Impacts of the Affordable Care Act's Medicaid Expansion on Access to Care and Use of Preventive Services for Women of Reproductive Age
*Names in bold indicate Presenter
Study Design: We conduct logistic cross-state analyses with two-way (state and year) fixed effects to estimate the effect of states’ ACA Medicaid expansions on the likelihood that WRA (19-44): 1) were uninsured; 2) needed to see a doctor, but could not due to cost; 3) had a primary care visit in the past year; 4) had no personal doctor; 5) ever had a Pap; 6) had a Pap in the past 3 years; 7) ever had an HIV test; and 8) had a flu shot in the past year. This analysis compares changes in the likelihood of each outcome for low-income WRA in Medicaid expansion states to changes for low-income women in non-expansion states. We use data from the Behavioral Risk Factor Surveillance Survey (BRFSS) 2012-2014 and control for individual and time varying state characteristics.
Population Studied: Our treatment group includes WRA with incomes affected by the ACA in 14 states that expanded Medicaid and our control group includes WRA in 16 states without expansions. We omit women in states with prior Medicaid waivers or early ACA expansions. We stratify our samples to identify effects specific to women with incomes ≤138% of the federal poverty level (FPL) (N=33,043); women with incomes 139-400% FPL (N = 47,841); and nulliparous women in these income ranges (N= 5,769; 13,437).
Findings: The ACA Medicaid expansion decreased the likelihood that WRA with incomes ≤138% FPL were uninsured by 8.9 percentage points (pp), a decline from the full sample the mean of 43.1% uninsured to 34.2% uninsured. This overall effect was driven by a decline of 24.4 pp for nulliparous women. Nulliparous women also experienced a decline in the likelihood of no personal doctor (13.9 pp) and an increase in the likelihood of having had a Pap test in the past three years (9.1 pp). These additional effects were not found for the full sample of women. Spillover effects of Medicaid expansion were found for women with incomes 139-400% FPL, who experienced a 5.0 pp decline in uninsurance and a 3.9 pp increase in the likelihood of a recent primary care visit. Significant effects were not found for the remaining outcomes.
Policy Implications: The ACA Medicaid expansion successfully increased insurance coverage among low-income WRA but no effects were found for the other measures of access to care or use of preventive services based on the short post-implementation period with available BRFSS data. The large magnitude of the effect and the additional significant results for nulliparous women suggest that these women may have faced greater barriers than mothers to health insurance pre-pregnancy. Such barriers are consistent with the previous categorical eligibility structure of Medicaid, which omitted childless adults. Increasing access for all WRA is important to several public health goals related to family planning and maternal and child health in the United States.