The Effects of Medicaid Expansion Under the Affordable Care Act on Health Insurance Coverage,Health Care Access,and Health Care Use for People with Disabilities: A Scoping Review

Abstract

More than 27% of individuals in the United States experience a disability. We conducted a scoping review of the literature to examine what is known about the impact of the 2010 Affordable Care Act Medicaid expansion on individuals with disabilities’ health care insurance coverage, health care access, and health care use. We followed the approach of Arskey and O’Malley in conducting our review. Electronic journal databases, hand searching of key health and disability journals, and reference checking were used to identify potential articles for the review. Individuals with disabilities or with conditions that could be disabling were included. The intervention used was the 2010 Affordable Care Act Medicaid expansion. Study eligibility criteria were peer-reviewed studies published in 2014 or later that conducted multivariate analyses of the effect of the Medicaid expansion on people with disabilities’ health insurance coverage, health care access, and health care use. The most consistent finding across studies was that the Medicaid expansion had a positive effect on health insurance coverage. It was generally found to have increased Medicaid coverage and decreased the uninsured rate. Its effect on private or employer-sponsored insurance coverage was a mix of no and negative effects. Findings related to health care access and use of care were more mixed. On a scale of 0 to 8 (highest quality), the quality of individual studies ranged from 2 to 6, with an average across studies of 4.2, the low end of adequate quality. Future studies should develop a more consistent approach to measuring disability and develop a core set of health care access and use measures to facilitate comparisons across studies so as to systematically evaluate the evidence related to the Medicaid expansion.

Keywords

Medicaid expansion people with disabilities scoping review

The U.S. Census Bureau estimated that more than 27% of people in the United States had a disability in 2014 (Taylor, 2018). Disability was measured by a range of physical, sensory, cognitive, mental, and/or emotional impairments as well as limitations one may experience in performing activities of daily living (e.g., dressing) and instrumental activities of daily living (e.g., taking medication). The measure used by the Census is in keeping with how disability is defined by the International Classification of Functioning, Disability, and Health (ICF) that considers disability as a collective term for “impairments, activity limitations and participation restrictions” (World Health Organization, 2002, p. 2). The ICF definition acknowledges disability as a result of interactions between individual health conditions and social contextual factors, instead of restricting disability to individual physiological conditions that require medical care.

Compared with nondisabled persons, people with disabilities have higher health care needs, higher health service utilization, and expenditures (Mitra et al., 2009; Pumkam et al., 2013; Reichard et al., 2015). They are also more likely to experience delayed and unmet need for medical care (Henning-Smith et al., 2013). Unmet health care needs not only lead to worsened health conditions but also affect the societal integration of people with disabilities (LaPlante et al., 2004; Long et al., 2005). While health insurance was found an important facilitator of access to health care (Hadley, 2003), more than 20% of U.S. working-age adults with disabilities did not have health insurance in December 2013 (Taylor, 2018). Among adults with permanent disabilities, the uninsured were found to be at least 3 times as likely as the insured to have postponed health care and forgone medicine because of cost (Hanson et al., 2003).

Obtaining health insurance has been challenging for many people with disabilities (The American Association on Health and Disability [AAHD], 2015). In the individual U.S. health insurance market, historically they were faced with prohibitively expensive premiums or denied insurance due to preexisting conditions. The Americans with Disabilities Act of 1990 (ADA) allows health insurers to have differential terms in some of their plans for people with disabilities so that they can mitigate underwriting risks. While these terms in theory need to be evidence-based, in reality insurers tend to refuse insurance issuance or offer expensive plans to a wide range of disability conditions based on little actuarial evidence (Yee, 2015). In the group health insurance market, the pathways for people with disabilities to obtain insurance are either through their employer or as a dependent on their family member’s insurance plan. However, they are much less likely to have a job compared with their peers who are not disabled (Kraus, 2017). When they do, they are less likely to work full-time and have health insurance covered by their employers (Musumeci & Foutz, 2017).

In the public U.S. health insurance domain, if a working-age adult becomes disabled and is eligible for Medicare, in most cases he or she needs to wait for 24 months before being able to enroll in the program. For many people who have newly become disabled, those first 2 years are a critical time in their life when they need health insurance most (AAHD, 2015). Medicaid is the second public health insurance source for people with disabilities. Prior to the enactment of the ACA, Medicaid eligibility was restricted to several categories of low-income individuals. Although people with disabilities were one of the eligibility categories, becoming eligible for Medicaid was difficult because the program uses the same definition to determine disability as Supplemental Security Income (SSI) does (Medicaid and CHIP Payment and Access Commission [MACPAC], 2017). The Medicaid/SSI definition of disability is restricted to impairments that significantly affect one’s ability to work. Many people with disabilities are not eligible for Medicaid because they have a nonqualifying disability (MACPAC, 2017). Only about 25% of people with disabilities in the United States in 2010 were Medicaid-eligible (National Council on Disability, 2013).

In March 2010, the ACA was signed into law. A central piece of the ACA provisions, the Medicaid expansion, was initially designed as a requirement for all states. However, the Supreme Court ruled in June 2012 in National Federation of Independent Business v. Sebelius that it was unconstitutional for the federal government to deny federal Medicaid matching funds for a state if the state chooses not to expand the program. Consequently, Medicaid expansion became optional (MACPAC, n.d.). To date, 37 states, including the District of Columbia, have expanded Medicaid (Kaiser Family Foundation, 2020).

