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Original Investigation | Health Care Reform

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, PhD1,2; Vincent Mor, PhD2,3; Susan Allen, PhD2,3; James F. Burgess Jr, PhD4,5; Amal N. Trivedi, MD, MPH2,3
[+] Author Affiliations
1Department of Health Management and Policy, Yale School of Public Health, New Haven, Connecticut
2Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
3Center of Innovation in Long-term Services and Supports for Vulnerable Veterans, Providence Veterans Affairs Medical Center, Providence, Rhode Island
4Center for Organization, Leadership and Management Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
5Department of Health Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
JAMA Intern Med. 2014;174(6):920-926. doi:10.1001/jamainternmed.2014.588.
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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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Annualized Change in Perceived Access to Care Among Medicaid Enrollees

Date of expansion is indicated by the vertical dotted line.

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