Southern Medical Students’ Views on Medicaid Expansion

The US Supreme Court’s 2012 ruling on the Affordable Care Act (ACA) made one of the law’s signature features optional rather than mandatory: states could choose whether to expand income-based eligibility for Medicaid programs. As of August 2015, 22 states declined expanding Medicaid; most of these are in the South, the US region with the highest proportion of uninsured individuals.¹ Medical students will inherit the reformed health care system and thus are stakeholders in these state decisions. We surveyed medical students in 8 Southern non–Medicaid-expanding states to ascertain their knowledge and attitudes toward coverage expansion.

In this cross-sectional study, we surveyed medical students in 8 Southern public medical schools (Table) between September and December 2014. We targeted all third- and fourth-year students with clinical experiences that included exposure to uninsured patients. We selected public allopathic medical schools with high in-state matriculation and physician retention. Using the American Medical Student Association (AMSA) network we recruited students and faculty at 8 of the eligible 16 public allopathic medical schools in non–Medicaid-expanding Southern states using the AMSA network to sponsor institutional review board approval and email the survey to the entire third- and fourth-year classes at their school.

Our survey included questions from a survey of medical students’ opinions of the ACA conducted in 2011 in Minnesota,² plus 6 questions on students’ knowledge and attitudes toward Medicaid expansion. Students were asked whether their state had expanded Medicaid, and to estimate their state’s Medicaid eligibility income level for single individuals (<$5750,<$11 490,<$16 000,<$22 980), with the 2014 federal poverty level ($11 490) provided as a reference point. After pilot testing, students were invited by email in September 2014 to participate in the survey.

The overall response rate was 60% (1312 of 2205). Demographic composition was comparable with all current US medical students in the Association of American Medical Colleges Graduation Questionnaire from 2014 and respondents closely matched class statistics at surveyed schools (Table).³

Sixty-two percent of students knew that their state had not expanded Medicaid. The Figure shows medical students’ inflated estimates of Medicaid income eligibility for individuals in their state. Only 17% knew that low-income adults in their state qualify for Medicaid only if they have dependent children.

Overall, 93% agreed that health policy is relevant to physician education and practice, 78% reported their health policy education had been insufficient, and half (51%) reported understanding the basics of the ACA. Overall support for the ACA was 49% (range by school, 35%-74%). Fifty-five percent (range by school, 41%-79%) of students supported Medicaid expansion, compared with 21% (range by school, 10%-29%) who opposed it. Among students self-identifying as conservative, 25% supported expansion, 45% opposed it, and 32% neither supported nor opposed it compared with the 87% with liberal ideology who support expansion.

State-by-state decisions about expanding Medicaid will determine access to care for nearly 4 million people in the Southern United States.¹ We found that medical students at Southern medical schools were poorly informed about Medicaid eligibility in their states, yet most endorsed coverage expansion, in contrast to their states’ decisions.

Coverage expansion for those living near or under the poverty level has revealed widely differing opinions among today’s physicians, especially in the Southern United States, where the ACA faces political opposition. Although we do not know the stability of student attitudes, we identify majority support and an opportunity for knowledge improvement. Less than two-thirds of the medical students knew their state had not expanded Medicaid, and their understanding of basic eligibility was flawed. Health policy curricula are gaining traction throughout US medical schools.⁴ Implementing this curricular content is important, though challenging, in regions where health policy reform is politically charged. Many medical students in these states embrace coverage expansion, but must be taught the terms of the debate in order to advocate for policies reflecting their values.

Correction: Errors in the first paragraph of the text and the figure were corrected online February 1, 2016.

Corresponding Author: Steven A. Schroeder, MD, Department of Medicine, University of California–San Francisco, 3333 California St, Ste 430, San Francisco, CA 94143-1211 (schroeder@medicine.ucsf.edu).

Published Online: December 7, 2015. doi:10.1001/jamainternmed.2015.6835.

Conflict of Interest Disclosures: Dr Hauer receives salary support from the American Board of Internal Medicine. No other disclosures are reported.

Funding/Support: The study was funded by the UCSF Clinical Translational Research fellowship.

Role of the Funder/Sponsor: The UCSF had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We are indebted to the students and faculty at the 8 participating medical schools whose generous participation made this study possible. We thank Liz Hamel, Kaiser Family Foundation, and Pooja Loftus, Stanford University, for support with survey development and data management.