The Virginia legislature recently voted to expand Medicaid, joining 32 states and the District of Columbia in accepting federal dollars to do so under the Affordable Care Act (ACA). The decision comes as the Trump administration and many congressional Republicans seek to shrink the program through repeals, spending caps, and block grants, or through work requirements and other waivers to limit eligibility.

Now, a new study led by a Boston University School of Public Health (BUSPH) researcher finds the first two years of Medicaid expansion under the ACA, 2014 and 2015, bolstered the quality and receipt of care for millions of low-income patients, especially those in rural areas.

The study, published in the June issue of Health Affairs, looked at community health centers, which mostly serve low-income and disproportionately uninsured patients. The researchers found community health centers in expansion states saw an 11.44 percentage point decline in uninsurance and a 13.15 percentage point increase in Medicaid coverage among their patients after two years of Medicaid expansion, compared with similar community health centers in non-expansion states. Rural community health centers also showed improvements in asthma treatment, body mass index screening and follow-up, and hypertension control, along with substantial increases in 18 types of visits—particularly for mammograms, abnormal breast findings, alcohol-related disorder, and other substance use disorders.

“Rural areas appear to disproportionately benefit from expanding Medicaid, even though rural states have been less likely to expand eligibility,” says lead author Megan Cole, assistant professor of health law, policy & management at BUSPH. “These findings may be particularly important to more rural states like Maine, Idaho, and Nebraska, who are actively considering or trying to implement Medicaid expansion, as well as for states that are considering repealing Medicaid expansion or imposing restrictions on eligibility.”

The study follows on previous research by Cole and her co-authors after one year of Medicaid expansion. That study looked at 1,057 community health centers in both expansion and non-expansion states, and found an 11 percentage point decrease in uninsurance among community health center patients, and a 12 percentage point increase in Medicaid coverage, with similar changes in both expansion and non-expansion states. They also found quality improvements in asthma treatment, Pap testing, body mass index assessment, and hypertension control.

For the new study, the researchers used 2011-2015 or 2012-2015 nationally-representative data collected by the Health Resources and Services Administration (HRSA). The sample included 1,009 community health centers in each year, including all 578 community health centers in states that had expanded Medicaid by 2014. The centers treated 18.5 million patients in 2011 and 21.2 million in 2015.

The researchers looked at 21 types of patient visit, finding 13 visit types that increased significantly with Medicaid expansion. These effects were largely driven by changes in rural areas, where researchers saw significant increases in 18 of the visit types.

At rural community health centers, Medicaid expansion was associated with approximately 437,000 visits for depression, 141,000 visits for Pap testing, and 457,000 visits for hypertension over the two-year period, “totals that would likely be much higher if more states had expanded Medicaid,” the authors wrote.

Community health centers in rural areas also saw improvements over their non-expansion counterparts in several treatment areas, including a 3.5 percentage point increase in patients with asthma receiving appropriate pharmacologic treatment, a 6.7 percentage point increase in adults receiving a BMI screening and follow-up if needed, and a marginally significant increase in the percentage of patients receiving a Pap test. The researchers also found a 2.1 percentage point increase in blood pressure control for hypertensive patients, with the greatest relative gains in this area seen among Hispanic patients in rural areas, who had a 5.2 percentage point increase.

The authors wrote that they may not have seen an association between more visits and Medicaid expansion at urban community health centers because patients in urban areas have greater access to other providers, whereas rural patients have fewer choices and so are more likely to continue going to a community health center when they gain insurance coverage.

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