Medicaid:

Access to Health Care for Low-Income Adults in States with and without Expanded Eligibility

GAO-18-607: Published: Sep 13, 2018. Publicly Released: Oct 15, 2018.

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Carolyn L. Yocom
(202) 512-7114
yocomc@gao.gov

 

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As of December 2017, 31 states and the District of Columbia have expanded access to Medicaid for low-income adults under the Patient Protection and Affordable Care Act. In 2017, these adults made up 20% of all Medicaid recipients.

We reviewed available survey results and found that low-income adults in states that expanded Medicaid generally reported better access to health care. For example, they were less likely to report having unmet medical needs (such as not being able to afford their prescriptions)—whether or not they were insured.

Percentage of low-income adults reporting unmet medical needs

Chart showing adults in expansion states reported fewer unmet needs, whether they had Medicaid, private insurance, or no insurance

Chart showing adults in expansion states reported fewer unmet needs, whether they had Medicaid, private insurance, or no insurance

Additional Materials:

Contact:

Carolyn L. Yocom
(202) 512-7114
yocomc@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

According to the 2016 National Health Interview Survey (NHIS), an estimated 5.6 million uninsured, low-income adults—those ages 19 through 64—had incomes at or below the income threshold for expanded Medicaid eligibility as allowed under the Patient Protection and Affordable Care Act (PPACA). Estimates from this nationally representative survey showed that about 1.9 million of the 5.6 million uninsured, low-income adults lived in states that chose to expand Medicaid under PPACA, while the remaining 3.7 million lived in non-expansion states—those that did not choose to expand Medicaid. In 2016, over half of uninsured, low-income adults were male, over half were employed, and over half had incomes less than 100 percent of the federal poverty level in both expansion and non-expansion states.

The 2016 NHIS estimates showed that low-income adults in expansion states were less likely to report having any unmet medical needs compared with those in non-expansion states, and low-income adults who were insured were less likely to report having unmet medical needs compared with those who were uninsured. Among the low-income adults who were uninsured, those in expansion states were less likely to report having any unmet medical needs compared with those in non-expansion states.

Low-Income Adults Who Reported Having Any Unmet Medical Need in Expansion and Non-Expansion States and by Insurance Status, 2016

Low-Income Adults Who Reported Having Any Unmet Medical Need in Expansion and Non-Expansion States and by Insurance Status, 2016

Notes: The difference between all low-income adults in expansion and non-expansion states was statistically significant at p < 0.05 (a common indictor that denotes statistical significance). The difference between low-income adults who were uninsured in expansion and non-expansion states was statistically significant at p < 0.05.

Differences between low-income adults who were uninsured in expansion or non-expansion states and low-income adults who were insured—Medicaid or private health insurance—in expansion or non-expansion states were statistically significant at p < 0.05.

The 2016 NHIS estimates also showed that low-income adults in expansion states were less likely to report financial barriers to needed medical care and other types of health care, such as specialty care, compared with those in non-expansion states, and low-income adults who were insured were less likely to report financial barriers to needed medical care compared with those who were uninsured.

Among low-income adults who were uninsured, those in expansion states were less likely to report financial barriers to needed medical care compared with those in non-expansion states.

Low-Income Adults Who Reported Financial Barriers to Needed Medical Care in Expansion and Non-Expansion States and by Insurance Status, 2016

Low-Income Adults Who Reported Having Any Unmet Medical Need in Expansion and Non-Expansion States and by Insurance Status, 2016

Notes: The difference between all low-income adults in expansion and non-expansion states was statistically significant at p < 0.05. The difference between low-income adults who were uninsured in expansion and non-expansion states was statistically significant at p < 0.05.

Differences between low-income adults who were uninsured in expansion or non-expansion states and low-income adults who were insured—Medicaid or private health insurance—in expansion or non-expansion states were statistically significant at p < 0.05.

Finally, the 2016 NHIS estimates showed that low-income adults in expansion states were more likely to report having a usual place of care to go when sick or needing advice about their health and receiving selected health care services compared with those in non-expansion states. The estimates also showed that low-income adults who were insured were generally more likely to report having a usual place of care and receiving selected health care services compared with those who were uninsured. Among the uninsured, relatively similar percentages of low-income adults in expansion and non-expansion states reported having a usual place of care. Similarly, estimates showed that relatively similar percentages of low-income adults who were uninsured in expansion and non-expansion states reported receiving selected health care services, such as receiving a flu vaccine or a blood pressure check.

Low-income Adults Who Reported Having a Usual Place of Care in Expansion and Non-Expansion States and by Insurance Status, 2016

Low-Income Adults Who Reported Having Any Unmet Medical Need in Expansion and Non-Expansion States and by Insurance Status, 2016

Notes: The difference between all low-income adults in expansion and non-expansion states was statistically significant at p < 0.05.

Differences between low-income adults who were uninsured in expansion or non-expansion states and low-income adults who were insured—Medicaid or private health insurance—in expansion or non-expansion states were statistically significant at p < 0.05.

Why GAO Did This Study

Under PPACA, states could choose to expand Medicaid coverage to certain uninsured, low-income adults. As of December 2017, 31 states and the District of Columbia chose to expand Medicaid to cover these adults, and 19 states did not.

GAO was asked to provide information about the demographic characteristics of and access to health care services for low-income adults—those with household incomes less than or equal to 138 percent of the federal poverty level—in expansion and non-expansion states. This report describes 2016 national survey estimates of (1) the number and demographic characteristics for low-income adults who were uninsured in expansion and non-expansion states, (2) unmet medical needs for low-income adults in expansion and non-expansion states and by insurance status, (3) barriers to health care for low-income adults in expansion and non-expansion states and by insurance status, and (4) having a usual place of care and receiving selected health care services for low-income adults in expansion and non-expansion states and by insurance status.

GAO obtained 2016 NHIS estimates from the National Center for Health Statistics (NCHS), the federal agency within the Department of Health and Human Services that maintains these survey data.

NHIS is a household interview survey designed to be a nationally representative sample of the civilian, non-institutionalized population residing in the United States. Estimates were calculated for demographic characteristics for uninsured, low-income adults. In addition, estimates were calculated for unmet medical needs, barriers to health care, and having a usual place of care and receiving selected health services for low-income adults in expansion and non-expansion states and by insurance status The estimates were based on responses to selected survey questions. GAO selected these survey questions from the Family and Adult Access to Health Care and Utilization and another section of the 2016 NHIS.

GAO took steps to assess the reliability of the 2016 NHIS estimates, including interviewing NCHS officials and examining the data for logical errors. GAO determined that the data were sufficiently reliable for the purposes of its analyses.

The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.

For more information, contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov.

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