The Medicaid expansion has significant implications for people with disabilities. By simplifying its eligibility criteria to income-based only, the Medicaid expansion eliminates the program’s traditional categorical restrictions, which means that any individual with income up to 138% of Federal Poverty Level (FPL) would be eligible. The expansion thus has the promise of increasing Medicaid coverage for many people with disabilities who were previously ineligible due to their higher income or a disability that did not meet Medicaid eligibility criteria.

A number of systematic reviews have been published regarding the impacts of the ACA, including the Medicaid expansion (Breslau et al., 2018; French et al., 2016; Mazurenko et al., 2018; Moss et al., 2020). For example, French and colleagues (2016) examined several provisions of the ACA, including the dependent coverage provision, the Medicaid expansion, health insurance exchanges, and the availability of subsidies. These ACA changes were found to reduce the number of people who were uninsured, but affordability continued to be a concern, as were disparities by race/ethnicity, income, and geography. A systematic review focused on the dependent coverage provision found consistent support for improvements in health insurance coverage, but findings related to the impacts of such improved health insurance coverage were mixed (Breslau et al., 2018). Focusing specifically on the Medicaid expansion, Mazurenko and colleagues (2018) found evidence for increases in health insurance coverage and service use, as well as improvements in the quality of care. We are unaware of a systematic review that has examined the effect of the Medicaid expansion on people with disabilities, whose experiences are an important test for the efficacy of the Medicaid expansion. As a first step toward such a review, we conduct a scoping review. A scoping review can be a useful approach when information on a topic is complex and heterogeneous, or when the topic has not been comprehensively reviewed (Munz et al., 2018; Sucharew & Macaluso, 2019). We follow steps suggested by Arksey and O’Malley (2005), which include (a) identifying a research question, (b) identifying relevant studies, (c) developing study inclusion and exclusion criteria, (d) charting the data, and (e) collating, summarizing, and reporting results. We include an assessment of the quality of the studies reviewed, an optional component of a scoping review (Munz et al., 2018); we believe it is informative in assessing the strength of the current literature.

Method

Review Question

This scoping review addresses the following research question: What empirical evidence do we have so far about the effects of the Medicaid expansion under the ACA on health insurance coverage, health care access, and health care use for working-age adults with disabilities?

Information Sources

Searches for eligible studies were conducted in three sources: first, multidisciplinary and health databases (Academic Search Complete, Academic Search Premier, CINAHL, CINAHL Plus, Health Source—Consumer Edition, Health Source—Nursing/Academic Edition, MEDLINE, Web of Science, and JSTOR); second, key health journals (Disability and Health Journal, Medical Care Research and Review, Health Affairs, Health Services Research, and American Journal of Public Health); and, third, the bibliographies of articles that met the eligibility criteria.

Search Strategy

A combination of electronic and manual search strategies was used depending on the available search function of the information sources. For the multidisciplinary and health databases, the following sets of keywords were combined with a Boolean AND:

Policy of interest: Medicaid expansion

Scope of the policy: ACA OR “Affordable Care Act”

Population: “activity limitations” OR “activities of daily living” OR “participation restrictions” OR disab* OR impair* OR “special needs” OR “chronic conditions” OR “functional limitations”

Outcomes: health* OR care OR coverage OR medical OR access OR use OR visit OR delay OR “usual source of care” OR expense

where the first set of keywords was restricted to search in abstract only and the remaining three sets were searched in all fields. The phrase Medicaid expansion was not wrapped by quotation marks to capture the two words anywhere in the abstract. The asterisk (*) is a wildcard used to capture words that have the root “health,” “disab,” or “impair,” such as healthcare, disabled, disability, disabilities, impaired, and impairment. The search was conducted manually for health journals and the bibliographies of eligible articles.

Study Selection

Following the above eligibility and search procedures, identified articles were first examined for duplicate articles, which were removed. Titles and abstracts were reviewed for relevance, followed by a full-text screening. Reference searches of the included articles were examined for additional articles. Finally, relevant journals were hand searched back to 2014, as previously described.

Inclusion Criteria

The following criteria were decided a priori to identify studies for the analysis:

Type and year of publication: Published in a peer-reviewed journal in English language since January 2014;

Study design: Quasi-experimental design with a comparison group and analyzed individual-level data that included a postexpansion period;

Population: Working-age adults with disabilities either as the population of interest or as a subgroup of the population of interest;

Policy of interest: the Medicaid expansion under the ACA. Following Mazurenko et al. (2018), the review included early Medicaid expansions, those implemented between 2010 and 2014 when states had more flexibility in determining income eligibility level; and

Outcomes: Must relate to health insurance coverage, health care access, and/or health care use.

Based on the above criteria, the following types of study were excluded: descriptive studies such as those that only reported the prevalence of Medicaid coverage, studies that examined the Medicaid expansion effect in one state without a comparison group, analyzed data at an aggregated level, or utilized data from a preexpansion period to simulate the expansion effect. Studies that examined previous Medicaid expansions that were not a part of the ACA and studies that only estimated the effect of the ACA as a whole without separately doing so for the Medicaid expansion were also excluded.

