How the Affordable Care Act (ACA) and Medicaid Expansion Impacted Access, Cost, & Quality of Care & Population Health for Newly Eligible Non-Elderly Adults

How the Affordable Care Act (ACA) and Medicaid
Expansion Impacted Access, Cost, & Quality of Care &
Population Health for Newly Eligible Non-Elderly Adults
HLTHCOMM 410: Fall 2017-The U.S. Healthcare System
Chelsea Dade
2018 Master of Science Candidate in Health Communication
Northwestern University

Medicaid Expansion To Non-Elderly Adults
The creation of the Patient Protection and Affordable Care Act (ACA) in 2010 and its initiation in 2014 contributed to
better access, quality, and cost of healthcare for many Americans. The act also impacted population health. A defining
piece of this law was the expansion of Medicaid coverage to individuals with incomes ≤133 percent of the Federal
Poverty Level (FPL). Prior to the ACA, Medicaid only covered specific categories of people, including children 18 and
under, their caretakers, pregnant women, and some elderly and disabled individuals. This inadvertently placed some
low-income, non-elderly adults, ages 19-64, in a coverage gap. By changing the minimum income eligibility to ≤133%
FPL, and expanding covered groups, it made it easier for the patient population of childless, non-elderly U.S adults in
expanded states to become insured.

Goal For This Paper Presentation
This paper focuses on how the ACA Medicaid expansion impacted access, quality, and cost of care, as well as
population health, for the newly eligible group of non-elderly adults. Even with Medicaid expansion, increased access
to care did not necessarily contribute to better quality of care. This situation is seen in the 2008 Oregon Experiment by
Baicker et al. (2013), and in a study by Sommers, Blendon, Orav, and Epstein (2016). The following examination of the
literature on the strengths and weaknesses of access, quality, cost of care, and population health, before and after the
ACA, shows the benefits and areas of improvement of Medicaid expansion for the non-elderly adult population.

Overview of Medicaid Expansion & Early Results
Medicaid expansion impacted access, quality, and cost of care of insurance for individuals with incomes ≤133% FPL. In
general, it improved population health for non-elderly and childless adults in expanded states. Prior to the ACA, many
of these adults were uninsured. Even though Medicaid expansion is a relatively new initiative, some early
improvements in access, quality of care, and cost have already begun to show. In one study by Tipirneni et al. (2015),
access to primary care appointments for new Medicaid recipients increased following expansion in Michigan. In
another study by Hu, Kaestner, Mazumder, Miller, and Wong (2016), Medicaid expansion reduced the amount of
unpaid bills among previously uninsured, low-income individuals.

Overview of Medicaid Expansion & Early Results (cont.)
Another study reported that uninsured rates for non-elderly adults were significantly reduced and Medicaid coverage
increased in expanded states versus non-expanded states after two years (Miller & Wherry, 2017, p. 947). Still, this did
not change appointment wait times for new Medicaid recipients. Changes in access, quality, and cost of care directly
influence population health. Improvements in adult population health can help improve Medicaid in general. These are
some examples of the early results and room for improvement of Medicaid expansion.

Pre-ACA: Prior Deficiencies in
Access To Care for Non-Elderly
Adults

Pre-ACA: Deficiencies In Access To Care
Prior to the ACA, non-elderly adults were uninsured for various reasons. Many were not eligible for coverage based on
their income alone, and the high costs of private insurance deterred many adults from getting covered. Once an
individual became insured through Medicaid, access to care was not necessarily guaranteed. Access to care is defined
as the timely use of services to achieve the best possible outcomes (Millman, 1993, p. 4). There are various barriers to
receiving prompt care, from transportation issues to timeliness problems.

