- 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.
- Economic measures: Analyses find positive effects of expansion on numerous economic outcomes, despite Medicaid enrollment growth initially exceeding projections in many states.
A substantial body of research has investigated effects of the Medicaid expansion under the Affordable Care Act 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 Medicaid expansions under the ACA published beginning in January 2014 and updates earlier versions of this brief with studies through February 2018.1 More recent studies continue to support earlier findings but provide additional findings in key areas, including expansion’s 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.
- Access to care, utilization, affordability, and health outcomes: Most research demonstrates that Medicaid expansion has positively affected access to care, utilization of 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 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. 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.
This literature review includes studies, analyses, and reports published by government, research, and policy organizations using data from 2014 or later. This brief only includes studies that examine impacts of the Medicaid expansion in expansion states. It excludes studies on impacts of ACA coverage expansions generally, studies investigating potential effects of expansion in states that have not expanded Medicaid, and reports from advocacy organizations and media sources. Findings are separated into three broad categories: Medicaid expansion’s 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 expansion’s effects on health outcomes, access to services and medications for behavioral health and other needs, and providers’ financial stability. Among other findings, new studies in these areas show that expansion is associated with infant mortality rate reductions, increases in cancer diagnosis rates, increases in prescriptions for and Medicaid coverage of medications to treat opioid use disorder and opioid overdose, and reduced probability of hospital closure.
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 suggest that adding new restrictions or program complexities to Medicaid through Section 1115 waivers could compromise coverage and access gains achieved under expansion or slow future progress.
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Date: March 28, 2018