The May issue of Health Affairs, a variety issue, contains several studies examining whether some expected consequences of the Affordable Care Act (ACA) have come to pass. As editor-in-chief Alan Weil wrote in his May issue letter, “We didn’t plan it this way, but this month’s Health Affairs could have been called the myth-busting issue.”
ACA did not reduce access for those already insured
Studies about the impact of the Affordable Care Act (ACA) have documented how access to care has improved for the newly insured. However, less discussed has been whether the ACA diminished access to care for those who already had health coverage—a problem predicted by some policy makers before the ACA’s implementation. To investigate this issue, Salam Abdus and Steven Hill, both with the Agency for Healthcare Research and Quality (AHRQ), reviewed eight measures of access in AHRQ’s Medical Expenditure Panel Survey (MEPS) data for the period 2008–14 to determine the proportions of continuously insured adults with worsened access (see exhibit below). They found no consistent evidence that increases in insurance coverage rates among adults during that time were associated with worsened access to care among adults who were continuously insured. This finding held true for those who are particularly vulnerable to access barriers: Medicaid enrollees and people living in areas with shortages of health professionals.
Medicaid expansion did not erode private insurance
Previous research about the ACA’s Medicaid expansion in 2014 has shown large gains in insurance coverage during its first year, with coverage increases among low-income adults largest in expansion states. Sandra Decker of AHRQ and coauthors used survey data for the period 2008–15 from the National Health Interview Survey (NHIS) to examine changes in coverage through 2015, the expansion’s second year. The authors found that coverage gains from expansion were larger in 2015 than in 2014, with the uninsurance rate falling about 7.5 percentage points more in expansion than nonexpansion states from 2013 to 2015. According to the authors, states that expanded Medicaid saw no reductions in private coverage, implying that increases in Medicaid coverage in those states came from low-income adults who would have otherwise been uninsured, not from people who dropped private coverage to sign up for Medicaid. The authors also analyzed subgroups and found that Medicaid expansion produced its largest coverage gains among men and childless adults, groups less likely to be eligible for Medicaid before the ACA’s Medicaid expansion. The study finds persistent improvements in coverage in expansion relative to nonexpansion states, providing evidence that the ACA has produced important benefits for consumers.
Also of interest:
Iowa’s Healthy Behaviors Program: many new Medicaid enrollees and clinics not aware of it
As part of its Medicaid expansion efforts, the State of Iowa created the Healthy Behaviors Program, an optional service designed to waive monthly premiums for Medicaid beneficiaries who complete certain healthy activities. Natoshia Askelson and coauthors from the University of Iowa evaluated the implementation of the Healthy Behaviors Program in its first year (2014) using claims data and interviews with clinic managers and Medicaid expansion enrollees. The authors found that no more than 17 percent of those enrolled in the program had a physical examination and a health risk assessment, prerequisite steps for participating in any other program activities. There was limited evidence that clinics and enrollees were aware of the program. The authors conclude that the results raise questions as to whether the inherent complexities of a program promoting personal responsibility can be effectively communicated without significant programmatic cost and effort.
How long a wait to see the doctor? If you’re a Medicaid patient, chances are it will be longer
Complaints about the length of time spent in the doctor’s office waiting to see a provider are a shared national experience and can color a patient’s view of the quality of care received. However, according to Tamar Oostrom of the Massachusetts Institute of Technology and coauthors, not all waiting time is equal. In what is believed to be the first large-scale administrative study of wait times in an ambulatory setting, the authors analyzed nationwide data on outpatient visits during 2013 obtained from electronic health record systems. They found that Medicaid patients were 20 percent more likely than privately insured patients to wait longer than twenty minutes for their appointment. Most of this reflected differences in providers seen. However, even when a Medicaid patient and a privately insured patient saw the same physician in the same practice, Medicaid patients had a 5 percent longer wait. This study complements other work on this subject, suggesting that Medicaid patients face some additional barriers in the receipt of care.
Weak relationship between physician price and quality
As a rule, consumers expect that “you get what you pay for.” To find out if this adage holds true for health care, Eric Roberts and coauthors from Harvard Medical School examined the association between physician practices’ commercial prices for office visits and the quality of care provided, using national data from the 2013 Medicare Consumer Assessment of Healthcare Providers Survey (CAHPS) and linked Medicare claims for survey respondents. The authors used commercial claims data to classify practices as being high- or low-price. According to the study, high-price practices were nearly four times larger and received an average of $84.45 for an office visit, 36 percent more than the $62.06 that their low-price counterparts received. However, the quality and efficiency of care provided by high-price and low-price practices differed minimally across a broad range of patient experience measures, preventive care, acute care use, and spending. In a few areas, including care coordination, vaccination, and office waiting times (patients being able to see their doctor within fifteen minutes of a scheduled appointment), high-price practices performed somewhat better. But even in these areas, performance was no better among the highest-price practices compared with lower-price practices. The authors conclude that the generally weak association they found between practices’ prices and the quality of care calls into question claims by consolidated providers that their higher prices signal higher-value care.