Did Medicaid slow declines in access to health care during the great recession?

OBJECTIVE: We examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007-2009 Great Recession. DATA SOURCE: 2004-2010 Behavioral Risk Factor Surveillance System (BRFSS). STUDY DESIGN: Flexible difference-in-difference regressions were used to compare the impact of county-level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines. DATA COLLECTION/EXTRACTION METHODS: Nonelderly adults (aged 19-64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics' Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state's 2007 Medicaid guidelines using data from the 2007 Current Population Survey's Annual Social and Economic Supplement. PRINCIPAL FINDINGS: A percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9-1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6-1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county-level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost-a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines. CONCLUSIONS: Increased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.

Trends in hospital ED closures nationwide and across Medicaid expansion, 2006-2013.

STUDY HYPOTHESIS: Low reimbursement from the uninsured has been claimed to threaten hospital finances and even hospital emergency department (ED) closure. We hypothesized in advance of beginning data collection that states that expanded Medicaid ("expansion states") under the 2010 Patient Protection and Affordable Care Act would experience a reduced rate of ED closure compared with states that did not. METHODS: We compiled a national census of EDs from 2006 through 2013 from federal databases and manually confirmed each closure. We used difference-in-differences regression on this longitudinal panel to compare the probability over time that a hospital was in operation in expansion states to nonexpansion states. RESULTS: The number of hospitals grew every year nationally and in nonexpansion states. In expansion states, the number fell from 2027 in 2009 to 2019 in 2010, not surpassing the 2009 peak until 2012. In regression estimates, hospitals in expansion states were 2.2% (95% confidence interval, 0.3%-4.1%) less likely to be in operation after 2010 compared with the trend in nonexpansion states. CONCLUSIONS: States that expanded Medicaid experienced increased, rather than reduced, ED closure rates from 2010 through 2013. The financial benefits of the Affordable Care Act may be poorly targeted to the hospitals most vulnerable to closure.