Charting the Data and Risk of Bias Assessment

Information extracted from each eligible article included general information such as authors and year published, study scope, and methodology. Assessing risk of bias is optional in a scoping review (Munz et al., 2018). We followed the Agency for Healthcare Research and Quality’s (AHRQ) guidance on assessing the risk of bias of studies in systematic reviews. The term “risk of bias” was interchangeable with “internal validity,” which was defined as “the extent to which a single study’s design and conduct protect against all bias in the estimate of effect” (Viswanathan et al., 2012, p. 3). The guidance suggested five types of bias to be included: (a) selection bias, which refers to systematic differences between experimental groups as a result of self-selection or treatment selection; (b) performance bias, which occurs when there are systematic differences between the protocol and the execution of an intervention; (c) attrition bias, which are systematic differences between participants who drop out of a study and those who do not; (d) detection bias, which refers to systematic differences in outcome assessment as a result of inadequate or faulty measurement; and (e) reporting bias, which refers to selective outcome reporting due to factors such as the influence of a funding source. Additional information related to data charting and risk of bias assessment criteria can be found in the online supplemental materials (Tables S1 and S2). The sixth and optional step of consultation was not used in our review.

Both authors developed the inclusion and exclusion criteria, search strategy, data to be charted, and assessment of risk of bias. The first author conducted the search as described above in the search strategy, data charting and risk of bias assessment, consulting with the second author when questions arose. Findings were grouped by outcome and included health insurance coverage, access to health care, and use of health care.

Results

Study Selection

Supplemental Figure S1 illustrates the search and screening process for this review. All searches were conducted in February and March of 2019. A total of 727 articles were located, of which 293 duplicates were identified and removed. The titles and abstracts of the remaining 434 studies were screened for relevance, of which 391 were excluded. A full-text screening was then conducted of the remaining 43 studies, 35 of which were excluded because they did not fully meet the eligibility criteria, including 12 that did not study adults with disabilities, three that were not about the ACA Medicaid expansion, three that estimated the impact of the ACA but not the Medicaid expansion, 10 that did not use a quasi-experimental design with a comparison group, three that did not conduct individual-level analyses or include postexpansion data, and four that studied outcomes beyond the scope of this review. One eligible study was identified through backward and forward reference searches of the eight finalists, yielding a total of nine studies for further analysis.

Study Characteristics

Among the nine studies, Sommers et al. (2014) examined low-income adults with health-related limitations in a subgroup analysis while the remaining eight investigated people with health conditions that may be disabling, including trauma (Akande et al., 2018; Zogg et al., 2019), substance use disorders (Olfson et al., 2018), mental health conditions (Thomas et al., 2018), and chronic conditions (Sommers, Blendon, & Orav, 2016; Sommers, Blendon, Orav, & Epstein, 2016; Torres et al., 2017; Winkelman & Chang, 2017). A summary of data extracted from these studies can be found in the online supplemental materials (Tables S3 and S4).

Study Design and Analytic Methods

All studies used a difference-in-differences (DD) design with the treatment group being states that expanded Medicaid and the comparison group being those that did not. Four studies included all states in experimental groups while the remaining five included a selected number of states. Both pre- and posttreatment periods were predominantly limited to 1 or 2 years, with the exception of two studies (Winkelman & Chang, 2017; Zogg et al., 2019) whose pretreatment period was 3 years. For the pretreatment period, two studies excluded the last 3 months of 2013, reasoning that those were a “wash-in period,” when transitional changes were made in preparation for the expansion (Zogg et al., 2019). All studies used multivariate logistic or linear regression models controlling for individual characteristics. Five studies controlled for state and four studies controlled for year fixed effects.

Data Source

Studies of trauma patients utilized State Inpatient Databases (SID), a part of the Healthcare Cost and Utilization Project sponsored by AHRQ (Akande et al., 2018). The study of adults with substance use disorders used the National Survey on Drug Use and Health (NSDUH) sponsored by the Substance Abuse and Mental Health Services Administration (Olfson et al., 2018). The study of adults with a mental health condition used the Health Reform Monitoring Survey (HRMS) funded by the Robert Wood Johnson Foundation (Thomas et al., 2018). Among the remaining five studies of adults with chronic conditions or health-related limitations, two analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) administered by state health departments and the Centers for Disease Control and Prevention (Torres et al., 2017), one used the American Community Survey administered by the Census Bureau, and two used data from a survey that the researchers conducted in the study states. All nine studies’ data were repeated cross-sectional.

Findings

Table 1 presents a summary of findings from the eligible studies. Details of the findings are discussed below by outcome.

Table 1.

Summary of Findings by Outcome.

Findings	Alande et al. (2018)	Olfson et al. (2018)	Sommers, Blendon, & Orav (2016)	Sommers, Blendon, Orav, & Epstein (2016)	Sommers et al. (2014)	Thomas et al. (2018)	Torres et al. (2017)	Winkelman & Chang (2017)	Zogg et al. (2019)
Insurance coverage
Medicaid	Positive	ND^a			Positive^b	Positive			Positive
Medicaid		Positive^c			ND^d				Positive
Private/employer sponsored	Negative				Negative^b	ND			Negative
Private/employer sponsored					ND^d				Negative
Uninsured	Negative	Negative^a			Negative^b	Positive			Negative
Uninsured		ND^c			ND^d				Negative
Any insurance							Positive	Positive
Access to care
Access to rehabilitation	Positive								Positive
Have USC/personal physician						ND	ND	Positive(at p < .1)
Unmet health care need because of cost							Positive	Negative	Negative
Unmet health care need because of cost							ND^e	Negative	Negative
Health care utilization
Treatment receipt	ND^a
Routine checkup in past 12 months								ND	Positive(p < .1)
Received regular care			Positive	Positive

Note. ND = no significant difference; positive = positive and statistically significant; negative = negative and statistically significant (all significance is at .05 level unless noted otherwise).

