Finally, Some Answers on the Effects of Medicaid Expansion

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Do more conservative versions of Medicaid work?

Indiana expanded Medicaid through a waiver process, creating the Healthy Indiana Plan 2.0. Enrollees must make contributions to a health savings account, on a sliding scale based on income, to qualify for full benefits. If enrollees miss a payment, they receive reduced benefits. If they earn more than the poverty line and miss a payment, they can be locked out of coverage for half a year.

Many experts (including me) feared that Indiana would, consequently, see less benefit from the Medicaid expansion. These concerns have national implications: Other states are trying to expand Medicaid in novel ways, encouraged by Seema Verma, one of the architects of Healthy Indiana Plan 2.0 and current head of the Centers for Medicare and Medicaid Services.

Researchers from Indiana University’s School of Public and Environmental Affairs published a paper to see how Indiana had fared compared with other expansion states. They used data from the American Community Survey, which gathers information on three million people across the United States each year. Specifically, they looked at whether adults 18 to 64 (who might be affected by the expansion) had Medicaid or other insurance from 2009 through 2016.

All states that expanded Medicaid saw greater gains in coverage than those that did not. Indiana ranked in the middle, 13th of 27 states. In general, states with higher uninsurance rates before expansion saw larger gains, and Indiana ranked in the middle before and after expansion.

The good news is that even with these extra requirements, Indiana saw significant gains in Medicaid coverage. But we don’t know if gains would have been even larger without them. It’s possible that the churn caused by cost-sharing requirements may be causing the state to underperform. Neighboring states did see larger gains than Indiana itself. But Indiana overperformed compared with other, more distant states, making this unclear.

What’s the big picture?

These are individual studies. Looking at all the research together might provide a more accurate picture of how the Medicaid expansion is performing. Another study in Health Affairs by Indiana University health services researchers (I was one of them) systematically reviewed the literature to gather all available peer-reviewed evidence.

Since the start of Medicaid expansion, 77 studies, most of them quasi-experimental in design, have been published. They include 440 distinct analyses. More than 60 percent of them found a significant effect of the Medicaid expansion that was consistent with the goals of the Affordable Care Act.

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