Pre-ACA: Deficiencies In Access To Care (cont.)
The first deficiency in access to care comes from a 2001 study that compared the differences in access and utilization
of care between women with varying insurance (Almeida, Dubay, & Kao, 2001, p. 29). After comparing multiple health
care measures, the study found that Medicaid covered non-pregnant women ages 18-64, faired comparably to
privately insured women of the same cohort, except for dental coverage. 69 percent of privately covered women
reported having a dental visit within the past year, followed by 58.4 percent of Medicaid covered women, and only 39.3
percent of uninsured women (Almeida et al., 2001, p. 36). These health disparities between insurance groups are an
example of how care was unequal prior to the ACA.

Pre-ACA: Deficiencies In Access To Care (cont.)
Accessibility and acceptability are alternative measures used to determine access to care. A retrospective study by
Kullgren, McLaughlin, Mitra, and Armstrong (2012) showed how prior to the ACA, two-thirds of low-income adults
would often delay their care due to non-financial constraints (p. 462). Adult Medicaid enrollees reported the highest
rates of access issues, especially in accessibility and acceptability. Accessibility refers to the difficulty a person faces
getting to their care facilities or finding an appointment. Acceptability refers to the types of plans a health provider or
specialist will take. According to a 2013 Survey by the Kaiser Family Foundation (KFF), 35% of non-elderly women ages
18-64 on Medicaid reported going without care due to cost-related barriers (Salganicoff, Ranji, Beamesderfer, &
Kurani, 2014, p. 15). As seen in the Oregon Experiment, expanded Medicaid coverage does not completely reduce
other barriers to care, such as geographic barriers or timeliness of care delivery. This represents the fine line between
access to care and quality of care.
Accessibility and Acceptability in Healthcare

Pre-ACA: Prior Deficiencies in Quality of
Care for Non-Elderly Adults

Pre-ACA: Prior Deficiencies in Quality of Care
As previously stated, access to care is defined as the proper use of health services to help people achieve the right
care, at the right time. On the contrary, quality of care is described as the care processes, including the overuse,
underuse, and misuse of health services. In this way, it is through quality of care that healthcare providers can make
strides to improve patient outcomes. High quality care is defined as care that increases the likelihood of beneficial
health outcomes (Chassin & Galvin, 1998, p. 1001). Sometimes, even with the best quality measures, patient outcomes
are not guaranteed.
Access To Care vs. Quality of Care

Pre-ACA: Prior Deficiencies in Quality of Care (cont.)
The 2008 Oregon Experiment by Baicker et al. (2013) shows the importance of balance between access and quality of
care. After a 2-year surveillance period, researchers found that Medicaid had no significant effects on patient
outcomes, like cholesterol levels, on non-elderly adults in Oregon. Greater access to care improved the chance of an
adult having a depression or diabetes diagnosis. The expansion improved self-reported health and increased
utilization of health services, such as doctors’ visits. However, it did not significantly improve the health quality for
those in the study.
Access To Care vs. Quality of Care

A two-year study by Sommers et al. (2016) compared coverage gains between Medicaid and privately insured
individuals ages 19-64 in three states. Arkansas adopted an expanded Medicaid private insurance option, Kentucky used
traditional Medicaid, and Texas did not expand. As expected, the greatest gains in Medicaid coverage and lowest
numbers of uninsured persons were seen in Kentucky, then Arkansas, and finally Texas. Measurements that fell under
the tier of clinical interventions that improved access were having a primary physician and regular care for chronic
conditions, like diabetes. With regard to patient outcomes, this study is similar to the Baicker paper in that they did not
significantly improve with Medicaid coverage. In short, access helped insure low-income adults, but it did not guarantee
patient outcomes. As previously stated, access to care does not guarantee quality of care. This finding is also seen in
McGlynn et al. (2003). They found that non-elderly adults only received about half of the recommended levels of care.
This figure is not much better for the target population of non-elderly adults Medicaid enrollees who are also people of
color.
Private Insurance vs. Medicaid Expansion