Adults with substance use disorders (SUD). ^bAdults with health-related limitations in Connecticut. ^cAdults with SUD who were treated for their disorders. ^dAdults with health-related limitations in D.C. ^eUnmet mental health need.

Insurance coverage

Four measures of health insurance coverage were examined, including Medicaid, private or employer-sponsored insurance, uninsured, and any insurance. In their study of hospitalized young adult trauma patients, Akande et al. (2018) found that the Medicaid expansion led to a statistically significant increase in Medicaid coverage, decrease in uninsured rate, and decrease in private insurance coverage in expansion states. Zogg et al. (2019) found similar statistically significant effects among adult trauma patients on the same three measures of coverage.

Among adults with a mental health condition, Thomas et al. (2018) reported a significantly greater gain in Medicaid coverage in expansion states. However, they found that the decrease in being uninsured all year in expansion states was significantly less than that in nonexpansion states. They also examined the impact of the Medicaid expansion on employer-sponsored and directly purchased insurance, but did not detect any statistically significant effects.

Olfson et al. (2018) found a larger increase in Medicaid coverage among low-income adults with substance use disorders, but the effect was not statistically significant. The larger decrease in the uninsured, on the contrary, was statistically significant. When the analytic sample was limited to adults receiving treatment, the increase in Medicaid coverage was significantly larger, whereas the difference in decrease in the uninsured was not statistically significant.

Sommers et al. (2014) studied the effect of early Medicaid expansions on low-income adults in Connecticut and the District of Columbia, both having expanded their Medicaid programs in 2010. In their subgroup analyses on those with health-related limitations, the authors found statistically significant effects in Connecticut: A larger increase in Medicaid coverage, decrease in the uninsured, and decrease in private insurance. However, they did not detect any statistically significant effect in the District of Columbia.

Two studies examined whether the Medicaid expansion was associated with any changes in health insurance coverage, without breaking it down by insurance type. In their study of adults with at least one chronic condition, Torres et al. (2017) found a statistically significant greater gain in insurance coverage in expansion states. Winkelman and Chang (2017) examined the Medicaid expansion effect on low-income childless adults and, in their subgroup analyses of those with one or more chronic conditions, they found a significantly larger increase in insurance coverage in expansion states.

Access to care

Three measures of access to care were examined, including access to rehabilitation, having a usual source of care or personal physician, and unmet health care need because of cost. Both studies of hospitalized trauma patients found that the Medicaid expansion significantly increased access to rehabilitation after patients were discharged from the hospital (Akande et al., 2018; Zogg et al., 2019). Both expansion and nonexpansion states experienced an increase in a usual source of care among adults having a mental health condition, but there were no significant differences between the two groups (Thomas et al., 2018). Torres et al. (2017) investigated the effect of the Medicaid expansion on having a personal physician among adults having at least one chronic disease, and did not detect any change in either expansion or nonexpansion states. In their subgroup analyses on childless adults with one or more chronic conditions, Winkelman and Chang (2017) found the expansion had increased the proportion of respondents having a personal doctor with borderline statistical significance (p < .1).

The above three studies also examined unmet health care need because of cost. Torres et al. (2017) found both expansion and nonexpansion states improved for not having to forgo a needed physician visit because of cost, with the increase in the former group slightly more and the difference between the two groups statistically significant. Winkelman and Chang (2017) found a significant decrease in the proportion of respondents who did not seek care due to cost. In contrast, Thomas et al. (2018) detected a significantly smaller decrease in unmet need for health care in expansion states. The same study did not detect any effect on unmet need for mental health care. For the ease of comparison, a positive effect on not having to forgo a needed physician visit because of cost is coded as a negative effect on unmet health care need because of cost in Table 1.

Health service utilization

Three measures of health service use were examined, including receiving treatment for substance use disorders, having a routine checkup in the past 12 months, and having received regular care. In their study of low-income adults with substance use disorders, Olfson et al. (2018) did not detect any significant change in the percentage of respondents receiving treatment from pre- to post-Medicaid expansion periods in either expansion or nonexpansion states.

Torres at al. (2017) noted some improvement in having had a routine checkup in the past 12 months among respondents having at least one chronic disease in both expansion and nonexpansion states, but did not observe any statistically significant difference between the states. Winkelman and Chang (2017) likewise examined the effect of the expansion on having a checkup within the previous year among childless adults with chronic conditions. Both expansion and nonexpansion states experienced improvement, with the former having a slightly bigger increase, statistically significant at p < .1.

Sommers, Blendon, and Orav (2016) conducted a subgroup analysis of low-income adults with at least one chronic condition and found that the Medicaid expansion was associated with a significantly larger increase in the proportion of respondents having received regular care. In a follow-up study, Sommers, Blendon, Orav, and Epstein (2016) detected a slightly larger increase in the same subgroup analysis when comparing the second year of expansion (2015) with 2013.

Assessment of Risk of Bias

Table 2 presents the assessment of risk of bias for the studies. Because all studies used cross-sectional instead of panel data, attrition bias was not applicable. The two points associated with this measure were subsequently excluded from quality assessment and the total maximum score possible became 8. A score that fell between 6.4 and 8 was in the high quality range (80%–100%), 4.0 and 6.3 was in the adequate quality range (50%–79%), and 0 and 3.9 was in the low-quality range (0%–49%). Scores received by the studies ranged from 2 to 6 with a mean of 4.2, which was the low end of the adequate quality range. Seven studies were in the adequate quality range and two studies were in the low-quality range.

