Both the ‘Private Option’ and Traditional Medicaid Expansions Improved Access to Care for Low-Income Adults Low-income adults in Kentucky and Arkansas, which both expanded Synopsis Medicaid eligibility under the Affordable Care Act, were more likely to be insured and less likely to have problems paying medical bills or Jan. 5, 2016 affording prescriptions than low-income adults in Texas, which did not Authors Benjamin D. Sommers, expand Medicaid. Robert J. Blendon, and E. John Orav Journal Health Affairs, Jan. 2016 Contact Benjamin D. Sommers, The Affordable Care Act (ACA) gives states the option to expand The Issue Assistant Professor, Department of Medicaid eligibility to all adults with incomes under 138 percent of the Health Policy and Management, federal poverty level (about $16,000 for an individual or $33,000 for a Harvard School of Public Health family of four). So far, 30 states and the District of Columbia have chosen bsommers@hsph.harvard.edu to do so. Most have taken a traditional approach to expanding Medicaid, Access to full article. but several have elected the “private option”—using Medicaid funds to purchase private insurance through the federal and state marketplaces. This Commonwealth Fund–supported article in Health Affairs examines the experiences of low-income adults during the first year of the ACA Medicaid expansion in three states that adopted different strategies: Kentucky, which expanded traditional Medicaid coverage; Arkansas, which used the private option; and Texas, which did not expand Medicaid. The uninsured rate in Kentucky and Arkansas Key Findings dropped 14 percentage points more than in Texas • between 2013 and 2014. In 2013, the uninsured rate was about 40 percent in all three states. But by 2014, it had dropped to • 19 percent in Arkansas and 12 percent in Kentucky, while falling to 27 percent in Texas. Even in nonexpansion states like Texas, the streamlined Medicaid application process and the publicity surrounding the ACA helped increase coverage among uninsured populations, the authors point out. Moreover, in all states, low- income people living between 100 percent and 138 percent of the federal poverty level are eligible for subsidies when buying coverage in the marketplaces. In Kentucky and Arkansas, the share of adults who said they were struggling to pay medical bills fell by nearly 9 percentage points more than in Texas. The share of those reporting not filling a prescription • because of the cost fell nearly 10 percentage points more in the expansion states. Low-income adults in Kentucky experienced an even larger decline in medical bill problems compared with those in Arkansas, suggesting that Medicaid provides greater financial protection than private • coverage, even with cost-sharing subsidies. The percentage of people visiting emergency departments (EDs) because they could not get a timely appointment in a physician’s office increased nearly 5 percentage points more in Kentucky and Arkansas • compared with Texas. However, the share of adults in those two states reporting that the ED was their usual source of care dropped by 5 percentage points. Among adults with chronic illnesses like high blood pressure or diabetes, the share who reported receiving regular care for those conditions increased nearly 12 percentage points more in the expansion states than • in Texas. While there has been debate regarding the merits of the two Medicaid The Big Picture expansion approaches, this study found no significant differences (other than trouble paying medical bills) between Kentucky’s traditional approach and Our findings suggest that Arkansas’s private option. “[O]ur findings suggest that deciding whether or deciding whether or not not to expand matters much more than deciding how to expand,” the authors to expand [Medicaid] write. Both models appear to be promising strategies to improving access to matters much more than care among low-income adults. The authors note that additional research will deciding how to expand. be critical for evaluating the ACA’s long-term impact on this population. Researchers surveyed low-income adults in Kentucky, Arkansas, and Texas from November to December About the Study 2013, and again one year later. The survey asked people about health insurance; access to care (e.g., having a personal doctor, experiencing cost-related delays in seeking care or taking medications); care utilization (e.g., ED and office visits); preventive care (e.g., blood glucose or cholesterol check); quality of care (e.g., regular communications with a provider for a chronic condition); and overall health. Both traditional Medicaid expansion and the private option, which uses federal funds to purchase private The Bottom Line plans, improve the likelihood that low-income adults will be able to get insurance coverage, afford needed health care, and obtain regular care for chronic conditions. B. D. Sommers, R. J. Blendon, and E. J. Orav, “Both the ‘Private Option’ and Traditional Medicaid Expansions Improved Access to Care for Low- Income Adults,” Health Affairs, Jan. 2016 35(1):96–105. ______________________________________________________________________________________________________________________________________________________________ This summary was prepared by Deborah Lorber.