One study, by Horvitz-Lennon et al. (2014), examined the quality of care for Medicaid enrollees with schizophrenia
residing in California, Florida, New York, and North Carolina after Medicaid expansion. The quality of care measures
they used to evaluate underuse were the receipt of routine services, and follow up after care. After examining the
racial demographics against the quality of care, they observed that care for schizophrenia was severely underused
depending on the race of the participants. Though all participants in the study had access to Medicaid, there were
significantly poorer qualities of care for schizophrenia for minority groups, especially for Blacks and Latinos. Each
state’s mental health spending was budgeted similarly, but the dispersal of resources was unbalanced among
demographics within states.
Health Care and Social Determinants of Health

This study represents how underuse in the quality of care interacts with the social determinants of health. These are
societal factors such as poverty and discrimination that are inherently tied to health outcomes. They explain the
underuse discrepancies seen among people of color. For example, in all four states, Blacks had the lowest quality of
care. The disparities between Blacks and Whites were smaller in liberal states like California and New York. Therefore,
in this study, the underuse of services might be based on the political ideologies and discrimination practices in health
care. In this scenario, mental health resources were available, but were not allocated equally based on racial
differences. This research points to the importance of improving quality of care by reducing the underuse of important
services, as well as pushing health care towards health equity and the eradication of health disparities.
Health Care and Social Determinants of Health

Immunizations are another underused service for non-elderly adults. Prior to the ACA, low-income adults often had
difficulty obtaining immunizations for free. According to the CDC, in 2009, the adult vaccination rate was approximately
40% (“Flu Vaccination Coverage”, 2016). States determine whether or not adult immunizations are free for adults, as
they typically only cover children 18 and under for free. Thus, immunizations are seldom offered for free to adults. The
underuse of primary care services, like immunizations, were seen in a study by Levine, Linder, & Landon (2016).
According to Levine, one reason why vaccinations and other primary care services were underused prior to the ACA
and Medicaid expansion is because the U.S has traditionally underinvested in primary care, especially for non-elderly
adults.
Underuse of Immunizations

Pre-ACA: Prior Deficiencies in the Cost
of Care for Non-Elderly Adults

Pre-ACA: Cost of Care for Non-Elderly Adults
The Medicaid Oregon Health Plan (OHP), created in 1989, provides a better picture of health care costs on the target
population prior to the ACA. Cost sharing was used before Medicaid expansion to reduce state health care costs. The
Medicaid plan expanded health care coverage to childless adults up to 100 percent FPL. Six months following its
implementation, measures, like insurance coverage, were collected. Following the first year of enrollment in 1994, the
uninsured rate fell from 18 percent to 10 percent in 1998 (Wright et al., 2005, p.1107).
Impacts of Cost-Sharing

Nonetheless, expanding access to care is not free. A subset of the Oregon Health Plan, the OHP Standard, was later
added for “expanded eligibility” groups, such as non-elderly adults, which provided a slimmer benefit package with
increased cost sharing. As expected, both copays and premiums went up for this target population. Ultimately,
participation in the OHP Standard Plan fell, with enrollees reporting inferior access to care and immeasurable health
care costs. These findings suggest that states who choose to increase cost sharing to save state Medicaid programs
may actually cause more the poorest adults to lose insurance coverage altogether.
Pre-ACA: Cost of Care for Non-Elderly Adults
Impacts of Cost-Sharing

Similar to the cost sharing issue in the Oregon Health Plan, in the RAND Experiment, the relationship between
expanded access to care and health care costs is not always harmonious. The main finding that the researchers found
in the 1982 study was that cost-sharing increases caused both non-poor and low-income people to use less health
care services (Lohr et al., 1986, p. 30). The main moral hazard effect was that cost sharing groups, as opposed to free
care groups, spent less on their healthcare. In terms of the non-elderly adult population, use of care services
decreased with increased cost sharing for both poor and non-poor adults.
Impacts of Cost-Sharing: The RAND Experiment

