So often when we implement new policy, I wish we had better ways to capture its effects so we could expand our knowledge base as to how our decisions change health and healthcare. The Oregon Health Insurance experiment, and its older brother, the Rand Health Insurance experiment, were randomized controlled trials designed to look at how insurance affected utilization in health. While these were impressive studies, they had their flaws.

RCTs are hard to do, though, and they're really expensive. Some times, other designs are necessary. Recently in Annals of Internal Medicine Laura Wherry and Sarah Miller looked at how the Medicaid expansion has changed things. Let's discuss. This is Healthcare Triage News.

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To the research! Early Coverage, Access, Utilization, and Health Effects Associated With the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study. 

As we've discussed many, many times before, only about half of states initially decided to join the Medicaid expansion. This meant that in those states, anyone making less than 138% of the federal poverty line could get Medicaid. In other states, many poor people were out of luck. The law provided no subsidies to people earning less than the poverty line. And without new Medicaid, many had no affordable options for insurance.

This study sought to compare how adults who would qualify for the expansion compared to those in states with and without out. The researchers used data from the 2010 and 2014 National Health Interview Surveys to compare health insurance coverage, utilization, diagnosis of some illnesses, self-reported health, and depression.

They used a quasi-experimental difference-in-difference design to compensate for secular changes as well as time-invariant differences in characteristics across states. They excluded five states that already pretty much provided expansion-like coverage before 2014. 

They found that by the second half of 2014, adults in the expansion states had seen their health insurance coverage increase 7.4%; Medicaid coverage increased 10.5%. That's not surprising, as increased coverage was the main intent of the Afforable Care Act. Coverage was found to have improved as well (7.1% of the time). They also found that in Medicaid expansion states, there are increases in physician visits (6.6%), hospital stays (2.4%), rates of diagnoses of diabetes (5.2%) and of high cholesterol (5.7%).

Of course, this is an observational study. It's possible that other confounders exist that are the reasons for these changes. These are also very short-term data. They also couldn't find real differences in terms of access. 

But, as we've discussed many, many times before, insurance coverage is just the first step in improving access. What this studies adds are some data showing that expanding Medicaid through the ACA resulted in increased coverage, improved coverage, more physician visits, and more diseases diagnosed.

It will be important for us to continue these types of studies as we move forward to understand better the full impact of the Affordable Care Act. But, if future analyses continue to show improvements in coverage, utilization, and, perhaps heath from the Medicaid expansion, it may become more difficult for the 19 remaining states to refuse it without offering alternative paths to the same achievements.

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