­­Access to Health Insurance and Treatment Utilization for Opioid Use Disorder: Evidence From State Medicaid Expansions

Background. Medicaid is a major payer of substance use disorder treatment, yet the impact of Medicaid expansion on the opioid epidemic has not been sufficiently quantified. This study exploits state-level differences in Medicaid expansion to assess the impact of access to health insurance on treatment utilization for opioid use disorder (OUD) for adults in need.Method. We use admissions data from Treatment Episode Data Sets (TEDS) to fit a multivariate difference-in-difference model, with non-expanding states as controls, adjusting for age, gender, race/ethnicity, education, and other state-level factors. Results. Medicaid expansion led to substantial gain in OUD treatment utilization. Admissions for substance use disorder among Medicaid beneficiaries increased by 20-33 percentage points in expansion states. Admissions were significantly higher for the newly eligible Medicaid beneficiaries in the 30-34 age group. We also see an increase in treatment admissions for opioid and heroin use among the elderly over the age of 55. Uninsurance rates show a commensurate decline in the expansion states. Finally, we do not find strong evidence of crowding-out of private insurance. Conclusions. Overall, our findings suggest that Medicaid expansions had a positive impact on the financing and utilization of opioid use treatment.

Effects of the 2014 Affordable Care Act Medicaid Expansions on Health Care Access and Health Status of Poor Adults Aged 60-64 Years: Evidence from the First Six Years

Background and Objectives Little is known on effects of the Affordable Care Act (ACA) Medicaid expansions on health care access and health status of adults closest to 65. This study examines the effects of ACA Medicaid expansion on access and health status of poor adults aged 60-64 years. Research Design and Methods The study employs a difference-in-differences design comparing states that expanded Medicaid in 2014 under the ACA and non-expansion states over six years post expansion. The data are from the 2011-2019 Behavioral Risk Factor Surveillance System for individuals aged 60–64 years below the Federal Poverty Level. Results Having any health care coverage rate increased by 8.5 percentage-points (p<0.01), while the rate of forgoing a needed doctor’s visit due to cost declined by 6.6 percentage points (p<0.01). Similarly, rates of having a personal doctor/provider and completing a routine checkup increased by 9.1 (p<0.01) and 4.8 (p<0.1) percentage-points, respectively. Moreover, days not in good physical health in the past 30 declined by 1.5 days (p<0.05), with suggestive evidence for decline in days not in good mental health and improvement in self-rated health. Discussion and Implications The ACA Medicaid expansions have improved health care access and health status of poor adults aged 60-64 years. Expanding Medicaid in the states that have not yet done so would reduce barriers to care and address unmet health needs for this population. Bridging coverage for individuals 60-64 years old by lowering Medicare eligibility age could have long-term effects on wellbeing and health services utilization.

Change in facility-level share of Medicaid patients with cancer following implementation of the affordable care act.

e18543 Background: Although Medicaid expansions associated with the Affordable Care Act (ACA) significantly increased insurance coverage for Americans with cancer, there is evidence that some facilities limit the number of Medicaid patients they treat due to lower reimbursement. We aimed to assess facility-level changes in the proportion of patients with Medicaid who were diagnosed with cancer in relation to Medicaid expansions associated with the ACA. Methods: We identified adult patients with the 19 most commonly diagnosed cancers using the National Cancer Database who were diagnosed with cancer from 2010 through 2017. We clustered Commission on Cancer (CoC) accredited institutions and included those diagnosing at least 10 patients in each year. The primary study endpoint was the change in the proportion of Medicaid-insured individuals relative to the implementation of the ACA (pre- and post-Jan 1, 2014). We used adjusted difference-in-differences (DID) estimation and multivariable logistic regression to examine patient and facility-level factors associated with changes in the proportion of Medicaid insured individuals. Results: We identified 1,064 eligible facilities in the study period. There were considerable changes in the share of Medicaid insured patients at the facility-level (range -20.0% to +44.7%, IQR -0.64% to +5.63%). There were significantly larger changes in facilities located in Medicaid expansion states (11.5 to 16.5% percentage points) versus non-expansion states (9.2 to 8.9% percentage points) with adjusted DID +5.79% (p < 0.001). Despite overall increases, 14.6% of facilities in expansion states experienced reductions in their share of Medicaid insured patients. Facility factors associated with decreasing share of Medicaid patients were non-expansion status (OR: 6.25, 95% CI 3.89 – 9.98, p < 0.001) and higher baseline Medicaid population (OR: 2.93, 95% CI 2.00 – 4.35, p < 0.001). There was also significant regional variation with larger decreases in the West South Central (OR: 5.86, 95% CI 2.30 – 15.74, p < 0.001) and West North Central (OR: 2.46, 95% CI 1.07 – 5.87, p = 0.037) regions. Conclusions: Although state expansions associated with the ACA led to increases in the share of Medicaid-insured patients diagnosed with cancer at CoC facilities, there was considerable variation in changes at the facility-level. These findings highlight that improved insurance coverage may not be sufficient to improve access to care, and facility-level policies may remain a source of access disparity.

The Impact of the Affordable Care Act Medicaid Expansions on the Sources of Health Insurance Coverage of Undergraduate Students in the United States

This article examines how the Affordable Care Act Medicaid expansions affected the sources of health insurance coverage of undergraduate students in the United States. We show that the Affordable Care Act expansions increased the Medicaid coverage of undergraduate students by 5 to 7 percentage points more in expansion states than in nonexpansion states, resulting in 17% of undergraduate students in expansion states being covered by Medicaid postexpansion (up from 9% prior to the expansion). In contrast, the growth in employer and private direct coverage was 1 to 2 percentage points lower postexpansion for students in expansion states compared with nonexpansion states. Our findings demonstrate that policy efforts to expand Medicaid eligibility have been successful in increasing the Medicaid coverage rates for undergraduate students in the United States, but there is evidence of some crowd out after the expansions—that is, some students substituted their private and employer-sponsored coverage for Medicaid.