Reversing Course on Medicaid Expansion Could Hurt Rural Healthcare, Study Warns

Repealing or phasing out Medicaid expansion could reverse improvements in quality and service use and could be particularly harmful to low-income rural populations, said the authors of a study looking at the effect of Medicaid on community health centers (CHCs).

Patients in rural areas are predominantly low-income and disproportionately uninsured, noted the study, which was published in the June issue of Health Affairs.

Although there have been many positive effects noted from Medicaid expansion­—a recent literature review found that Medicaid expansion was associated with increases in coverage, service use, quality of care, and Medicaid spending—the effect on rural CHCs is unknown.

The researchers used nationally representative data to assess the 2-year impact of Medicaid expansion on insurance coverage and quality of care in CHCs. They also looked at the impact of expansion on the volume of CHC services for specific chronic conditions, such as asthma and diabetes, preventive visits, and mental health and substance abuse care.

Additionally, they looked at the different impacts of Medicaid expansion on CHCs in urban versus rural areas. The study compared all 578 CHCs in states that had expanded Medicaid by 2014 with a control group of all 431 CHCs in states that had not expanded Medicaid by 2014.

Using data for 2011 to 2015 on all CHCs, the study found that after 2 years, Medicaid expansion was associated with a decline of 11.44 percentage points in the share of CHC patients who were uninsured and an increase of 13.15 percentage points in those covered by Medicaid.

The 3 main outcomes were:

• Insurance coverage (the percentages of patients without insurance, with Medicaid coverage, and with private insurance)
• Patient and visit volumes (numbers of unique patients and of 21 types of visits per CHC)
• Quality of care for 8 quality measures potentially sensitive to Medicaid expansion Prescription drug treatment for patients with asthma Lipid-lowering therapy for patients with coronary artery disease Aspirin for patients with cardiovascular disease Body mass index (BMI) screening and follow-up in adults Pap testing Colorectal cancer screening Blood pressure control (less than 140/90 mm Hg) in patients with hypertension Blood sugar control (glycated hemoglobin at or below 9%) in patients with diabetes.

Rural CHCs in expansion states saw improvements in asthma treatment, BMI screening and follow-up, and hypertension control.

There were also increases in volumes for 18 of 21 types of visits—particularly those for mammograms, abnormal breast findings, alcohol-related disorders, and other substance abuse disorders.

Similar relative gains were not observed in urban CHCs in expansion states.

Repealing or phasing out Medicaid expansion could reverse these gains, the researchers noted. The study was released about a month after CMS released its strategy to improve rural healthcare.

However, some fear that one of the priorities of the Trump administration currently being carried out by CMS—imposing work requirements in order to get Medicare benefits—will fall the hardest on those in rural areas precisely because of some of the challenges that CMS is trying to address with its rural health strategy, such as a lack of transportation and providers

Reference

Cole MB, Wright B, Wilson IB, Galárraga O, Trivedi AN. Health Aff (Millwood). 2018;37(6):900-907. doi: 10.1377/hlthaff.2017.1542.