In a review of the RAND Experiment by Brook et al. (2006), poor adults were found to have the lowest probabilities of
episodes of care. When non-elderly adults did have access to free care, or Medicaid, it had the highest rates “rarely
effective” care in comparison to cost sharing groups of adults (Brook et al., 2006, p. 4). While these adults were
receiving care at a low cost, the quality was substandard. In this way, more work needs to be done through Medicaid
Expansion by improving the quality of low cost care that Medicaid recipients often receive.
Impacts of Cost-Sharing: The RAND Experiment

Post-ACA: Impacts On Access To Care,
Quality of Care, and Cost of Care for
Non-Elderly Adults

Post-ACA: Impacts On Access To Care
for Non-Elderly Adults

Post-ACA: Potential Impacts For Access To Care
Prior deficiencies in access to care, quality of care, and costs, prior to the ACA have been pointed out. The following
summaries represent potential impacts of the ACA Medicaid expansion on access, quality and cost of care for low-
income, non-elderly adults. In general, Medicaid expansion increased the access to primary care services. This was
accomplished by the mandate for state Medicaid programs to provide preventative health services recommended by
the U.S Preventive Services Task Force. The services included in this mandate that are most beneficial to the newly
eligible group include well-woman check-ups, adult cancer screenings, and family planning options. Dental care
coverage is another access measure that improved under Medicaid Expansion. A study by Decker and Lipton (2015)
focused on the aftereffects of Medicaid expansion on dental coverage for adults ages 21-54 across the U.S. They
found an increased likelihood of having a dental appointment within the past 6 months or year for adult Medicaid
enrollees after Medicaid expansion (Decker & Lipton, 2015, p. 224).

Post-ACA: Changes in Access and Use of Primary Care
For Non-Elderly Adults
Another way to demonstrate how access to care improved for the newly eligible group involves the examination of
accessibility of primary care. Researchers Starfield, Shi and Macinko (2005), defined good primary care as first-
contact access for each new need; long term person- (not disease) focused care; comprehensive care for most health
needs; and coordinated care when it must be sought elsewhere (Starfield, Shi, & Macinko, 2005, p. 458). Prior to
expansion, access to primary care was not always consistent due to the lack of primary care physicians in the medical
community. The researchers pointed out the importance of a consistent and even amount of primary care doctors, in
order to provide a regular source of care for the adult Medicaid population. For low-income adults of color, such as
African Americans, access to a regular primary doctor eliminated the impact of income inequality (Starfield et al., 2005,
p. 470). In addition, patients with a general physician experienced lower health care costs than others without a general
physician (Bodenheimer, Berenson, & Rudolf, 2007, p. 304).

Post-ACA: Changes in Access and Use of Primary Care
For Non-Elderly Adults
Medicaid expansion has begun to address this issue. In a study by Polsky et al. (2015), 10 expanded states were tested
for their ability to improve accessibility and acceptability of primary care appointments for adult Medicaid enrollees.
They found that increases in Medicaid reimbursements through Medicaid expansion were associated with an average
58.7 percent to 66.4% percent increase in availability of new-patient appointments among all 10 states (Polsky et al.,
2015, p. 527). Low cost primary care is a critical health measure for low-income non-elderly adults who are solely
dependent on providers who accept Medicaid. In this way, Medicaid expansion must also address non-financial
barriers to care, such as continuity of primary care.

Post-ACA: Impacts On Quality Of Care
for Non-Elderly Adults

The first impact on quality of care from Medicaid expansion is a mandate to cover immunizations at no cost for non-
elderly adults in expanded states. Non-expanded states still have the option to charge adult Medicaid recipients based
on the types of immunizations. However, in 2015, the rate of adult immunizations increased from roughly 40 percent in
2009 to 43.6 percent (“Flu Vaccination Coverage”, 2016). Coverage among adults increased with age, as the highest
rate of vaccination in the 18-64 groups was within the 50-64 age range. Immunizations are critical as they prevent
chronic and fatal infectious diseases.
Mandates on Providing Primary Prevention Services: Immunizations

