ACA’s benefits for low-income insured fell short of key goals

People with low incomes have benefited in key ways from the Affordable Care Act and Medicaid expansion, but without further federal and state health care policy revisions, millions of U.S. citizens will not receive the medical attention they need to truly improve their health.

That’s the conclusion of a recent study directed by David Levine, M.D. with Brigham and Women’s Hospital in Boston. Levine’s team set out to examine “the association of the ACA with changes in high-value care, low-value care, patient experience, utilization, and cost.”

They analyzed medical data from nearly 125,000 patients, comparing responses and care outcomes from two groups before the ACA’s adoption and after. The first group — the primary focus of the study — had incomes of less than 400% of the federal poverty level (FPL). The second had incomes of 400% of FPL or greater.

The study found that data from the lower income group with access to health insurance and with Medicaid expansion showed “the ACA was associated with more high-value diagnostic and preventive testing, improved patient experience and access, and decreased out-of-pocket expenditures.”

However, the data also suggested that the group’s experience with most quality measures, utilization, or the total cost of care was relatively unchanged even with coverage.

“The ACA was associated with improved patient experience, communication, and access and decreased out-of-pocket expenditures, but little or no change in quality, utilization, and total cost,” their submission to the Journal of the American Medical Association stated. “Surprisingly, the significant improvements in receipt of health insurance and respondent-reported access were not associated with increases in health care utilization or the total cost of care, as has typically been seen when health insurance coverage is extended to more people. Individuals with income less than 400% of the FPL continued to utilize care at lower levels compared with those with higher income.”

Given these results, Levine and his associates called for more aggressive health insurance reform, adding that universal health insurance could be part of the solution. In addition to universal health coverage, they recommend the following:

• Further expansion of Medicaid in states
• Larger changes in out-of-pocket cost subsidies to increase utilization
• Testing “different cost structures … to incentivize more high-value care and less low-value care”

“These findings may suggest that achieving universal insurance coverage could assist in transforming the U.S. health care delivery system into a high-value and equitable system,” the authors concluded.