Table 2.

Assessment of Risk of Bias.

Type of bias (available points)	Alande et al. (2018)	Olfson et al. (2018)	Sommers, Blendon, & Orav (2016)	Sommers, Blendon Orav, & Epstein (2016)	Sommers et al. (2014)	Thomas et al. (2018)	Torres et al. (2017)	Winkelman & Chang (2017)	Zogg et al. (2019)
Selection bias (3)
Individual-level controls (1)	Yes 1	Yes 1	Yes 1	Yes 1	Yes 1	Yes 1	Yes 1	Yes 1	Yes 1
State-level controls (1)	No 0	Yes 1	Yes 1	Yes 1	No 0	Yes 1	No 0	Yes 1	No 0
Time controls (1)	No 0	No 0	Yes 1	Yes 1	Yes 1	No 0	No 0	Yes 1	No 0
Attrition bias (2)	NA	NA	NA	NA	NA	NA	NA	NA	NA
Detection bias (3)	SID 1	NSDUH 2	RDS 1	RDS 1	ACS 2	HRMS 1	BRFSS 2	BRFSS 2	SID 1
Reporting bias (2)
Outcomes prespecified (1)	UTA	UTA	UTA	UTA	UTA	UTA	NA	UTA	UTA
Conflict of interests (1)	No 1	UTA	No 1	No 1	No 1	No 1	No 1	No 1	Yes 0
Total possible points (8)	3	4	5	5	5	4	4	6	2
Average score	4.2

Note. NA = not applicable; SID = State Inpatient Databases; NSDUH = National Survey on Drug Use and Health; RDS = Researcher-developed survey; ACS = American Community Survey; HRMS = Health Reform Monitoring Survey; UTA = Unable to assess; BRFSS = Behavioral Risk Factor Surveillance Survey.

On selection bias, all studies included individual-level controls in their analyses, five included state-level controls, and four included time controls. With regard to detection bias, seven of nine studies used survey data, four of which were surveys conducted by federal agencies (i.e., ACS, NSDUH, and BRFSS), one by a nonprofit agency (i.e., HRMS), and two by researchers themselves. Two studies utilized SID, which were administrative data that were part of an AHRQ project; it was reasonable to assume there was some form of check to measure validity and reliability. The two studies therefore received the same points as those using nonprofit- or researchers-developed surveys on this criterion.

The first measure of reporting bias asked whether a study prespecified its outcomes and whether all prespecified outcomes were reported. Because none of the studies mentioned whether they had published a protocol before the study was conducted, there was no way to assess the studies on this measure. The second measure was related to conflicts of interest. All but one study provided a disclosure statement, seven of which declared no conflicts while one stating business involvement of one of its authors.

Discussion

The results of our scoping review indicated that the Medicaid expansion had a positive effect on health insurance coverage. It was generally found to have increased Medicaid coverage and decreased the uninsured rate. Its effect on private or employer-sponsored insurance coverage was a mix of no and negative effects. In terms of access to health care, the Medicaid expansion was generally found to have reduced unmet need because of cost. Two studies found the expansion to be associated with increased access to rehabilitation. However, the Medicaid expansion had either no effect or only a positive effect with borderline statistical significance (p < .1) on having a usual source of care. In the area of health service utilization, the expansion was found to have a positive effect on receiving regular care. However, no effect or only a borderline positive effect was detected on having a routine checkup in the past 12 months. The expansion was not found to result in any significant change in treatment receipt among adults with substance use disorders.

At the time that our scoping review was conducted, there were limited studies meeting our inclusion criteria that focused specifically on people with disabilities and the Medicaid expansion’s impact on health care coverage, health care access, and use of health care. Subsequently, Hill and Hyde (2020) as well as Hill et al. (2021) conducted analyses focused on working adults with disabilities. Their analyses are descriptive, trend analyses and, while presenting informative analyses, would not meet our inclusion criteria. Findings from their studies indicated decreased uninsurance and increased Medicaid coverage. In addition, they noted reduced cost barriers to care to some extent, but there was no decline in structural barriers. A third recently published study (Stimpson et al., 2019) would meet our inclusion criteria and is focused on people with disabilities. The study reported that the Medicaid expansion had increased coverage for Medicaid and private insurance as well as reduced the uninsured rate among individuals who had at least one disability that limits their ability to work.

Based on our scoping review, an important next step toward being able to systematically review the effect of the Medicaid expansion is to develop a more consistent definition of disability. Even in recent studies focused on individuals with disabilities, two limit their analyses to individuals who are working. As rates of employment continue to be significantly lower among people with disabilities (Kraus, 2017), this is a select subset of those with disabilities. One approach is to follow Altman and Bernstein’s (2008) construction, which has been used in the AHRQ annual health care disparities reports. They draw questions from the National Health Interview Survey to create categories of basic (e.g., sensory impairment) and complex (e.g., work-limiting impairment); the questions can be cross-walked across other national surveys such as the Medical Expenditure Panel Survey to create more comparable disability measures across studies.