An additional way that quality of care was improved with Medicaid expansion was through mandates on mental health
services. Mental health services are still an underused care process for all insurance groups, but prior to the ACA, they
were rarely provided for free to adult Medicaid enrollees. The ACA added a new requirement, the 10 Essential
Benefits, to standard primary care. They are now required items in Medicaid expanded states. The benefits include
coverage of mental health and substance abuse disorders. These essential benefits are crucial for reducing underuse
and establishing equity amongst primary care services in health care coverage for low-income adults.
Mandates on Primary Preventive Services: Mental Health Services

Post-ACA: Impacts on The Cost of
Care for Non-Elderly Adults

Post-ACA: Impacts on The Cost of Care
According to recent data from the Kaiser Family Foundation, the top 50 percent of the population with the lowest
incomes represent roughly 97 percent of the U.S healthcare costs. Costs are still driven by “super-users” of care
(“Health Care Costs”, 2012, p. 8). Many of these individuals are low-income adult Medicaid recipients. When cost
sharing comes in the picture, it places the most vulnerable populations at risk. According to Remler and Greene
(2009), cost sharing is most useful if it does four things (p. 296). First, it reduces harmful, non-effective care. Second,
cost-sharing that doesn’t decrease cost-effective care. Third, cost sharing is useful if it doesn’t cause an increase of
financial harm. Lastly, cost sharing is useful if it does not create other harmful side effects.

Post-ACA: Impacts on The Cost of Care
Similar to the findings in the RAND experiment on private insurance, a review by Saloner, Sabik, & Sommers (2014),
showed that with Medicaid expansion, Medicaid cost sharing among low-income adults typically results in the
underuse of important care and the overuse of unnecessary care. A poor adult may not be able to afford the extra
cost, which could result in an underuse of preventative services. Medicaid expansion does address this need by
mandating coverage of preventive services for Medicaid recipients, like breast cancer screenings for non-elderly adult
women, without cost sharing. Still, this mandate does not apply to all services, such as adult dental care.

Post-ACA: Impacts On The Cost of Care
Notably, when Medicaid expanded in participating states to non-elderly adults, the patient demand for health care
increased. According to Kaiser Family Foundation (2016), the number of uninsured non-elderly adults decreased
from 40 million before the ACA in 2013, to 25 million in 2015 after the ACA. As of 2016, Medicaid enrollment grew by
over 15 million since 2013 (“The Uninsured”, 2016). Most gains were found among low-income people of color,
especially Hispanics and Blacks. However, this demand for care from non-elderly adults is dependent on costs and
cost sharing.
ACA Medicaid Expansion and Changes in Patient Demand for Health Care

The RAND Study showed that increased cost sharing decreases low-income adults’ use of services through private
insurance. In another study by Guy Jr. (2010), Medicaid expansion, regardless of cost sharing, reduced uninsured rates
among non-elderly, childless adults. Cost sharing did not affect use of physician services, but it did play a large part in
the use of preventative services. Within expanded Medicaid states with traditional Medicaid cost sharing, the use of
preventative services significantly increased. Within non-expanded with increased cost sharing, the use of
preventative services remained neutral. These findings show that in terms of patient demand, overall, a lower cost
share burden will cause more non-elderly adults to increase their use of preventative health care services.
ACA Medicaid Expansion and Changes in Patient Demand for Health Care

One of the many goals of the ACA Medicaid expansion was to increase shared decision making between patients,
insurers, and providers. Providers make the majority of resource spending decisions, and they determine the standard
costs of care. While patients determine the episodes of care by seeking services, it is up to the providers to decide the
costs per episode of care. This is why in the RAND review by Brook et al. (2006), there was no significant difference in
costs per episode between the free care and coinsurance groups for poor and non-poor adults.
ACA Medicaid Expansion and Changes in Provider Decision Making

According to a study by Dieleman et al. (2017), the majority of rising national health care costs were largely related to
increased health care service price and intensity in five factors. These factors, including ambulatory care, inpatient
care, prescribed retail pharmaceuticals, nursing facility care, and emergency care, were associated with a $9333.5
billion increase in annual U.S. health care spending between 1996 and 2013 (Dieleman, 2017, p. 1675). Prices and
intensity of health care services were more responsible for rising costs than was health care service utilization. Health
care service prices on emergency care and dental care were the largest spending areas for non-elderly adults under
ages 65. In short, this study shows that while patient demand determines the use of care, health care costs determined
solely by providers and market trends are better predictors of national health care spending.

