Implications of the ACA Medicaid Expansion: A Look at the Data and Evidence

More than four years after the implementation of the Medicaid expansion included in the Affordable Care Act, debate and controversy around the implications of the expansion continue. Despite a large body of research that shows that the Medicaid expansion results in gains in coverage, improvements in access and financial security, and economic benefits for states and providers, some argue that the Medicaid expansion has broadened the program beyond its original intent diverting spending from the “truly needy”, offers poor quality and limited access to providers, and has increased state costs. New proposals allow states to implement policies never approved before including conditioning Medicaid eligibility on work or community engagement. New complex requirements run counter to the post-ACA movement of Medicaid integration with other health programs and streamlined enrollment processes. This brief examines evidence of the effects of the Medicaid expansion and some changes being implemented through waivers. Many of the findings on the effects of expansion cited in this brief are drawn from the 202 studies included in our comprehensive literature review that includes additional citations on coverage, access, and economic effects of the Medicaid expansion. Key findings include the following:

• Coverage: Research and data show that Medicaid expansion has resulted in coverage gains without diverting coverage from traditional groups; for example, data do not support a relationship between states’ expansion status and community-based services waiver waiting lists. Reductions in Medicaid coverage would result in an increase in the uninsured population.
• Access, Affordability, and Health Outcomes: Research demonstrates that Medicaid generally, and expansion specifically, positively affects access to care, utilization of services, the affordability of care, and financial security among the low-income population. While there is a growing body of evidence on Medicaid and outcomes, further research is needed to more fully determine the health effect of expansion on outcomes given that measureable changes take time to occur.
• Economic Effects: Analyses find positive economic effects of expansion largely tied to the infusion of federal dollars, despite Medicaid enrollment growth initially exceeding projections in many states. Some studies look at 2014-2016 when expansion costs were 100% financed by the federal government, others studies project net fiscal gains even after states start to pay a share of expansion costs (up to 10% by 2020). Studies also show that Medicaid expansion resulted in reductions in uninsured visits and uncompensated care costs for hospitals, clinics, and other providers.
• Expansion and Work: Studies find that Medicaid expansion has had positive or neutral effects on employment and the labor market and new work requirement proposals add complexity and could result in coverage losses for many who are working or face barriers to work.