The studies we reviewed were generally consistent in their approach to examining health care coverage changes. Measures related to health care access and use were more varied, but this heterogeneity can also be seen in the broader literature related to the Medicaid expansion (Mazurenko et al., 2018). Following a core set of measures, such as those tracked in the AHRQ disparities reports, would be one approach to reducing the heterogeneity in the literature.

Findings that health insurance coverage increased, primarily through increased Medicaid coverage, coupled with more mixed findings related to access and use, suggest that other factors beyond health insurance coverage are important to consider, particularly for individuals with disabilities. In an analysis of insurance trends for the period 2001 through 2017, Hill and Hyde (2020) found that structural barriers (e.g., lack of transportation, lack of timely appointments) for workers with disabilities increased over the period, from 18.4% to 24.8%. Hall and colleagues (2019) conducted interviews with people with disabilities regarding their health care experiences after implementation of the ACA, finding that many barriers to accessing care persisted. For example, provider networks and capacity appeared to be problematic, as illustrated by a participant with mental illness and Medicare and Medicaid dual coverage, who explained that “for my physical health it’s been a problem finding good doctors that take Medicaid and Medicare” (p. 354). Inaccessibility of providers and equipment continues to create barriers to care (Bachman et al., 2006; Lagu et al., 2013). There is also evidence that provider knowledge and attitudes toward individuals with disabilities may serve as an impediment and contribute to disparities in their care (Agaronnik et al., 2019; Deb & Miller, 2018).

More broadly, there is evidence to suggest that providers are less willing to provide care to individuals insured through Medicaid, due to typically lower reimbursement levels (Decker, 2012). Although the ACA included an increase in primary care payments in Medicaid, the increase was time limited and the evidence that it improved access mixed. While one study found an increase in available appointments for Medicaid patients in some states (Polsky et al., 2015), another did not detect any difference in physician participation in Medicaid (Decker, 2018). As with individuals with disabilities, physician capacity is also a barrier to access in the broader Medicaid population (Tipirneni et al., 2019).

Study Limitations

Studies related to the Medicaid programs, including those we reviewed that focused on the ACA Medicaid expansion, have not used randomized controlled trials (RCTs), reducing overall study quality. Only Oregon’s 2008 Medicaid expansion employed an RCT and it predates the ACA Medicaid expansion we examined. The search results of a scoping review are a function of search terms and information sources. Although every effort was made to ensure the exhaustiveness of search terms, it was likely that they did not capture some of the studies that met the inclusion criteria. Likewise, all databases and key journals used for the searches were selected because they were commonly used in health policy research; however, there were likely to be other information sources that the authors were unaware of. By limiting our review to peer-reviewed manuscripts, we may have introduced some potential bias to our findings. Another type of potential bias may exist in the assessment process. Although the criteria and corresponding measures were based on the AHRQ guidance on assessing the risk of bias of studies in systematic reviews (Viswanathan et al., 2012), the number of points assigned to each criterion was determined by the study authors.

Conclusion

The results revealed that the Medicaid expansion had a positive effect on improving insurance coverage for people with disabilities or conditions that may be disabling. Findings related to access and use were mixed, similar to findings in the broader literature on the Medicaid expansion. Based on our scoping review, useful next steps would be to follow a more consistent definition of people with disabilities so that findings would be more comparable across studies. Tracking some core health care access and health care use measures, such as those used in the Congressionally mandated AHRQ disparities reports, would reduce heterogeneity and enhance efforts to systematically review the literature.

Supplemental Material

sj-docx-1-dps-10.1177_10442073221118124 – Supplemental material for The Effects of Medicaid Expansion Under the Affordable Care Act on Health Insurance Coverage, Health Care Access, and Health Care Use for People With Disabilities: A Scoping Review

Supplemental material, sj-docx-1-dps-10.1177_10442073221118124 for The Effects of Medicaid Expansion Under the Affordable Care Act on Health Insurance Coverage, Health Care Access, and Health Care Use for People With Disabilities: A Scoping Review by Xiaobei Dong and Nancy A. Miller in Journal of Disability Policy Studies

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material is available on the Journal of Disability Policy Studies webpage with the online version of the article.

References

Agaronnik

N. D.

Campbell

E. G.

Ressalam

Iezzoni

L. I.

(2019). Exploring issues relating to disability cultural competence among practicing physicians. Disability and Health Journal, 32, 403–410. https://doi.org/10.1016/j.dhjo.2019.01.010

*Akande

Minneci

P. C.

Deans

K. J.

Xiang

Cooper

J. N.

(2018). Association of Medicaid expansion under the Affordable Care Act with outcomes and access to rehabilitation in young adult trauma patients. JAMA Surgery, 153(8), 1–11. https://doi.org/10.1001/jamasurg.2018.1630

Altman

Berstein

(2008). Disability and health in the United States, 2001-2005. National Center for Health Statistics.

The American Association on Health and Disability. (2015). Guide to disability for healthcare insurance marketplace navigators. https://nationaldisabilitynavigator.org/wp-content/uploads/Materials/Disability-Guide.pdf

Arksey

O’Malley

(2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methods, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616

Bachman

M. L.

Tobias

Maisels

(2006). Provider perceptions of their capacity to offer accessible health care for people with disabilities. Journal of Disability Policy Studies, 17(3), 130–136. https://doi.org/10.1177/10442073060170030101

Breslau

Stein

B. D.

Han

Shelton

(2018). Impact of the Affordable Care Act’s dependent coverage expansion on the health care and health status of young adults: What we know. Medical Care Research and Review, 75(2), 131–152. https://doi.org/10.1177/1077558716682171

Deb

Miller

N. A.

(2018). Mental health status, gender, race/ethnicity and patient-provider interactions. Journal of Disability Policy Studies, 29(3), 131–141. https://doi.org/10.11771044207313772064

Decker

S. L.

(2012). In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but raising fees may help. Health Affairs, 31(8), 1673–1679. https://doi.org/10.1377/hlthaff.2012.0294

10.

