- In the United States, since the expansion of Medicaid eligibility as part of the Affordable Care Act (ACA), some states have opted in, and some have declined to participate.
- A new study finds that control measures for blood pressure and glucose have improved in expansion states compared with non-expansion states.
- The improvements in blood pressure and glucose control are greatest for Black and Hispanic residents.
As part of the ACA, U.S. states were given the option of expanding Medicaid coverage to more people as a means of reducing the number of people without health insurance.
As of September 2021, 39 states, including Washington, D.C., have adopted Medicare expansion. Currently, 12 states have not expanded Medicaid eligibility.
A new study finds that blood pressure and glucose control measures have improved in states participating in Medicaid expansion.
The recent study investigated the extent to which individuals’ blood pressure and glucose have been monitored in the last 5 years at federally qualified health centers (FQHCs) in the 26 states that expanded Medicaid by 2014 and in non-expansion states.
Dr. Megan Cole Brahim, lead author of the study and co-director of Medicaid Policy Lab at Boston University (BU) School of Public Health, says:
“Once a patient gains health insurance coverage, associated health outcomes likely don’t improve overnight. It takes time for patients to become better connected to care and care management while gaining access to prescription medications. It also takes time for FQHCs to invest new patient revenue into things that improve quality of care.”
“Our results suggest that over the longer run, expanding Medicaid eligibility may improve key chronic disease health outcomes for low-income, marginalized populations, which is an important consideration for the 12 states that have not yet adopted Medicaid expansion.”
– Dr. Megan Cole Brahim
The study appears in the journal JAMA Health Forum.
Hypertension and diabetes control
Monitoring blood pressure and glucose levels is critical for the detection and management of hypertension and diabetes, respectively.
According to the Centers for Disease Control and Prevention (CDC), out of the 108 million people in the U.S. with hypertension, just 1 in 4 have their condition under control. This puts them at elevated risk of heart attack and stroke.
Moreover, diabetes is the seventh leading cause of death in the U.S. Thirty-four million people in the U.S. have diabetes, although 1 in 5 do not know that they have it. Of the 88 million additional people who have prediabetes, 84% are unaware of their risk.
Medicaid expansion
Before the expansion of Medicaid eligibility, assistance was available only to people aged 65 years and older unless they had children under the age of 18. Eligibility was calculated based on income, household size, disability, family status, and other factors.
Millions of people in the U.S. from low income households could not afford health insurance coverage.
Dr. Brahim told Medical News Today, “The key difference between expansion and non-expansion states is that childless adults [earning] up to 138% of the federal poverty level qualify for Medicaid in expansion states, whereas this population is without access to coverage in states that haven’t expanded eligibility to this group.”
As of December 2020, 14.8 million newly eligible people were enrolled in Medicaid, nationally.
Between Medicaid expansion and the ACA Marketplace, 31 million people in the U.S. have gained health insurance, and the uninsured rate for citizens who do not qualify as older adults has dropped from 48.2 million to 28.2 million people.
FQHCs
In the present study, the researchers analyzed data from 946 FQHCs that serve 18.9 million patients annually in the states studied.
Together, all of the nation’s FQHCs serve 30 million people in the U.S. from low income households each year, regardless of their ability to pay for services.
FQHCs serve, the study says, “1 in 5 Medicaid enrollees, 1 in 5 rural residents, and 1 in 3 persons with an income lower than the federal poverty level.”
Previous research has tied Medicaid expansion to improvements in service capacity and quality of care at FQHCs in expansion states. Dr. Brahim shared with MNT two possible explanations:
“First, more patients gained access to health insurance and thus regular care, which in turn improves health. Second, FQHCs received more patient revenue because more patients had coverage, which could be invested into expanded staffing, quality improvement programs, and other resources that improve quality for all patients.”
After 5 years of Medicaid expansion
The FQHCs in the expansion states included in the study saw a 9.2 percentage point (PP) reduction in uninsured patients over the 5-year period, compared with the FQHCs in the states without Medicaid expansion.
The number of uninsured people also decreased in the states that did not expand eligibility, although to a lesser extent.
Co-author Timothy Levengood, a doctoral student in the Department of Health Law, Policy & Management at BU School of Public Health, told MNT that “this is largely due to another major policy change under the [ACA], wherein low-income patients in all 50 states could purchase low cost (subsidized) private insurance plans on Marketplace exchanges if they made too much money for Medicaid but not enough money to afford private health insurance on their own.”
The study found that during the 5-year period, expansion states saw an overall 1.61 PP comparative improvement in blood pressure control and a 1.84 PP improvement in glucose control.
Hypertension and diabetes control measures most steadily improved for Black and Hispanic individuals. By year 5, the comparative improvement in hypertension control was 3.38 PP for Black people and 3.03 for Hispanic people.
Improvement in diabetes measures also steadily rose to 3.88 PP for Black people and 2.93 PP for Hispanic people.
Even with these improvements, however, healthcare inequities remain. Levengood tells BU School of Public Health:
“We have a good sense that these disparities are reflective of the political, economic, and social systems we live in that do not currently provide equal opportunities for health on the basis of skin color. Whether you can afford to regularly see a doctor and keep these conditions in check contributes substantially to whether you will develop these chronic conditions or die from them. It’s important to study relevant policy changes to these systems to combat these disparities and to craft a more equitable society for all Americans.”
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