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Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

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Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood.

Objective

We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates.

Design

Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states.

Participants

512,744 low-income adults aged 20–64 in the 2011–2019 Behavioral Risk Factor Surveillance System.

Main Measures

Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year.

Key Results

Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states.

Conclusions

Medicaid’s fee structure should be considered as a factor influencing large-scale coverage expansions.

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Figure 1

Source: authors’ own analysis of the Medicaid-to-Medicare Fee Index data developed by Zuckerman et al. (2017). Note: The median Medicaid-to-Medicare fee ratio for all services was 0.77 in 2012. Expansion status was based on whether states had expanded Medicaid eligibility under the ACA as of 2014. States with expanded Medicaid after 2014 or unavailable fee data were excluded.

Figure 2
Figure 3

Source: authors’ own estimates using the 2011–2019 BRFSS. Note: All estimations were weighted to account for the complex sampling design of the BRFSS. Analytical sample was limited to adults with imputed household incomes up to 138% of the Federal Poverty Limit (FPL). Expansion status was based on whether states had expanded Medicaid eligibility under the ACA as of year 2014. Medicaid payment generosity was based on the estimation of Zuckerman et al. (2017). States with expanded Medicaid after 2014 or unavailable fee data were excluded.

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Authors and Affiliations

  1. Department of Health Management & Policy, College of Public Health, University of Kentucky, Lexington, KY, USA

    Joseph Benitez PhD, Huang Huang PhD & Tolulope Oladele MBBS, MPH

  2. Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, D.C, USA

    Salama S. Freed PhD

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Correspondence to Joseph Benitez PhD.

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Conflict of Interest:

At the time this was written, Joseph Benitez was receiving financial support from KFF as a non-residential fellow working in the KFF Program on Medicaid and the Uninsured. All other authors declare that they have no conflicts of interest.

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Benitez, J., Freed, S.S., Huang, H. et al. Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?. J GEN INTERN MED (2024). https://doi.org/10.1007/s11606-023-08558-w

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