Decker

S. L.

(2018). No association found between the Medicaid primary care fee bump and physician-reported participation in Medicaid. Health Affairs, 37(7), 1092–1098. https://doi.org/10.1377/hlthaff.2018.0078

11.

French

M. T.

Homer

Gumus

Hickling

(2016). Key provisions of the Patient Protection and Affordable Care Act (ACA): A systematic review and presentation of early research findings. Health Services Research, 51(5), 1735–1771. https://doi.org/10.1111/1475-6773.12511

12.

Hadley

(2003). Sicker and poorer- the consequences of being uninsured: A review of the research on the relationship between health insurance, medical care use, health, work, and income. Medical Care Research and Review, 60(2 Supp.), 3S–75S. https://doi.org/10.1177/1077558703254101

13.

Hall

J. P.

Kurth

N. K.

Gimm

Smith

(2019). Perspectives of adults with disabilities on access to health care after the ACA: Qualitative findings. Disability and Health Journal, 12, 350–358. https://doi.org/10.1016/j.dhjo.2019.01.014

14.

Hanson

K. W.

Neuman

Dutwin

Kasper

J. D.

(2003). Uncovering the health challenges facing people with disabilities: The role of health insurance. Health Affairs, W3, 552–565. https://doi.org/10.1377/hlthaff.w3.552

15.

Henning-Smith

McAlpine

Shippee

Priebe

(2013). Delayed and unmet need for medical care among publicly insured adults with disabilities. Medical Care, 51(11), 1015–1019. https://doi.org/10.1097/MLR.0b013e3182a95d65

16.

Hill

Hyde

J. S.

(2020). Insurance coverage and access to care for workers with disabilities. Disability and Health Journal, 13, 1–8. https://doi.org/10.1016/j.dhjo.2019.100843

17.

Hill

Shin

Hyde

J. S.

(2021). Access to care and health insurance coverage for workers with disabilities: Outcomes by state-level responses to the ACA. Disability and Health Journal, 14(4), 1–6. https://doi.org/10.1016/j.dhjo.2021.101099

18.

Kaiser Family Foundation. (2020). Status of state Medicaid expansion decisions: Interactive map. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/

19.

Kraus

(2017). 2016 Disability statistics annual report. University of New Hampshire. https://disabilitycompendium.org/sites/default/files/user-uploads/2016_AnnualReport.pdf

20.

Lagu

Hannon

N. S.

Rotherberg

M. B.

Wells

A. S.

Green

K. L.

Windom

M. O.

. . . Kindenauer

P. K.

(2013). Access to subspecialty care for patients with mobility limitations: A survey. Annals of Internal Medicine, 138(6), 441–446. https://doi.org/10.7326/0003-4819-158-6-201303190-00003

21.

LaPlante

Kaye

Kang

Harrington

(2004). Unmet need for personal assistance services: Estimating the shortfall in hours of help and adverse consequences. Journals of Gerontology, B, 59(2), S98–S108. https://doi.org/10.1093/geronb/59.2.s98

22.

Long

S. K.

King

Coughlin

T. A.

(2005). The implications of unmet need for future health care use: Findings for a sample of disabled Medicaid beneficiaries in New York. Inquiry, 42, 413–420. https://doi.org/10.5034/inquiryjrnl_42.4.413

23.

Mazurenko

Balio

C. P.

Agarwal

Carroll

A. E.

Menachemi

(2018). The effects of Medicaid expansion under the ACA: A systematic review. Health Affairs, 37(6), 944–950. https://doi.org/10.1377/hlthaff.2017.1491

24.

Medicaid and CHIP Payment and Access Commission. (n.d.). Overview of the Affordable Care Act and Medicaid. https://www.macpac.gov/subtopic/overview-of-the-affordable-care-act-and-medicaid/

25.

Medicaid and CHIP Payment and Access Commission. (2017). People with disabilities. https://www.macpac.gov/subtopic/people-with-disabilities/

26.

Mitra

Findley

P. A.

Sambamoorthi

(2009). Health care expenditures of living with a disability: Total expenditures, out-of-pocket expenses, and burden, 1996 to 2004. Archives of Physical Medicine and Rehabilitation, 90(9), 1532–1540. https://doi.org/10.1016/j.apmr.2009.02.020

27.

Moss

H. A.

Kaplan

S. J.

Zafar

S. Y.

(2020). The Affordable Care Act’s Medicaid expansion and impact along the cancer care continuum: A systematic review. Journal of the National Cancer Institute, 112(8), 779–791. https://doi.org/10.1093/jnci/djaa043

28.

Munz

Peters

M. D.

Stein

Tufanaru

McArthur

Aromataris

(2018). Systematic review or scoping review? Guidance for authors when choosing a systematic or scoping review approach. BMC Medical Research Methodology, 18, Article 143. https://doi.org/10.1186/s12874-018-0611-x

29.

