Coverage, Affordability, and Care for Low-Income People with Diabetes: 4 Years after the Affordable Care Act’s Medicaid Expansions (Journal of General Internal Medicine)

​Diabetes is one of the most common and expensive diseases in the nation. Although the positive impact of the Affordable Care Act’s (ACA) Medicaid expansions on insurance coverage, access, and health have been extensively studied in the general population, the extent to which the ACA Medicaid expansions affect people with diabetes is unclear. 

In this study, authors use data from 2011 to 2017 Behavioral Risk Factor Surveillance System (BRFSS) and compare residents in 24 Medicaid expansion states with those in 20 non-expansion states using a difference-in-differences (DD) approach. The analytic sample includes low-income nonelderly BRFSS respondents (income less than or equal to 138% Federal Poverty Level, ages 19–64) who reported having ever been told that they have diabetes in the 2011 to 2017 BRFSS. To reveal possible changes in policy effects across the years, authors fit two sets of models: The first set considers 2015 and 2016 as the early post-expansion period (year 2 and 3 effect), while the second set uses data from 2017 as the later post-expansion period (year 4 effect). All models control for the following variables: age, gender, educational attainment, language of interview, employment status, marital status, race/ethnicity, self-reported health, income level, number of children in the household, number of adults in the household, state and year-quarter fixed effects, and state annual unemployment rates. 

In the results, the final sample includes 16,666 respondents from expansion states and 19,176 respondents from non-expansion states. Characteristics of individuals between the two groups are similar. The year 2 and 3 effect of the expansions on health insurance coverage is 7.0 percentage points (pp), and is 6.2 pp on having no financial barriers to care. However, the effects decreased and became insignificant in 2017. The year 4 effect (3.2 pp) of receiving a routine annual checkup is larger than the year 2 and 3 effect (2.7 pp), but still insignificant. 

While non-Hispanic whites saw continued gains in health insurance coverage (9.5 pp in year 2 and 3, and 7.0 pp in year 4) and significant increases in routine checkups in year 4 (7.9 pp), blacks and Hispanics did not.

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• Journal Article: Coverage, Affordability, and Care for Low-Income People with Diabetes: 4 Years after the Affordable Care Act’s Medicaid Expansions