Report: The Importance of Health Coverage

Today, approximately 90 percent of U.S. residents have health insurance with significant gains in health coverage occuring over the past five years. Health insurance facilitates access to care and is associated with lower death rates, better health outcomes, and improved productivity. Despite recent gains, more than 28 million individuals still lack coverage, putting their physical, mental, and financial health at risk.

Meaningful health care coverage is critical to living a productive, secure and healthy life. U.S. residents obtain health coverage from a variety of private and public sources, such as through their employers or direct purchase on the individual market (private sources), as well as through the Medicare, Medicaid, or Veterans Affairs programs (public sources).

The number of people with health insurance has increased significantly in recent years, with nearly 20 million individuals newly insured. Most of these individuals were able to enroll in coverage offered through the Medicaid program, their employer, or the individual market as a result of coverage programs and insurance market reforms authorized by the Affordable Care Act (ACA).

Impact of Coverage

Enrollment in coverage supports the health and well-being of individuals and communities. Studies confirm that coverage improves access to care; supports positive health outcomes, including an individual’s sense of their own health and well-being; incentivizes appropriate use of health care resources; and reduces financial strain on individuals, families and communities. A list of resources can be found on page 4.

In particular, recent studies that evaluated changes in states that expanded Medicaid compared to those that didn’t underscore the value of coverage.¹

Coverage Improves Access to Care

• Adult Medicaid enrollees are five times more likely to have regular sources of care and four times more likely to receive preventative care services than individuals without coverage. Children with Medicaid coverage are four times more likely to have regular sources of care and two to three times more likely to receive preventative care services than uninsured children.² In addition, low-income children with parents covered by Medicaid are more likely to receive well-child visits than those with uninsured parents.³
• A higher proportion of individuals in Medicaid expansion states have a personal doctor than those in nonexpansion states.⁴
• Individuals with coverage are more likely to obtain access to prescription drug therapies. Individuals in states that expanded Medicaid have improved access to diabetes and asthma medications, contraceptives, and cardiovascular drugs.^5,6,7
• Individuals with coverage are more likely to obtain an early diagnosis and treatment, which may ultimately contribute to improved health outcomes.⁸
  • Individuals in Medicaid expansion states have higher rates of diabetes diagnoses than those in states that did not expand.⁹
  • They receive more timely, and therefore less complicated, care for five common surgical conditions.¹⁰
  • Medicaid expansion is associated with access to timely cancer diagnoses and treatment.^{11,12,13,14,15}
• Coverage improves access to behavioral health and substance use disorder treatment.¹⁶
  • Young adults with mental illness who have coverage have a higher rate of monthly outpatient mental health visits than those without coverage.¹⁷
• In Ohio, individuals who become eligible for and enrolled in Medicaid reported better access to mental health services after enrollment,¹⁸ and in Connecticut, one third of Medicaid expansion enrollees use their coverage for care related to mental health and substance use disorder.¹⁹
• Coverage is critical to efforts to fight the opioid epidemic.²⁰ In West Virginia, Medicaid expansion increased access to opioid use disorder (OUD) treatment. By 2016, 75% of Medicaid enrollees with OUD filled prescriptions for medication treatment.²¹
• Coverage diminishes cost barriers to accessing care. Fewer individuals in states that expanded Medicaid report cost as a barrier to care than those in states that did not expand Medicaid,²² and fewer individuals in expansion states report skipping their medications because of cost.²³ In rural areas specifically, individuals were 8% less likely to report cost as a barrier to care in Medicaid Expansion states.²⁴

Coverage Is Associated with Improved Health Outcomes

• Coverage expansion is associated with decreases in mortality.²⁵ After Massachusetts implemented coverage expansion through both Medicaid and private coverage, the all-cause mortality rate in the state declined significantly.²⁶ Medicaid expansion is associated with lower cardiovascular mortality specifically.²⁷
• More individuals in expansion states quit smoking, consistent with Medicaid coverage for preventive care and evidence-based smoking cessation services.^28,29
• A study of Oregon’s earlier expansion found that individuals who became eligible for Medicaid experienced lower rates of depression than those who did not.³⁰
• Individuals with coverage report a greater sense of well-being, with an increase in individuals reporting being in excellent health after states expanded Medicaid.^31,32

Coverage Supports Appropriate Health Care Utilization

• Coverage can help direct individuals to the most appropriate site of care. Young adults who could stay on their parents’ health plan experienced decreases in non-emergent emergency department (ED) visits.³³ Expansion populations in some states also experienced a decrease in ED visits and an increase in outpatient visits.^34,35,36
• Coverage facilitates use of preventive care and management of chronic conditions. Individuals in expansion states saw significant increases in screening for diabetes, glucose testing among patients with diabetes, and regular care for chronic conditions.³⁷

