Ohio medicaid expansion enrollees: Impact of loss of coverage on access to care,2018

Abstract

This study investigates the extent to which former Medicaid expansion enrollees transition to other forms of health insurance coverage, and whether loss of Medicaid is associated with greater difficulties accessing health care. Findings from a 2018 survey of current and former enrollees in Ohio’s Medicaid expansion program revealed that nearly two-thirds of respondents no longer covered by Medicaid had transitioned to another form of insurance coverage. The most prevalent reason for not having coverage among the remaining one-third was affordability. Former Medicaid enrollees that obtained other sources of coverage also reported greater difficulties accessing health care services than their counterparts remaining on Medicaid. The prevailing explanation as to the cause of experiencing difficulties in accessing health care was the expense. These findings demonstrate that for former Medicaid enrollees, perceived high costs are a significant barrier to obtaining non-Medicaid coverage and accessing health care services.

Keywords

Medicaid expansion health insurance coverage access to care

1. Introduction

Ohio’s ACA Medicaid expansion came into effect in January 2014, expanding the pool of Ohioans eligible for Medicaid to all adults ages 19 to 64 with income at or below 138% of the Federal Poverty Level. As of late 2017, almost one fifth of Ohio adults age 19 to 64 have participated in Ohio’s Medicaid expansion program – approximately 1.26 million individuals – although only about half (52.5%) remained enrolled in Medicaid at the end of 2017 [1]. This high rate of turnover was anticipated by prior research, which identified fluctuations in income and administrative burden as common drivers of un-enrollment [2, 3]. Among those former enrollees with other health insurance (EXHIBIT 1), about half (49.3%) report difficulties accessing care, while two thirds (66.1%) without health insurance report such difficulties (EXHIBIT 3). The critical barrier to accessing care and obtaining health coverage is cost (Exhibits, 2, 4, 5). These findings underscore the fact that affordability remains a major obstacle to continuity of care for former Medicaid enrollees.

2. Data and methods

This research study uses the 2018 Ohio Medicaid Group VIII Assessment telephone survey ( $N=$ 5,867), which asked current and former Medicaid expansion enrollees about their access to care along with other topics, including employment, health status, household dynamics, and reasons for un-enrollment and re-enrollment in Medicaid. The analyses presented here are limited to former Medicaid expansion enrollees who lost their coverage within the last twelve months and who reported no longer having Medicaid coverage ( $N=$ 905), and individuals who were currently enrolled in Ohio’s Medicaid expansion program and who had been continuously enrolled in Medicaid for at least one year prior to 2018 ( $N=$ 1,710). The survey was limited to individuals who were enrolled in Ohio’s Medicaid expansion 2014–2017, excluding individuals were dual eligible, living in a nursing home or other institutional setting, third party liability or were enrolled in the Aged, Blind, and Disabled program at any point during this period. In order to be included for the continuously enrolled group, individuals also had to be enrolled for at least one year, un-enrolled for less than 30 days in the year prior to November 30, 2017, and enrolled as of November 2017. In order to be included in the former enrollee group, an individual needed to be enrolled for at least one year, un-enrolled within the 12 months prior to November 30, 2017, and un-enrolled for at least six months and not currently enrolled as of November 30, 2017. The survey employed a stratified random sample design among eligible respondents, with individuals stratified by gender, Medicaid enrollment type (e.g. continuously enrolled or former enrollee), age (19–44 years or 45–64 years of age), and county type (rural, suburban, metro, and whether the county recruited respondents into a post-survey biometric screening). The response rates were 9.1% for the unenrolled sample and 15.8% for the continuously enrolled sample [4, 5]. The difference in response rates was likely due to the fact that the sample frame was constructed from Medicaid administrative data and former enrollees were less likely to have accurate, updated contact information than current enrollees.

More than half (56.0%) of survey respondents who were not enrolled at the time of the survey reported still having Medicaid coverage. We limit the analyses of former enrollees here to those who reported no longer being enrolled because only these individuals could be asked about their experiences since losing Medicaid coverage. All estimates use survey weights, including significance tests, which are calculated as design-based F statistics using Stata 14 [6].

3. Insurance status for former enrollees

Nearly two thirds (63.6%) of former enrollees had obtained some other form of insurance, with 39.4% having employer-sponsored insurance and 24.2% having some other insurance, including through a family member’s work, health insurance exchange, or Medicare (Fig. 1).

Figure 1.