While the provider is the ultimate decider of care, too much provider control can lead to overuse, underuse, or misuse
of health care services, as previously noted in this paper. This could lead to unnecessary health care spending.
According to Oshima Lee & Emanuel (2013), decision aids, first created in the 1960s, are a hidden solution of the ACA
Medicaid expansion. Section 3506 under the ACA calls for states to consider certifying for these aides, primarily for
recipients of federal health programs like Medicaid. Decision aids are written and visual materials to help inform a
patient about their care, side effects, and costs. These guides would prove especially beneficial to Medicaid insured
adults, who tend to have lower levels of education and health literacy than privately insured adults (U.S. Department
of Education, 2006, p.12).

The ACA, Medicaid Expansion &
Population Health

The ACA, Medicaid Expansion & Population Health
In addition to impacting access, quality, and cost of care, population health was affected by Medicaid expansion.
Population health is defined as the distribution of health outcomes within a group of people (Kindig, 2003, p.1).
Achieving population health through preventative efforts is not easy. There is little financial incentive for the
government to support prevention because the results take time to show up. Medicaid expansion has assisted in this
challenge. Thomas Frieden’s Five Tiers of Population Impact Pyramid (2010) can be used to examine population health
changes before and after Medicaid expansion. The five tiers of Frieden’s pyramid from the bottom up include
socioeconomic factors, changing the context to make individuals’ default decisions healthy, long-lasting protective
interventions, clinical interventions, and counseling and education.
The Frieden Pyramid: How Does the ACA Improve Population Health?

Medicaid expansion meets the first tier of the pyramid by expanding health insurance for low socioeconomic status,
non-elderly adults with income ≤133%. Many of the uninsured prior to the ACA Medicaid were low-income,
marginalized adults of color. By opening up access to more low-income adults, Medicaid expansion works against
economic barriers to getting healthcare. Medicaid expansion does not directly change the contextual setting
adjustment that Frieden’s pyramid includes. However, it does directly improve equity in health care by minimizing low-
income status as barrier to care. Medicaid expansion does meet the third tier of the pyramid, as it improves access to
long-lasting clinical interventions for non-elderly adults, such as breast cancer screenings. Under recommendation by
the United States Preventive Services Task Force (USPSTF), they became mandatory covered services for women in
the age group of 50-75 (Wyatt, Pernekil, & Akinyemiju, 2017, p. 239).

Expansion of Medicaid for non-elderly adults meets the fourth tier of the pyramid, as regular primary medical care is
considered a clinical intervention. Taking medications for heart conditions falls under this category. While Medicaid
expansion increases access to care and a provider, the fourth tier is also heavily influenced by a patient’s personal
accountability to follow suggestions given by providers. The top tier of Frieden’s pyramid refers to counseling and
education services. Expansion meets this tier by mandating behavioral health counseling for mental health and
substance use disorder, and for chronic disease management education through the new 10 Essential Health Benefits
(EHBs) in the form of Medicaid Alternative Benefit Plans (ABPs). Medicaid expansion also meets this tier as states that
expanded their Medicaid programs are required provide all 10 benefits.

