval from the Trump administration, findings from this literature review on states with existing expansion waivers (such as Indiana) suggest that adding new restrictions or program. Impacts on coverage, uninsured Rate and Medicaid coverage Changes.

Access to care, utilization, affordability, and health outcomes: Most research demonstrates that Medicaid expansion has positively affected access to care, utilization of paper services, the affordability of care, and financial security among the low-income population. However, findings on provider capacity were mixed, with some studies suggesting that provider shortages are a challenge in certain contexts. Studies show improved self-reported health following expansion, and multiple new studies demonstrate a positive association between expansion and health outcomes. Further research is needed to more fully determine effects on outcomes given that it may take additional time for measureable changes in health outcomes to occur. Economic measures: Analyses find positive effects of expansion on numerous economic outcomes, despite medicaid enrollment growth initially exceeding projections in many states. Total (federal and state) Medicaid spending increased following expansion implementation, but research suggests that there were no significant increases in state spending from state funds as a result of the expansion through 2015 (although an uptick in state medicaid spending growth was projected for 2017. Studies also show that Medicaid expansions result in reductions in uncompensated care costs for hospitals and clinics as well as positive or neutral effects on employment and the labor market.

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A substantial body of research has investigated effects of the medicaid expansion under the Affordable care Act (ACA) on coverage; access to care, utilization, affordability, and health outcomes; and various economic measures. This issue brief summarizes findings from 202 studies of the impact of state measles medicaid expansions under the aca published beginning in January 2014 (when the coverage provisions of the aca went into effect) and updates earlier versions of this brief with studies through February 2018. More recent studies continue to support earlier findings but provide additional findings in key areas, including expansions effects on health outcomes, access to services and medications for behavioral health and other needs, and providers financial stability. This body of research suggests that the expansion presents an opportunity for gains in coverage, improvements in access and financial security, and economic benefits for states and providers. Coverage: Studies show that Medicaid expansion states experienced significant coverage gains and reductions in uninsured rates, among the low-income population broadly and within specific vulnerable populations. States that implemented the expansion through a waiver have seen coverage gains, but some waiver provisions appear to compromise coverage. Data do not support a relationship between states expansion status and community-based services waiver waiting lists.


literature review in a report
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