Former Ohio Medicaid Expansion Enrollees: Current Insurance Status, 2018. Source: Authors’ analysis of data from the 2018 Ohio Medicaid Group VIII Assessment Telephone Survey.

Figure 2 depicts the reasons for not having insurance – answers to this question were not exclusive – with the most common reasons being unable to afford insurance (69.7%) or being unable to afford insurance that covers needed care (32.6%). About one fifth of respondents reported not knowing how to get health insurance (19.1%) or not wanting any insurance (19.2%).

Figure 2.

Former Ohio Medicaid Expansion Enrollees without Insurance: Reasons for not Having Insurance, 2018. Source: Authors’ analysis of data from the 2018 Ohio Medicaid Group VIII Assessment Telephone Survey.

4. Loss of medicaid coverage and difficulties accessing care

Compared to current Medicaid expansion enrollees, former Medicaid expansion enrollees were significantly more likely to report difficulties accessing care: whereas 37.5% of current Medicaid enrollees reported having difficulties accessing care in the last twelve months, 49.3% of former Medicaid enrollees with insurance and 66.1% of those without insurance reported difficulties accessing care within the last twelve months since losing Medicaid coverage (Fig. 3). The differences between current Medicaid enrollees and former enrollees with health insurance and between former enrollees with health insurance and those without health insurance are significant at $p<$ 0.001 and $p<$ 0.01, respectively. Current Medicaid enrollees were also significantly less likely ( $p<$ 0.01) to report difficulties accessing care than former Medicaid enrollees with insurance for each type of care in the survey, including dental care, vision care, mental health care, prescriptions, and medical supplies.

Figure 3.

Percent of Current and Former Ohio Medicaid Expansion Enrollees Reporting Difficulties Accessing Care in the Last Year (Current Medicaid) or Since Loss of Medicaid Coverage within the Last Year (Former Medicaid), 2018. Source: Authors’ analysis of data from the 2018 Ohio Medicaid Group VIII Assessment Telephone Survey.

5. Cost as the critical barrier to access

The most common reason for difficulties accessing care among former Medicaid enrollees was perceived cost (Fig. 4). This was the case for both former Medicaid enrollees with insurance (83.6%) and without insurance (82.1%). The next most common reason was that insurance did not pay for needed care (51.8%) for unenrolled with insurance, unenrolled without insurance were not asked this question. Other reasons, including not being able to find a provider that took the respondent’s insurance, the provider was not available when the respondent needed to go, and the respondent did not have transportation, were less common.

Figure 4.

Former Ohio Medicaid Enrollees: Reasons for Difficulties Accessing Care by Current Insurance Status, 2018. Source: Authors’ analysis of data from the 2018 Ohio Medicaid Group VIII Assessment Telephone Survey.

When former Medicaid enrollees with insurance were asked to estimate annual out-of-pocket medical expenses not including premiums, about half (53.0%) reported less than $1,500, 24.4% reported $1,500–$3,500, and 15.4% reported more than $3,500 (Fig. 5). While this level of out-of-pocket expenses is not unusual for individuals with private insurance [7], these expenses could still represent a significant budget burden for the large percentage of former Medicaid enrollees who reported moderate-to-low incomes: 37.2% reported an annual income under 138% of the Federal Poverty Level (FPL) ($35,535 for a household of four), while 34.7% reported and annual income between 138%–250% FPL (up to $64,375 for a household of four).

Figure 5.

Estimated Annual Out-of-Pocket Costs (Minus Premiums) for Former Ohio Medicaid Enrollees with Health Insurance, 2018. Source: Authors’ analysis of data from the 2018 Ohio Medicaid Group VIII Assessment Telephone Survey.

6. Discussion

The results presented in this research study indicate that loss of Medicaid coverage often translates into difficulties accessing care, consistent with prior research [8, 9]. The most prevalent obstacle to obtaining care is cost – this encompasses the affordability of insurance premiums, the comprehensiveness of insurance coverage, and high out-of-pocket expenses besides premiums. Because participation in Medicaid through the ACA-based expansion is widespread yet often temporary, the barriers to care associated with transitioning off of Medicaid coverage will continue to be an important issue of concern for policymakers.

Footnotes

Acknowledgments

We would like to thank Elizabeth Truex-Powell and John Barley at the Ohio Department of Medicaid and Timothy Sahr at the Ohio Colleges of Medicine Government Resource Center for their thoughtful feedback on an earlier draft of the manuscript.

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