Researchers Berwick, Nolan, and Whittington (2008) suggest that the way to improve population health is through a
triple aim in health care: care, health, and cost. In certain ways, maximizing population health through quality of care is
connected to Frieden’s pyramid. By improving access to care for high risk, low-income adults through Medicaid
expansion, quality of care is improved, unnecessary costs are reduced, and population health can be improved. In their
study, the researchers cite the six dimensions of quality that need to be meet in order to improve care. These are
safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. While there is room for improvement in
terms of timeliness and effectiveness of care, Medicaid expansion does meet the triple aim Berwick and colleagues
call for.
The Triple Aim: To Improve the Patient Experience of Care, Population Health, and
Reduce Per Capita Cost

First, Medicaid expansion improves quality of care by reducing the underuse of immunizations and cancer screenings
for non-elderly adults. In this way, the third and fourth levels of the pyramid are met. Second, Medicaid expansion
improves the health of populations by factoring in the health of the non-elderly adult population into the broader
mission of health equity. In this way, the first and second levels of the pyramid are met. The researchers write that in
order to meet the three-aim mission, the health in one group, such as the elderly population, should not be achieved
at the expense of the health of younger adults. In short, health equity must be achieved at all ages to improve overall
population health. In this way, the third level of the pyramid is met. Last, Medicaid expansion meets the top tier of the
pyramid by offering necessary health education services, like diabetes management, for free or at a low cost for non-
elderly adults, which reduces the underuse of services by Medicaid recipients.
The Triple Aim: To Improve the Patient Experience of Care, Population Health, and Reduce Per
Capita Cost

In addition, Medicaid expansion could improve population health if new quality of care measures were created to
evaluate the delivery and use of care through Medicaid. This might include using technological innovations to monitor
care (Kantar et al., 2013, p.486). Such complete care innovations, like cancer screening effectiveness, are typically
applied to private insurance. However, they have the potential to improve the evaluation of Medicaid that low-income,
non-elderly adults receive. Prevention is the underlying factor that promotes population health, and it can be
accomplished if Medicaid expansion keeps care innovation and this triple aim of quality of care in focus.
The Triple Aim: To Improve the Patient Experience of Care, Population Health, and
Reduce Per Capita Cost

Closing Thoughts on the Impact of The ACA for the
Newly Eligible Group of Non-Elderly Adults
There are still some unknown aspects to Medicaid expansion. As expected, the more individuals that are given free or
low cost care through ACA’s Medicaid expansion, federal spending on Medicaid will increase. Medicaid expansion
might also negatively affect non-elderly adults willingness to work. Due to the fact that they are now receiving more
free health care services, able-bodied adults might choose to live idly and collect their benefits. It was found in a study
conducted in Michigan, researchers Ayanian, Ehrlich, Grimes, & Levy (2017) that Medicaid coverage lead to some
individuals who currently received employer-sponsored health insurance to work less (p. 409). This is one unintended
consequence of Medicaid expansion.
Medicaid Work Requirements

Another thing that remains unknown is the effect of societal stigma associated with receiving federal assistance,
especially for non-elderly, able-bodied adults. In a study by Stuber and Kronebusch (2004), the negative attitudes
coupled with public insurance actually reduced Medicaid enrollment among low-income adults. In this way, Medicaid
work requirements are one next step that is being considered to encourage able-bodied Medicaid recipients to work
while still receiving benefits (“Medicaid and Work Requirements,” 2017).
Medicaid Work Requirements

The ACA’s Medicaid expansion changed the framework of healthcare in the United States by impacting access,
quality, and cost of care, while also enhancing population health for Americans. Some of these changes specifically
improved the health of low-income, non-elderly adults. Improvements in immunization and mental health coverage
are only a selection of examples of care improvements for the newly eligible group. Still, as seen in the Baicker and
Sommers papers, improved access to health insurance does not always correlate with improved quality of care,
patient outcomes, or lower cost of care. Financial barriers and the social determinants of health are two external
factors that affect health outcomes. The ACA Medicaid expansion worked to reduce health disparities by removing
many cost related barriers to care for low-income adults. Nonetheless, in order to ensure health equity, a combination
of expanded health care access and quality improvements must be coupled with strategies to reduce cost barriers
and social determinants of health.

References
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