State Medicaid Coverage and Access to Care

In the Literature

In states where levels of Medicaid coverage are high, low-income adults enjoy better access to physicians and important preventive services than their counterparts in states where coverage levels are low and more restrictive, according to a Commonwealth Fund–supported study.

A team of Harvard Medical School researchers, led by Joel S. Weissman, Ph.D., found significant differences in unmet physician need among low-income, nonelderly adults between states with the highest and lowest Medicaid enrollment levels. In State Medicaid Coverage and Access to Care for Low-Income Adults (Journal of Health Care for the Poor and Underserved, Feb. 2008), the team concludes that Medicaid expansion may be a cost-effective way to improve access to care for low-income individuals.

Costs Deter Poor from Seeking Care

In the absence of national health insurance, ensuring that low-income individuals have adequate access to health care is a tall challenge, with the responsibility falling largely to the states. States try to meet the health care needs of the poor by offering public health insurance, such as Medicaid, and by funding safety net providers. Previous research has established Medicaid's beneficial effect on expanding access to care for enrollees. Less clear is whether broad coverage has advantages for the low-income population overall, regardless of insurance coverage.

To answer this question, the team used data from the Current Population Survey compiled by the Kaiser Commission on Medicaid and the Uninsured during 2000–2003, as well as data from the Behavioral Risk Factor Surveillance System, a survey of adults by state health departments. The researchers calculated access gaps between low-income and high-income adults within each state.

Nationally, the team found that approximately 25 percent of low-income individuals (defined as earning under $25,000 annually) were unable to see a physician because of cost, compared with about 5 percent of high-income people (earning more than $50,000 annually).

The gap between low-income and high-income individuals who could not see physicians because of cost was 19.2 percent in states with the broadest Medicaid coverage, after adjusting for age, race, and gender, compared with 23.7 percent for states with the narrowest coverage. "Thus, the size of the gap increased by nearly a quarter," noted the researchers.

Access Gaps for Preventive Services

Access gaps for preventive services were as much as 80 percent greater in the states with the narrowest Medicaid coverage. For all four measures—cholesterol test, colorectal screening, mammography, and Pap testing—low-income individuals had better access in the states with broader Medicaid coverage than in lower-coverage states.

Conclusions

As states struggle with rising Medicaid costs, pressure increases to limit eligibility. But states' existing support for public health service and other safety net components likely would not offset any reductions in Medicaid eligibility.

Expanding eligibility for Medicaid coverage, the researchers conclude, may be an effective strategy for states to improve access to care and preventive services for the poor. After all, rather than seeking charity care, which may be limited, low-income people with Medicaid coverage can go to any health care provider that accepts it. Broader Medicaid coverage may also have a spillover effect by helping to sustain safety-net providers, thus enhancing their ability to provide services to the uninsured and underinsured.

"For all those reasons, broad Medicaid coverage may play a complementary role to that of safety-net providers in addressing the health care needs of low-income neighborhoods and individuals," the authors concluded. "Given that some statewide health reform efforts do not sufficiently account for the limited financial means of low-income people, Medicaid expansions may be a cost-effective strategy for improving access to care among low-income residents."