Coverage Improves Individual, Family and Community Well-being

• Hospitals, particularly rural hospitals, in states that expanded Medicaid experienced improved financial performance and were less likely to close.^38,39
• Medicaid expansion is associated with a decrease in both violent and property crimes, and associated government spending to reduce crime.⁴⁰
• Coverage reduces individuals’ and families’ financial burden and risk by reducing annual out-of-pocket spending⁴¹ and essentially eliminating catastrophic expenditures.⁴²
• In Ohio, individuals who became eligible for and enrolled in Medicaid reported that enrollment made it easier to work and to seek work.⁴³
• In Montana, Medicaid expansion is estimated to create 5 thousand jobs annually between 2018 and 2020, resulting in roughly $270 million in personal income each year.⁴⁴
• In Michigan, enrollment in Medicaid following Medicaid expansion is found to be associated with improved financial health, including a reduction in unpaid medical bills. Enrollees with the greatest medical needs, e.g., chronic illness diagnoses, saw the greatest improvement in their financial health.⁴⁵

Many U.S. Residents Remain Uninsured

Despite these coverage gains, nearly 28 million U.S. residents remain uninsured. However, the proportion of people without health insurance varies dramatically across states, from a high of 17.7% in Texas to a low of 2.8% in Massachusetts.⁴⁶ Insurance status also varies by race and ethnicity. For example, Hispanics have disproportionately high rates of being uninsured, as compared to non-Hispanic whites.⁴⁷

Impact of the Uninsured on the Health Care System

The high rate of uninsured puts stress on the broader health care system. People without insurance put off needed care and rely more heavily on hospital emergency departments, resulting in scarce resources being directed to treat conditions that often could have been prevented or managed in a lower-cost setting. Being uninsured also has serious financial implications for individuals, communities and the health care system.

While all providers offer some level of charity care, it is insufficient to meet fully the needs of the uninsured. In 2017, hospitals provided $38.4 billion in uncompensated care to patients. However, hospitals also absorbed an additional $76.8 billion in underpayments from Medicare and Medicaid, and are facing additional funding reductions through cuts to the Medicare and Medicaid disproportionate share hospital payment programs. These factors dramatically reduce the resources available to hospitals to provide charity care.⁴⁸

