Three years after their states expanded Medicaid, low-income people in Arkansas and Kentucky continued to be more likely to have a doctor and less likely to have trouble paying medical bills or to delay seeking care because of the cost, a study has found.
The study, conducted annually since 2013 by researchers with the Harvard School of Public Health and Brigham and Women's Hospital in Boston, found those and other improvements in Arkansas and Kentucky continued to be significant compared with smaller or nonexistent gains in Texas, which did not expand Medicaid.
Meanwhile, the study found no statistically significant differences in the size of the improvements in Arkansas, which expanded Medicaid primarily through private plans under the so-called private option, and Kentucky, which provides coverage through managed-care companies.
"Consistent with prior comparisons, the results imply that coverage expansion is quite important for patients, but the type of coverage is less important," the researchers wrote in the journal Health Affairs last week.
The findings come as Arkansas prepares to seek federal approval to move about 60,000 Arkansans off its expanded Medicaid program, known as Arkansas Works, by limiting eligibility to adults with incomes of up to the poverty level, instead of up to 138 percent of the poverty level.
In a statement, Gov. Asa Hutchinson said Monday he doesn't expect the change to hurt the state's progress in improving access to health care.
The state will help those who lose Medicaid coverage enroll in similar coverage on the state's health insurance exchange, he said.
"We are going to work with our providers and healthcare community to ensure a smooth transition," he said.
Joe Thompson, director of the Arkansas Center for Health Improvement, said the study, which is based on a phone survey, "strongly suggests that Medicaid expansion had a major impact in Arkansas and Kentucky compared to Texas, where [expansion] did not happen."
He added that more research may be needed to assess the differences in outcomes in Arkansas and Kentucky.
Arkansas last week published a draft of its request for federal approval to shrink the expansion and impose a work requirement on many of those who would remain in the program. If approved, the changes would take effect Jan. 1.
Medicaid expansion in Arkansas, Kentucky and 29 other states extended coverage to adults with incomes of up to 138 percent of the poverty level.
Under this year's federal poverty guidelines, that cutoff is $16,643 for an individual, for instance, or $33,948 for a family of four.
The expansion was intended to be mandatory under the 2010 Patient Protection and Affordable Care Act but became optional after the U.S. Supreme Court in 2012 ruled that the requirement was unconstitutional.
Arkansas Works was covering 321,595 people as of April 30, down just 877 from the total at the end of March, according to information released Monday by the state Department of Human Services.
The April 30 total included 298,233 people assigned to the private option and 23,362 whose coverage was being provided under the traditional, fee-for-service Medicaid program because they were considered "medically frail," with health needs the private plans typically don't cover.
The expansions in Arkansas and Kentucky took effect in 2014.
In Texas, Medicaid coverage for nondisabled adults under age 65 is limited to parents with incomes of up to about 18 percent of the poverty level. Adults with no minor dependants are not eligible for the program regardless of income.
Through health insurance exchanges, the Affordable Care Act makes subsidized insurance available to people who don't qualify for Medicaid and have incomes of 100 percent to 400 percent of the poverty level.
Because Medicaid expansion was meant to be mandatory, people with incomes below the poverty level don't qualify for the credits, leaving many poor people ineligible for help in Texas and other states that did not expand Medicaid.
The phone survey commissioned for the study is conducted in November and December of each year and involves adults under age 65 with incomes up to 138 percent of the poverty level.
The total number of adults surveyed each year has ranged from 2,209 to 3,011, according to the study.
The study found that, from 2013 to 2016, the percentage of respondents who reported being uninsured fell in each state, but by larger amounts in Arkansas and Kentucky than in Texas.
The percentage of uninsured fell in Arkansas from 41.8 percent to 11.7 percent, in Kentucky from 40.2 percent to 7.4 percent and in Texas from 38.5 percent to 28.2 percent.
Most of the improvements found in the 2016 survey in Arkansas and Kentucky were similar to those reported in an earlier installment of the study, based on the 2015 survey.
For instance, the percentage of respondents who reported having a primary care doctor increased in Arkansas from 57.2 percent in 2013 to 63.8 percent in 2015 and 67.7 percent in 2016.
In Kentucky, the percentage fell from 71.7 percent in 2015 to 66.1 percent in 2016, but was still higher than the 56.6 who reported having a doctor in 2013.
In Texas, the percentage of respondents with a doctor fell from 52.4 percent in 2013 to 51.3 percent in 2015 and 44.9 percent in 2016.
Arkansas also saw a steady decrease in the percentage of respondents who reported putting off medical care because of the cost. The percentage fell from 39.5 percent in 2013 to 29.8 percent in 2015 and 29.3 percent in 2016.
In Kentucky, the percentage increased from 25.1 percent in 2015 to 29.5 percent last year, although it remained below the 39.6 percent who reported putting off care in 2013.
In Texas, the percentage of those who delayed care increased from 31.7 percent in 2013 to 38.4 percent in 2015 before falling to 34.4 percent in 2016.
The percentage of Arkansas respondents who reported having trouble paying medical bills fell from 43.1 percent in 2013 to 31.4 percent in 2015 and 29.6 percent last year.
In Kentucky, that percentage fell from 42.7 percent in 2013 to 27.4 percent in 2015, then rose to 34.2 percent in 2016.
In Texas, the percentage increased from 31.9 percent in 2013 to 32.9 percent in 2015, then fell to 31.6 percent last year.
The study also found a continued decrease in Arkansas and Kentucky in the percentage of respondents who put off taking medicine because of the cost, as well as a drop in the percentage who had visited an emergency room and increases in the percentages who had received a medical checkup and had their cholesterol checked.
Those with chronic health conditions, such as high blood pressure or diabetes, were more likely to have received care for those conditions.
Marquita Little, health policy director for Arkansas Advocates for Children and Families, said the study shows that expanding coverage leads to changes in behavior.
"One of the concerns early on, with the expansion, was if you give people coverage, does it actually translate into properly utilizing the system?" Little said.
The study shows that, "over time, it certainly does," she said.
Metro on 05/23/2017