Musumeci

Foutz

(2017). Medicaid restructuring under the American Health Care Act and nonelderly adults with disabilities. The Henry J. Kaiser Family Foundation. http://files.kff.org/attachment/Issue-Brief-Medicaid-Restructuring-Under-the-American-Health-Care-Act-and-Nonelderly-Adults-with-Disabilities

30.

National Council on Disability. (2013). Chapter 2. Medicaid, managed care, and people with disabilities. In National Council on Disability (Ed.), Medicaid managed care for people with disabilities (pp. 43–58).

31.

*Olfson

Wall

Barry

C. L.

Mauro

Mojtabai

(2018). Impact of Medicaid expansion on coverage and treatment of low-income adults with substance use disorders. Health Affairs, 37(8), 1208–1215. https://doi.org/10.1377/hlthaff.2018.0124

32.

Polsky

Richards

Basseyn

Wissoker

Kenney

G. M.

Zuckerman

Rhodes

K. V.

(2015). Appointment availability after increases in Medicaid payments for primary care. New England Journal of Medicine, 372(6), 537–545. https://doi.org/10.1056/NEJMsa1413299

33.

Pumkam

Probst

J. C.

Bennett

K. J.

Hardin

Xirasagar

(2013). Health care expenditures among working-age adults with physical disabilities: Variations by disability spans. Disability and Health Journal, 6(4), 287–296. https://doi.org/10.1016/j.dhjo.2013.03.002

34.

Reichard

Gulley

S. P.

Rasch

E. K.

Chan

(2015). Diagnosis isn’t enough: Understanding the connections between high health care utilization, chronic conditions and disabilities among U.S. working age adults. Disability and Health Journal, 8(4), 535–546. https://doi.org/10.1016/j.dhjo.2015.04.006

35.

*Sommers

B. D.

Blendon

R. J.

Orav

E. J.

(2016). Both the “private option” and traditional Medicaid expansions improved access to care for low-income adults. Health Affairs, 35(1), 96–105. https://doi.org/10.1377/hlthaff.2015.0917

36.

*Sommers

B. D.

Blendon

R. J.

Orav

E. J.

Epstein

A. M.

(2016). Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Internal Medicine, 176(10), 1501–1509. https://doi.org/10.1001/jamainternmed.2016.4419

37.

*Sommers

B. D.

Kenney

G. M.

Epstein

A. M.

(2014). New evidence on the Affordable Care Act: Coverage impacts of early Medicaid expansions. Health Affairs, 33(1), 78–87. https://doi.org/10.1377/hlthaff.2013.1087

38.

Stimpson

J. P.

Kemmick Pintor

McKenna

R. M.

Park

Wilson

F. A.

(2019). Association of Medicaid expansion with health insurance coverage among persons with a disability. JAMA New Open, 2(7), Article e197136. https://doi.org/10.1001/jamanetworkopen.2019.7136

39.

Sucharew

Macaluso

(2019). Methods for research evidence synthesis: The scoping review approach. Journal of Hospital Medicine, 14(7), 416–418. https://doi.org/10.12788/jhm.3248

40.

Taylor

D. M.

(2018). Americans with disabilities: 2014. https://www.census.gov/content/dam/Census/library/publications/2018/demo/p70-152.pdf

41.

*Thomas

K. C.

Shartzer

Kurth

N. K.

Hall

J. P.

(2018). Impact of ACA health reforms for people with mental health conditions. Psychiatric Services, 69(2), 231–234. https://doi.org/10.1176/appi.ps.201700044

42.

Tipirneni

Kieffer

E. C.

Ayanian

J. Z.

Campbell

E. G.

Salman

Clark

S. J.

. . . Kirch

M. A.

(2019). Factors influencing primary care providers’ decisions to accept new Medicaid patients under Michigan’s Medicaid expansion. American Journal of Managed Care, 25(3), 120–127.

43.

*Torres

Poorman

Tadepalli

Schoettler

Fung

C. H.

Mushero

. . . McCormick

(2017). Coverage and access for Americans with chronic disease under the Affordable Care Act: A quasi-experimental study. Annals of Internal Medicine, 166(7), 472–479. https://doi.org/10.7326/M16-1256

44.

Viswanathan

Ansari

M. T.

Berkman

N. D.

Chang

Hartling

McPheeters

L. M.

. . . Treadwell

J. R.

(2012). Assessing the risk of bias of individual studies in systematic reviews of health care interventions. In Methods Guide for Comparative Effectiveness Reviews (AHRQ Publication No. 12-EHC047-EF) (pp. 33). Agency for Healthcare Research and Quality.

45.

*Winkelman

T. N. A.

Chang

V. W.

(2017). Medicaid expansion, mental health, and access to care among childless adults with and without chronic conditions. Journal of General Internal Medicine, 33(3), 376–383. https://doi.org/10.1007/s11606-017-4217-5

46.

World Health Organization. (2002). Towards a common language for functioning, disability and health. https://cdn.who.int/media/docs/default-source/classification/icf/icfbeginnersguide.pdf

47.

Yee

(2015). The Affordable Care Act and people with disabilities. GP Solo, 32(2), 17–20. https://www.jstor.org/stable24632495

48.

*Zogg

C. K.

Scott

J. W.

Metcalfe

Gluck

A. R.

Curfman

G. D.

Davis

K. A.

. . . Haider

A. H.

(2019). Association of Medicaid expansion with access to rehabilitative care in adult trauma patients. JAMA Surgery, 154(5), 402–411. https://doi.org/10.1001/jamasurg.2018.5177

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