Resources

1. Antonisse, Larisa, et al., “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review,” Kaiser Family Foundation, August 2019.
2. America’s Health Insurance Plans, “The Value of Medicaid: Providing Access to Care and Preventive Health Services,” April 2018.
3. Venkataramani, Pollack, and Roberts, “Spillover Effects of Adult Medicaid Expansions on Children’s Use of Preventive Services,” Pediatrics, December 2017.
4. Simon, Soni and Cawley, “The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions,” Journal of Policy Analysis and Management, 2017.
5. Ghosh, Simon and Sommers, “The Effect of State Medicaid Expansions on Prescription Drug Use: Evidence from the Affordable Care Act,” National Bureau of Economic Research Working Paper Series, January 2017.
6. Myerson, Lu, Tonnu-Mihara and Huang, “Medicaid Eligibility Expansions May Address Gaps in Access to Diabetes Medicaitions,” Health Affairs, August 2018.
7. Connecticut Health Foundation, “Faces of Husky D: The Impact of Connecticut’s Medicaid Expansion,” May 2018.
8. Antonisse, Larisa, et al., “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review,” Kaiser Family Foundation, August 2019.
9. Kaufman, Chen, et.al., “Surge in Newly Identified Diabetes Among Medicaid Patients in 2014 within Medicaid Expansion States Under the Affordable Care Act,” Diabetes Care, May 2015.
10. Loehrer, Chang, Scott, et al., “Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions,” JAMA Surgery, March 2018.
11. Smith, Anna and Nickels, Amanda, “Impact of the Affordable Care Act on Early-State Diagnosis and Treatment for Women with Ovarian Cancer,” Journal of Clinical Oncology, June 2019.
12. Adamson, Blythe J. S., et al., “Affordable Care Act (ACA) Medicaid Expansion Impact on Racial Disparities in Time to Cancer Treatment,” ASCO Annual Meeting/Journal of Clinical Oncology, June 2019.
13. Mesquita-Neto, Jose, et al., “Disparities In Access To Cancer Surgery After Medicaid Expansion,” The American Journal of Surgery, June 2019.
14. Gan, Tong et al., “Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky,” Journal of the American College of Surgeons (Vol. 228, No. 4), April 2019.
15. Ajkay, Bhutiani, et al., “Early Impact of Medicaid Expansion and Quality of Breast Cancer Care in Kentucky,” Journal of the American College of Surgeons, April 2018.
16. Antonisse, Larisa, et al., “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review,” Kaiser Family Foundation, August 2019.
17. Kozloff and Sommers, “Insurance Coverage and Health Outcomes in Young Adults with Mental Illness Following the Affordable Care Act Dependent Coverage Expansion,” Journal of Clinical Psychiatry, July/August 2017.
18. The Ohio Department of Medicaid, “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly,” August 2018.
19. Connecticut Health Foundation, “Faces of Husky D: The Impact of Connecticut’s Medicaid Expansion,” May 2018.
20. Antonisse, Larisa, et al., “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review,” Kaiser Family Foundation, August 2019.
21. Saloner, Brendan, et al., “The Affordable Care Act in the Health of the Opioid Crisis: Evidence from West Virginia,” Health Affairs (Vol. 38, No. 4), April 2019.
22. Courtemanche, Marton, et.al., “Early Effects of the Affordable Care Act on Health Care Access, Risky Health Behaviors, and Self-Assessed Health,” National Bureau of Economic Research Working Paper Series, March 2017.
23. Sommers, Blendon, et.al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine, August 2016.
24. Wehby, George, et al., “Effects of the Patient Protection and Affordable Care Act on Coverage and Access to Care in Metropolitan vs. Non-Metropolitan Areas through 2016,” RUPRI Center for Rural Health Policy Analysis, August 2019.
25. Miller, Sarah, et al., “Medicaid and Mortality: New Evidence from Linked Survey and Administrative Date,” National Bureau of Economic Research, July 2019.
26. Sommers, Long, and Baicker, “Changes in Mortality after Massachusetts Health Care Reform,” Annals of Internal Medicine, 2014.
27. Khatana, Sameed A. M., et al., “Association of Medicaid Expansion with Cardiovascular Mortality,” JAMA Cardiology, June 2019.
28. Koma, Donohue, Barry, et al. “Medicaid Coverage Expansions and Cigarette Smoking Cessation Among Low-income Adults,” December 2017.
29. Antonisse, Larisa, et al., “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review,” Kaiser Family Foundation, August 2019.
30. Baicker, Taubman, et.al., “The Oregon Experiment – Effects of Medicaid on Clinical Outcomes,” New England Journal of Medicine, May 2013.
31. Sommers, Blendon, et.al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine, August 2016.
32. Antonisse, Larisa, et al., “The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review,” Kaiser Family Foundation, August 2019.
33. Antwi, Moriya, et. al. “Changes in Emergency Department Use among Young Adults after the Patient Protection and Affordable Care Act’s Dependent Coverage Provision,” Annals of Emergency Medicine, June 2015.
34. Sommers, Blendon, et.al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine, August 2016.
35. The Ohio Department of Medicaid, “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly,” August 2018.
36. Connecticut Health Foundation, “Faces of Husky D: The Impact of Connecticut’s Medicaid Expansion,” May 2018.
37. Sommers, Blendon, et.al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine, August 2016.
38. Lindrooth, Perraillon, Hardy, and Tung, “Understanding The Relationship Between Medicaid Expansions And Hospital Closures,” Health Affairs, January 2018.
39. US Government Accountability Office, “Rural Hospital Closures: Number and Characteristics of Affected Hospitals and Contributing Factors,” August 2018.
40. Vogler, “Access to Health Care and Criminal Behavior: Short-Run Evidence from the ACA Medicaid Expansions,” University of Illinois at Urbana-Champaign, September 2017.
41. Sommers, Long, and Baicker, “Changes in Mortality after Massachusetts Health Care Reform,” Annals of Internal Medicine, 2014.
42. Baicker, Taubman, et.al., “The Oregon Experiment – Effects of Medicaid on Clinical Outcomes,” New England Journal of Medicine, May 2013.
43. The Ohio Department of Medicaid, “Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly,” August 2018.
44. Ward and Bridge, “The Economic Impact of Medicaid Expansion in Montana,” Bureau of Business and Economic Research, University of Montana, April 2018.
45. Miller, et al., “The ACA Medicaid Expansion in Michigan and Financial Health,” National Bureau of Economic Research, September 2018.
46. U.S. Census Bureau, 2018 American Community Survey 1-Year Estimates.
47. Kaiser Family Foundation, “Key Facts about the Uninsured Population,” December 2018.
48. AHA Chart Book, 2017.