Another day, another study on the benefits of the Affordable Care Act, just one of the many public health gains on the table this November.
This time, it’s actually three studies — two on how the ACA’s Medicaid expansion impacted family planning access and another on how the expansion affected uninsured hospitalizations for major cardiovascular events such as stroke. We’ll start with access to family planning services, or as women refer to them, basic health care. Both of those studies found that while Medicaid expansion increased coverage, the impact on reproductive health outcomes is not yet clear.
First, some context: the Guttmacher Institute reports that nearly half of the 6.1 million pregnancies in the U.S. each year are unintended, with rates of unintended pregnancy highest among poor and low-income women and among young women ages 18 to 24. In 2010, total federal and state public expenditures on unintended pregnancies hit $21 billion. In 2014, about 20 million women were in need of publicly funded contraceptive services and supplies.
The first study was published in late August in JAMA Network Open and examined the impact of Michigan’s Medicaid expansion on access to birth control and family planning services. Researchers surveyed more than 4,000 Medicaid enrollees, 1,166 being women ages 19 to 44 years old. Overall, more than 35 percent of those women reported increased access to family planning since gaining Medicaid coverage, with the most pronounced effects among women ages 19 to 34 years old and among women who had gone the previous year without coverage, which makes sense since access and coverage are intrinsically link. Researchers said more study is needed to see if those access gains are translating into better health indicators.
In the second family planning study, published in September in Health Affairs, researchers examined how California’s Medicaid expansion impacted access to contraceptive counseling and prescription birth control.
They used data from the California Health Interview Survey between 2013 and 2016, which included more than 4,500 women ages 18 to 44 with incomes less than 138 percent of the poverty level, the new eligibility threshold under the ACA’s Medicaid expansion (that’s about $34,000 for a family of four and about $16,000 for a single person). The study found that post-Medicaid expansion, the proportion of uninsured, low-income California women decreased significantly, while the number covered by Medicaid went up.
More specifically, between 2013 and 2016, the proportion of low-income, uninsured women dropped from 29 percent to 11 percent, while the share enrolled in Medi-Cal, California’s Medicaid program, went up from 37 percent to 67 percent. While the study found big jumps in coverage, it didn’t reveal similarly big changes in health care utilization, including family planning, during the study period. Overall, researchers found only small increases in low-income women reporting a usual source of care and the ability to get needed care without delay. They also found no significant difference in the use of health care or family planning services.
One data point that did get better was the percentage of women ages 18 to 34 who reported having a usual source of care, which went from 73 percent to 84 percent.
Researchers said a number of reasons could explain why higher coverage rates didn’t translate into more women getting family planning services. One reason could be that prior to the ACA, low-income, uninsured women in California already reported fewer unmet birth control needs than their peers in other states, likely due to California’s investments in publically funded family planning. There may also be a lag between higher rates of insured women and having enough clinicians who are well versed in providing family planning services. Another reason: having an insurance card is only one of the factors that determine a person’s ability to get health care.
“Although obtaining health insurance should increase access to health care, it does not make it easier to find transportation or child care or get time off work when health care is needed,” researchers wrote. “Therefore, insurance enrollment through ACA’s Medicaid expansion might not lead automatically to the use of health insurance for preventive family planning services.”
The third of today’s studies, also published in August in JAMA Network Open, found that Medicaid expansion states experienced a bigger decrease in uninsured hospitalizations for major cardiovascular events than states where lawmakers rejected Medicaid expansion. Cardiovascular disease is a top reason for U.S. medical expenditures, with direct medical costs expected to reach $1 trillion by 2030, more than half of which is related to hospital care.
To conduct the study, researchers used data from the Healthcare Cost and Utilization Project covering 30 states and hundreds of thousands of hospitalizations. Compared to non-expansion states, expansion states experienced a nearly 6-percentage point decrease in the proportion of uninsured hospitalizations in the year after expansion kicked in. Medicaid expansion did not seem to impact in-hospital mortality rates for such cardiovascular events — those rates remained the same in both expansion and non-expansion states throughout the study years.
“That Medicaid expansion was associated with a significant reduction in the proportion of uninsured hospitalizations may have had important out-of-pocket cost implications for low-income patients who would have been previously uninsured but now had access to Medicaid,” authors wrote.
The Trump administration continues its undermining of the ACA, slashing outreach and navigation funds for this year’s enrollment period and refusing to defend the ACA in a court case on whether the law is still constitutional after Trump repealed the individual mandate last year. To keep track of the administration’s ACA attacks, check out “Sabotage Watch” at the Center on Budget and Policy Priorities.
For copies of the new ACA studies, visit JAMA Network Open and Health Affairs.