10 years in, the Medicaid expansion is failing the neediest Americans

As we mark the 10th anniversary of the first expansions of states’ Medicaid programs under the Affordable Care Act, which began in January 2014, it’s time to think again about the effects on the most vulnerable in our society.

Consider, for example, what is unfolding in North Carolina. 

Last month, it became the 40th state to expand Medicaid under the ACA, opening the program to an estimated 600,000 adults who, while relatively low-income earners, previously did not qualify. The immediate effects deserve to be celebrated: Thousands of uninsured people are gaining coverage, including some who are coping with debilitating illnesses.

Yet as new enrollees flood into the program, fewer providers will be left to care for the millions of needier people — children, people with disabilities and vulnerable seniors — for whom Medicaid was originally intended.

North Carolina’s own Department of Health and Human Services warns that the state faces “a severe shortage of behavioral health providers and dental professionals who serve Medicaid, uninsured and low-income patients.” The latest data shows that of North Carolina’s 100 counties, 93 are experiencing shortages of primary care clinicians, 94 face shortages of mental health practitioners and 100 — every single county in the state — lack enough dental care providers.

Expanding Medicaid has placed further strain on a health system already failing to provide adequate access to care to those who need it most. In the months and years ahead, North Carolinians already on the program will find it harder to obtain timely, high-quality health services.

The experiences of other states bear this out. 

Medicaid expansion has been linked to longer waits for appointments, slower ambulance response times and greater delays in the emergency room. A meta-analysis of 34 studies found that appointment availability for Medicaid patients declined sharply post-ACA relative to those with private insurance — due, at least in part, to the nearly 20 million additional adults nationwide who have joined Medicaid over the last decade.

These impediments to care have caused tangible harm. In a recent paper, my colleagues and I found that expansion worsened the mental health of existing Medicaid beneficiaries, causing an 11 percent increase in symptoms of depression among older adults. We uncovered even larger negative effects among rural residents and those living in areas without enough mental health providers, consistent with the idea that new enrollees have crowded out the neediest.

These findings help explain why long-promised gains in population health have failed to materialize in expansion states. Last year, an analysis of more than a dozen state Medicaid expansions from the 1990s and early 2000s found no evidence that the reforms reduced death rates. One study estimated that overall mortality trends actually worsened in states that expanded Medicaid compared to states that did not.

In short, any health benefits that have accrued to those gaining coverage under Medicaid expansion have been offset by declines among other groups, most likely the traditional Medicaid population.

To make matters worse, the prioritization of new enrollees over traditional Medicaid recipients is built into the program’s DNA. The federal government offers substantially more Medicaid funding to states to cover expansion enrollees than to cover other eligibility groups, including children and those with disabilities. As costs mount and cuts to Medicaid become fiscally unavoidable, this structure creates strong incentives for states to slash traditional Medicaid enrollees’ benefits first.

If current projections are accurate, the Medicaid rolls in North Carolina will grow by nearly 20 percent over the next year. As enrollment swells, the state’s declining uninsured rate is sure to be used as proof of expansion’s success. 

But having a health insurance card is a far cry from receiving the care you need. Just ask the millions whose struggle has been made more difficult.

Liam Sigaud is a postgraduate fellow with the Mercatus Center at George Mason University.