Improving Care for Medicaid Consumers Under the Affordable Care Act
One of the concerns about the ACA expressed by healthcare policymakers is the "churning" effect, where consumers are involuntarily moved through different coverage levels and to different providers.
Medicaid has made headlines in recent weeks as a major target in the "repeal & replace" efforts against the Affordable Care Act (ACA) of 2010. With the withdrawal of the intended replacement, the American Health Care Act (ACHA), in late March, just before a congressional vote on repeal, the ACA was left in place for the near future, allowing for Medicaid expansion to continue.
Initial Results of Medicaid Expansion
As of March 2017, 31 states and the District of Columbia have already signed legislation to expand Medicaid, with at least 2 more states poised to do the same.1,2 Under Medicaid expansion beginning in 2014, 11.7 million people signed up for coverage through the healthcare marketplace, and in 2015, 12.2 million more signed up for Medicaid or the Children's Health Insurance Program.3
A 2015 study of self-reported outcomes to ACA coverage showed that compared with the pre-ACA period, there was significant improvement in all categories, including access to and ability to afford coverage, access to primary care and medications, and health status.4 The benefits from the ACA were most pronounced among minority groups.4
A more recent investigation by Miller and Wherry,5 reporting in the March 9, 2016, issue of the New England Journal of Medicine, indicated that during the 2 years after initiation of Medicaid expansion across 29 states and Washington, DC, uninsured rates declined significantly compared with in states that did not expand coverage (difference-in-differences estimate, −8.2 percentage points; P <.001).
The study looked at health data collected from the National Health Interview Survey of 60,766 participants aged 19 to 64 years, with incomes less than 138% of the federal poverty level. Patients in expansion states were less likely to report inability to afford follow-up care and concern about paying medical bills (difference-in-differences estimate, −3.4 percentage points [P =.002] and −7.9 percentage points [P =.002], respectively).
Increased Wait Times Affecting Access to Care
Despite the increase in coverage, however, the data also suggest that Medicaid patients often had increased wait times for appointments to see healthcare providers.5 "We found significant increases in respondents delaying care because appointments were not available soon enough or because wait times were too long," the authors reported. The delays may have been attributable to the surge in new patients in the healthcare system or, alternatively, to a basic resistance by providers to quickly accommodate caring for new patients at the lower reimbursement rates offered by Medicaid, they suggested, although this was not studied.
Systematic factors can also influence wait times for appointments for Medicaid patients. According to Jesse D. McDonald, a certified insurance consultant and National Association of Health Underwriters ACA-certified broker who works with the Connecticut and New York markets: "Unless Medicaid is expanded in the states with more politically conservative governments, or unless more people qualify for Medicaid via income in the Medicaid expansion states, there may not be increased wait times." Wait times could be affected, however, if providers who now accept Medicaid began to leave the local Medicaid networks, he added.
The "Churning" Effect in Healthcare Coverage
One of the concerns about the ACA expressed by healthcare policymakers is the "churning" effect, in which consumers are involuntarily moved through different coverage levels and to different providers.6,7 Churning is a frequent problem among lower-income people who have fewer choices and fewer resources to rebound from personal and policy changes affecting their coverage. As an article by Buettgens and colleagues6 reported in 2012, "churning already occurs in Medicaid and [the Children's Health Insurance Program], but the ACA's Medicaid expansion and subsidized coverage in health benefit exchanges will expand its scope." Analysis at that time indicated that 29.4 million people in the United States younger than age 65 years would be subjected to forced changes in coverage in coming years under the ACA, including multiple moves between Medicaid, insurance subsidy programs, and being deemed ineligible because of incomes above 138% of the federal poverty level.6 This represented nearly one-third of the estimated 95.9 million estimated to receive either Medicaid or exchange subsidies in a year.6
Churning was a major factor in the withdrawal of the intended AHCA plan, as the Congressional Budget Office report released on March 13, 2016, estimated it would displace 14 million people from their current healthcare insurance by 2018, a number that rose to 21 million by 2020 and 24 million by 2026.8
Suggestions to reduce the effects of churning were offered in a 2014 article by Rosenbaum and colleagues, published by the Commonwealth Fund, advocating a 3-part strategy of multimarket plans, premium assistance for private coverage (subsidized), and continuous enrollment periods.7
The challenges to providing optimal levels of healthcare for people using Medicaid systems are many-fold, involving various levels of affordability and eligibility for suitable plans, maintaining consistency of coverage, and overcoming limited access to providers who potentially delay appointments to Medicaid participants.
As Medicaid expanded coverage is likely to grow in the wake of the current acceptance of the ACA as "law," attention needs to focus on improvements in how that coverage is segmented in the general population and improvements in wait times for appointments to provide optimum care.
- Where the states stand on Medicaid expansion. Advisory.com. https://www.advisory.com/daily-briefing/resources/primers/medicaidmap. Published March 28, 2017. Accessed March 30, 2017.
- Japsen B. More states to expand Medicaid now that Obamacare remains law. Forbes.com. Published March 26, 2017. Accessed March 28, 2017.
- Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the affordable care act. JAMA. 2015;314:366-374. doi: 10.1001/jama.2015.8421
- Health insurance marketplaces 2015 open enrollment period: March enrollment report. http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/Mar2015/ib_2015mar_enrollment.pdf. Office of the Assistant Secretary for Planning and Evaluation. Updated March 10, 2015. Accessed March 27, 2017.
- Miller S, Wherry LR. Health and Access to care during the first 2 years of the ACA Medicaid expansions. N Engl J Med. 2017;376:947-956. doi: 10.1056/NEJMsa1612890
- Buettgens M, Nichols A, Dorn S. Churning under the ACA and state policy options for mitigation: timely analysis of immediate health policy issues. http://www.urban.org/research/publication/churning-under-aca-and-state-policy-options-mitigation. Updated June 2012. Accessed March 28, 2017.
- Rosenbaum S, Lopez N, Dorley M, Teitelbaum J, Burke T, Miller J. Mitigating the effects of churning under the Affordable Care Act: lessons from Medicaid. Issue Brief (Commonw Fund). 2014;12:1-8.
- American Health Care Act: Cost Estimate. Congressional Budget Office. https://www.cbo.gov/publication/52486. Updated March 13, 2017. Accessed March 28, 2017.