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Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance

people health insurance


Researchers surveyed nearly 9,000 low-income adults in three states that made different choices with respect to Medicaid expansion: Kentucky, which expanded Medicaid eligibility to include more low-income adults; Arkansas, which used federal funding to purchase private plans for low-income adults; and Texas, which chose not to expand Medicaid at all. By 2015, two years after coverage expansion, low-income adults in Kentucky and Arkansas received more primary and preventive care, visited emergency departments less often, and reported better health than their counterparts in Texas.

The Issue

Medicaid expansion under the Affordable Care Act has led to well-documented gains in coverage in many states, but less is known about how it has affected beneficiaries’ use of health care services and their health status. This Commonwealth Fund–supported study explored the impact on residents in three Southern states—each with high poverty rates and high baseline uninsured rates but differing responses to the Medicaid expansion.

Key Findings

  • Between 2013 and 2015, there were dramatic drops in the uninsured rates in both Arkansas (41.8% to 14.2%) and Kentucky (40.2% to 8.6%), but much smaller changes in Texas (38.5% to 31.8%).
  • In Arkansas and Kentucky, having coverage was associated with a significant increase in the likelihood of having a personal physician (12.1 percentage points) and a decreased reliance on the emergency department as a usual source of care (–6.1 points).
  • Expanded coverage also was associated with fewer delays obtaining care because of cost (–18.2 points), fewer skipped prescriptions (–11.6 points), and less difficulty paying medical bills (–14.0 points). Annual out-of-pocket medical spending dropped by 29.5 percent.
  • Expanded coverage in the two states also led to an increased likelihood of having a checkup (16.1 points) and a glucose check (6.3 points) in the past year. Diabetics had an increased likelihood of glucose monitoring (10.7 points).
  • Compared with Texas, the share of adults receiving regular care for chronic conditions increased 12.0 points, the share of adults reporting fair or poor quality of care declined 7.1 points, and the proportion reporting excellent health increased 4.8 points.
  • Arkansas’ coverage gains were primarily through private insurance, and Kentucky’s were through Medicaid. While changes in glucose monitoring were larger in Kentucky than in Arkansas, none of the other 26 outcomes differed significantly between the two states.

For other states still considering whether to expand, our study suggests that coverage expansion under the ACA — whether via Medicaid or private coverage — can produce substantial benefits for low-income populations.

The Big Picture

This study provides evidence that could inform state debates over whether and how to expand health insurance coverage to low-income adults. Earlier research may have underestimated the effects of expanded coverage, the authors say: it takes time to see the impact on use of services and, especially, health status. By 2015, two years after the coverage expansion in Kentucky and Arkansas, the surveys found marked increases in the use of preventive care, checkups, and chronic disease care and reduced reliance on emergency departments that were not evident in 2014. Notably, survey respondents also reported modest improvements in health. There appear to be few differences in outcomes for beneficiaries insured through public or private insurance, including no significant difference in their access to primary or specialty care.

About the Study

The researchers surveyed U.S. adults with family incomes below 138 percent of the federal poverty level (about $16,000 annually for an individual or $33,000 for a family of four) in November and December of 2013, 2014, and 2015 to evaluate changes in health insurance, service utilization, preventive care, and self-reported health. About 1,000 individuals were surveyed each year in each of the states, with no one individual surveyed in more than one year.

The Bottom Line

Low-income adults in Kentucky and Arkansas, with coverage through Medicaid and private insurance, received more primary and preventive care, made fewer emergency department visits, and reported better quality of care and better health than low-income adults in Texas, which did not expand Medicaid.

Publication Details



Benjamin D. Sommers, Professor of Health Policy and Economics, Harvard T.H. Chan School of Public Health

[email protected]


Benjamin D. Sommers et al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine, published online Aug. 8, 2016.