Medicaid Expansion Linked to Increased Access, Quality of Care

Andrew P. Loehrer, MD, MPH

A recent study conducted on the Affordable Care Act’s (ACA) state expansion of Medicaid has revealed it to be linked to increased insurance coverage and improved receipt of care for patients undergoing surgery for appendicitis, cholecystitis, diverticulitis, aortic aneurysm, or peripheral artery disease (PAD).

Additionally, Medicaid expansion was associated with a 1.8% increase in the probability that a patient presented without complications (95% CI, 0.7—2.9; P = .001) and a 2.6% increase in the probability of a patient receiving optimal care (95% CI, 0.8—4.4; P = .006), defined as care that improved morbidity, mortality, effect on quality of life, and costs.

Led by Andrew P. Loehrer, MD, MPH, a clinical fellow in complex general surgical oncology at MD Anderson Cancer Center in Houston, Texas, the quasi-experimental, difference-in-differences study analyzed hospital administrative data on more than 290,000 hospital admissions in order to compare patient outcomes pre-expansion (2010—2013) and post-expansion (2014–2015) Medicaid expansion.

"The Affordable Care Act was the most significant health care policy change in a generation, expanding coverage to millions and attempting to improve the quality of care delivered," Loehrer told MD Magazine. "However, the fate of the law, including the role of Medicaid, remains a point of contentious debate. Our findings provide important new evidence that the ACA’s Medicaid expansion is improving the quality of care for serious conditions that affect tens of thousands of Americans every year."

"These data along with an ongoing evaluation of other components of the ACA, including the insurance marketplaces and pay-for-performance initiatives, can provide empiric evidence to assess the improvements after the ACA as well as the challenges that remain," he added.

Using data involving 293,529 patients in both Medicaid expansion states (n = 225,572) and non-expansion states (n = 67,957), investigators found that those in expansion states were 7.5% more likely to be insured (95% CI, 12.2—2.9; P = .002) and 8.6% more likely to be covered by Medicaid (95% CI, 6.1—11.1; P <.001).

In states that expanded, in the pre-expansion, 14.1% of patients were uninsured, while 22.1% were covered by Medicaid, and 63.9% were covered by private insurance. Post-expansion, only 6.8% were uninsured, and 30.5% were covered by Medicaid. There was a -1.2% decrease for those privately insured, however.

In states that did not expand, in the pre-expansion period, 21.2% were uninsured, 18.0% were covered by Medicaid, and 60.8% were privately insured. When compared post-expansion, 21.9% were uninsured (0.7% increase), 18% were covered by Medicaid (0% increase), and 60.1% were privately covered (0.7% decrease).

When analyzed among subgroups, the data revealed a 3.7% increase in the probability of receiving optimal care for those who were on Medicaid or uninsured (95% CI, 0.7—6.7; P = .02).

"A growing number of studies have examined the effects of the Affordable Care Act’s Medicaid expansion. But none to date have looked at effects on surgical conditions, which are both expensive and potentially life-threatening," Loehrer said. "We found that expansion of Medicaid coverage was linked to increased insurance coverage for these patients, but even more importantly, Medicaid expansion led patients to come to the hospital earlier before complications set in, and they also received better surgical care once they got there."

For specific conditions, there were also a number of increases seen. Patients with diverticulitis saw a 1.6% increase in early presentation (95% CI, 0.5—2.7; P = .004), while patients with acute cholecystitis experienced a 2.8% increase in optimal care (95% CI, -0.0—5.7; P = .05).

The remaining conditions saw increases in optimal care, although they were not deemed statistically significant. For aortic aneurysm, an increase of 1.3% [95% CI, −1.1 to 3.8], P = .29; for PAD, an increase of 2.3% (95% CI, -0.2—4.9; P = .07); for minimally invasive appendectomy, an increase of 1.9% (95% CI, -0.7—4.5; P = .15); and for limb-sparing PAD, an increase of 1.5% (95% CI, 0.9—4.0, P = .22).

"I think the study design is an important aspect to consider when contextualizing our findings," Loehrer said. "Our difference-in-differences design compares changes over time in surgical care delivery for patients in states that expanded Medicaid coverage, with any changes in care that occurred over the same time period for patients living in states that did not expand Medicaid coverage. This approach attempts to measure the effect of states choosing to expand Medicaid under the ACA. It’s a much stronger study design than some previous analyses of surgical care and Medicaid that simply compare people with Medicaid to people with private insurance."

The study authors named a number of limitations, including the vulnerability of the data set—administrative data is susceptible to coding errors. Also, there are limitations to the clarity of the data on improved quality of care, as well as the translation of this data to non-studied conditions, and the definition of the post-reform period does not include data from the 5 states that expanded prior to 2014. The authors noted that “the insurance coverage trends seen in our dataset had the most marked shift starting in 2014.”

The study, “Association of the Affordable Care Act Medicaid expansion with access to and quality of care for surgical conditions,” was published in JAMA Surgery.

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