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Editorial
August 13, 2021

Medicaid Expansion and Access to Care for Low-Income Adults in 4 Southern States During COVID-19

Author Affiliations
  • 1Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 2Editor in Chief, JAMA Health Forum
JAMA Health Forum. 2021;2(8):e212000. doi:10.1001/jamahealthforum.2021.2000

For the US, the COVID-19 pandemic has been the greatest health shock to the nation in more than a century, with an estimated 522 000 excess deaths associated with this contagion through early January 2021.1 These deaths have not fallen evenly across the population. In 2020, the disproportionate mortality among Latinx and Black individuals is projected to reduce life expectancy in these groups by more than 2 and 3 years, respectively.2 These reductions are 3- and 4-fold larger than the corresponding decline in life expectancy of less than 0.7 years for White individuals in the US.

Within this COVID-19 context, in this issue of JAMA Health Forum, Figueroa and colleagues3 report on a recent telephone survey of insurance coverage and access to care among low-income adults in 4 Southern states.3 Conducted during the last 3 months of 2020 when COVID-19 infections were surging in this region,1 the survey focused on 3 states that have expanded Medicaid to low-income adults under the US Affordable Care Act (Arkansas and Kentucky since 2014 and Louisiana since 2016) and 1 state that has not expanded Medicaid (Texas). The authors surveyed US citizens with incomes below the threshold for expanded Medicaid coverage (<138% of the federal poverty level). The authors compared their findings with similar surveys that they conducted in the same states during 2018 and 2019 before the COVID-19 pandemic.

This study had 3 main findings. First, the adjusted rate of uninsurance worsened significantly in 2020 among low-income adults in Texas (by 7.4 percentage points) but did not change significantly in the 3 Medicaid expansion states. Second, an adjusted difference-in-difference analysis demonstrated that the increase in uninsurance among Black and Latinx adults was significantly greater in Texas than in the Medicaid expansion states (by 9.5 percentage points) but did not differ significantly among White adults. Third, measures of access to care (eg, having a personal physician) and affordability (eg, skipping medications because of cost) worsened significantly and similarly in Texas and the 3 Medicaid expansion states.

These key findings are tempered by some limitations, as noted by the study authors. In particular, by studying only 4 states, differences other than Medicaid expansion in the states’ populations or health care systems may have affected the findings. For example, 51% of survey participants in Texas were Latinx compared with only 5% in Arkansas, Kentucky, and Louisiana, whereas the proportion of Black participants was more than twice as large in the 3 Medicaid expansion states than in Texas (28.4% vs 13.6%). Low-income Latinx adults in Texas may have faced added barriers to insurance coverage and access to care beyond the lack of Medicaid expansion. From 2013 through February 2020, 21 rural hospitals closed in Texas compared with a total of 6 rural hospitals in Arkansas, Kentucky, and Louisiana,4 which may have been associated with the lack of Medicaid expansion in Texas.

A growing body of research since 2014 has demonstrated the benefits of the Affordable Care Act and Medicaid expansion for improving the financial well-being and health of low-income adults5,6 and for narrowing racial and ethnic disparities in insurance coverage and access to care.7 For low-income adults with chronic health conditions who receive care from community health centers in the South, Medicaid expansion was associated with significantly slower declines in health.8 In a large national study of adults aged 55 to 64 years who had high rates of chronic health conditions, Medicaid expansion was associated with a 9.4% relative reduction in mortality, and this positive association has been increasing over time.9 Figueroa and colleagues3 add a timely study during the COVID-19 pandemic to this growing body of research.

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Article Information

Published: August 13, 2021. doi:10.1001/jamahealthforum.2021.2000

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Ayanian JZ. JAMA Health Forum.

Corresponding Author: John Z. Ayanian, MD, MPP, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd, Ann Arbor, MI 48109 (ayanian@umich.edu).

Conflict of Interest Disclosures: Dr Ayanian reported grants from the Michigan Department of Health and Human Services, National Institute on Aging, and National Library of Medicine; personal fees from JAMA Network, New England Journal of Medicine, Harvard University, University of Massachusetts Medical School, and University of Chicago; and nonfinancial support from the National Institutes of Health, National Academy of Medicine, and AcademyHealth outside the submitted work.

References
1.
Woolf  SH, Chapman  DA, Sabo  RT, Zimmerman  EB.  Excess deaths from COVID-19 and other causes in the US, March 1, 2020, to January 2, 2021.   JAMA. 2021;325(17):1786-1789. doi:10.1001/jama.2021.5199 PubMedGoogle ScholarCrossref
2.
Andrasfay  T, Goldman  N.  Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations.   Proc Natl Acad Sci U S A. 2021;118(5):e2014746118. doi:10.1073/pnas.2014746118 PubMedGoogle Scholar
3.
Figueroa  JF, Khorrami  P, Bhanja  A, Orav  EJ, Epstein  AM, Sommers  BD.  COVID-19 related insurance coverage changes and disparities in access to care among low-income US adults in 4 southern states.   JAMA Health Forum. 2021;2(8):e212007. doi:10.1001/jamahealthforum.2021.2007Google Scholar
4.
US General Accountability Office. Rural hospital closures: affected residents had reduced access to health care services. Accessed June 20, 2021. https://www.gao.gov/assets/gao-21-93.pdf
5.
Soni  A, Wherry  LR, Simon  KI.  How have ACA insurance expansions affected health outcomes? findings from the literature.   Health Aff (Millwood). 2020;39(3):371-378. doi:10.1377/hlthaff.2019.01436 PubMedGoogle ScholarCrossref
6.
Courtemanche  C, Marton  J, Ukert  B, Yelowitz  A, Zapata  D.  The impact of the Affordable Care Act on health care access and self-assessed health in the Trump Era (2017-2018).   Health Serv Res. 2020;55(suppl 2):841-850. doi:10.1111/1475-6773.13549 PubMedGoogle ScholarCrossref
7.
Buchmueller  TC, Levy  HG.  The ACA’s impact on racial and ethnic disparities in health insurance coverage and access to care.   Health Aff (Millwood). 2020;39(3):395-402. doi:10.1377/hlthaff.2019.01394 PubMedGoogle ScholarCrossref
8.
Graves  JA, Hatfield  LA, Blot  W, Keating  NL, McWilliams  JM.  Medicaid expansion slowed rates of health decline for low-income adults in Southern states.   Health Aff (Millwood). 2020;39(1):67-76. doi:10.1377/hlthaff.2019.00929 PubMedGoogle ScholarCrossref
9.
Miller  S, Johnson  N, Wherry  LR.  Medicaid and mortality: new evidence from linked survey and administrative data.   Q J Economics. 136(3):1783-1829. doi:10.1093/qje/qjab004Google ScholarCrossref
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