The Effect of the ACA Insurance Expansions on the Experiences of Previously Insured Medicare Beneficiaries Accessing Care

The percent uninsured in the United States fell sharply in 2014 following the introduction of health insurance marketplaces, the individual mandate, and the expansion of Medicaid eligibility in 26 states and Washington DC. In states that expanded Medicaid, gains in coverage for low-income adults (i.e., those directly targeted by the expansions) were larger and their experiences with health care services were reportedly better in some ways (fewer barriers, more health care use, more preventative care) and worse in others: timely appointments for care were reportedly more difficult to schedule in expansion states by 2015. Less is known about whether the experiences of the previously insured were also affected by the changing coverage landscape in expansion and non-expansion states. Of particular interest are the experiences of elderly adults covered by Medicare—a population that relies heavily on access to health services and whose satisfaction with care is important politically for policy setting. There are several plausible stories for why access to care would have changed for the Medicare population following the coverage expansions in 2014. Access to care may have become more difficult if the size of the coverage gains strained or exceeded the capacity of local health care providers to meet demand. On the other hand, access to care may have improved if sufficient financial resources were injected into local health care systems from the insurance expansions.

In this paper, we use a 6-year panel of the Consumer Assessment of Healthcare Providers & Systems (2010-2015) survey linked with Medicare claims and a difference-in-differences design to test if the experiences of Medicare beneficiaries accessing health care changed because of the insurance expansions in 2014. We focused on three measures of access as our outcomes: did you get urgent care when you needed it, did you get routine care when you needed it, and did you get specialist care when you needed it. We also created and evaluated a composite measure of “timely access to care”, which was an average of all three access measures. Our treatment variable was the gain in insurance from the 2014 expansion policies at the county level. Because uninsurance rates are a function of many factors—some of which are unrelated to policy changes in 2014—we developed an instrumented treatment variable that captured changes in county uninsurance due to the 2014 expansion policies only. We used predicted county level uninsurance in 2009 as our instrument, with the intuition that counties with higher uninsurance rates in 2009 would have been more likely to see larger gains in coverage after the expansion policies took effect in 2014.

Across all counties, we found no significant relation between county level coverage gains from the insurance expansions in 2014 and Medicare experiences accessing care. In subsample analyses, we found that experiences changed differentially in states that expanded Medicaid and states that did not. Access to care improved in states that did not expand Medicaid coverage, while access to care worsened in states that did.