Medicaid: Access to Health Care for Low-Income Adults in States with and without Expanded Eligibility

Under PPACA, states could choose to expand Medicaid coverage to certain uninsured, low-income adults. As of December 2017, 31 states and the District of Columbia chose to expand Medicaid to cover these adults, and 19 states did not.

GAO was asked to provide information about the demographic characteristics of and access to health care services for low-income adults—those with household incomes less than or equal to 138 percent of the federal poverty level—in expansion and non-expansion states. This report describes 2016 national survey estimates of (1) the number and demographic characteristics for low-income adults who were uninsured in expansion and non-expansion states, (2) unmet medical needs for low-income adults in expansion and non-expansion states and by insurance status, (3) barriers to health care for low-income adults in expansion and non-expansion states and by insurance status, and (4) having a usual place of care and receiving selected health care services for low-income adults in expansion and non-expansion states and by insurance status.

GAO obtained 2016 NHIS estimates from the National Center for Health Statistics (NCHS), the federal agency within the Department of Health and Human Services that maintains these survey data.

NHIS is a household interview survey designed to be a nationally representative sample of the civilian, non-institutionalized population residing in the United States. Estimates were calculated for demographic characteristics for uninsured, low-income adults. In addition, estimates were calculated for unmet medical needs, barriers to health care, and having a usual place of care and receiving selected health services for low-income adults in expansion and non-expansion states and by insurance status The estimates were based on responses to selected survey questions. GAO selected these survey questions from the Family and Adult Access to Health Care and Utilization and another section of the 2016 NHIS.

GAO took steps to assess the reliability of the 2016 NHIS estimates, including interviewing NCHS officials and examining the data for logical errors. GAO determined that the data were sufficiently reliable for the purposes of its analyses.

The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.

According to the 2016 National Health Interview Survey (NHIS), an estimated 5.6 million uninsured, low-income adults—those ages 19 through 64—had incomes at or below the income threshold for expanded Medicaid eligibility as allowed under the Patient Protection and Affordable Care Act (PPACA). Estimates from this nationally representative survey showed that about 1.9 million of the 5.6 million uninsured, low-income adults lived in states that chose to expand Medicaid under PPACA, while the remaining 3.7 million lived in non-expansion states—those that did not choose to expand Medicaid. In 2016, over half of uninsured, low-income adults were male, over half were employed, and over half had incomes less than 100 percent of the federal poverty level in both expansion and non-expansion states.

The 2016 NHIS estimates showed that low-income adults in expansion states were less likely to report having any unmet medical needs compared with those in non-expansion states, and low-income adults who were insured were less likely to report having unmet medical needs compared with those who were uninsured. Among the low-income adults who were uninsured, those in expansion states were less likely to report having any unmet medical needs compared with those in non-expansion states.

The 2016 NHIS estimates also showed that low-income adults in expansion states were less likely to report financial barriers to needed medical care and other types of health care, such as specialty care, compared with those in non-expansion states, and low-income adults who were insured were less likely to report financial barriers to needed medical care compared with those who were uninsured.

Among low-income adults who were uninsured, those in expansion states were less likely to report financial barriers to needed medical care compared with those in non-expansion states.

Finally, the 2016 NHIS estimates showed that low-income adults in expansion states were more likely to report having a usual place of care to go when sick or needing advice about their health and receiving selected health care services compared with those in non-expansion states. The estimates also showed that low-income adults who were insured were generally more likely to report having a usual place of care and receiving selected health care services compared with those who were uninsured. Among the uninsured, relatively similar percentages of low-income adults in expansion and non-expansion states reported having a usual place of care. Similarly, estimates showed that relatively similar percentages of low-income adults who were uninsured in expansion and non-expansion states reported receiving selected health care services, such as receiving a flu vaccine or a blood pressure check.

Historically, eligibility for Medicaid—a federal-state health care financing  program—has been limited to certain categories of low-income  individuals, including children, parents, pregnant women, and individuals  who have disabilities or who are aged 65 and older. Beginning in 2014,  the Patient Protection and Affordable Care Act (PPACA) gave states the  option of expanding Medicaid eligibility beyond these categories to  include certain adults with incomes that do not exceed 138 percent of the  federal poverty level (FPL). As of December 2017, there were 31  “expansion states”—those states and the District of Columbia that chose  to expand Medicaid eligibility—and 19 “non-expansion states”—those that  had not expanded Medicaid eligibility to this additional adult population.

Several years have passed since PPACA gave states the option of  expanding Medicaid eligibility. You asked us to provide the most recently  available information on the demographic characteristics of uninsured,  low-income adults, and the extent to which low-income adults are  accessing health care services in two groups of states: expansion states  and non-expansion states. This report describes what 2016 national  survey estimates showed regarding:  1.  the number and demographic characteristics for low-income adults  who were uninsured in expansion and non-expansion states,  2.  unmet medical needs for low-income adults in expansion and non- expansion states and by insurance status,  3.  barriers to health care for low-income adults in expansion and non- expansion states and by insurance status, and  4.  having a usual place of care and receiving selected health care  services for low-income adults in expansion and non-expansion states  and by insurance status.

To address our research objectives, we used data from the 2016 National  Health Interview Survey (NHIS), from the Centers for Disease Control and  Prevention, National Center for Health Statistics (NCHS). These data  were the most recent data available when we conducted our analyses.

To describe the number and demographic characteristics for low-income  adults—individuals ages 19 to 64, with incomes that did not exceed 138  percent FPL—who were uninsured in expansion and non-expansion  states, we requested that NCHS calculate estimates based on responses  to survey questions on demographic characteristics. Responses to  survey questions were calculated as an estimated percentage of the total  population for three groups of low-income adults: those in expansion  states, in non-expansion states, and for all states. We also requested  that NCHS test for statistically significant differences between expansion  states and non-expansion states. Using these estimates, we summarized  the uninsured, low-income adult population by expansion states, non- expansion states, and all states combined for demographic  characteristics including race and ethnicity, gender, and employment  status.

To describe unmet medical needs, barriers to health care, and having a  usual place of care and receiving selected health care services for low- income adults in expansion and non-expansion states and by insurance  status, we requested that NCHS also calculate estimates using the 2016  NHIS. Estimates were based on responses to selected survey questions  and composite measures—NCHS-developed measures based on  responses to NHIS questions on related topics. We selected survey  questions and their related composite measures from the Access to  Health Care and Utilization and Health Behaviors sections of the 2016  NHIS. These survey questions and composite measures allowed us to  summarize access to health care for low-income adults in terms of unmet  medical needs, barriers to health care, and having a usual place of care  and receiving selected health care services. Responses to survey  questions and composite measures were calculated as an estimated  percentage of the total population for eight groups of low-income adults:  (1) those in expansion states, (2) those in non-expansion states, (3) those  who had Medicaid in expansion states, (4) those who had Medicaid in  non-expansion states, (5) those who had private health insurance in  expansion states, (6) those who had private health insurance in non- expansion states, (7) those who were uninsured in expansion states, and  (8) those who were uninsured in non-expansion states. We also  requested that NCHS test for statistically significant differences between  the groups of low-income adults, specifically: all low-income adults in expansion states compared with all low- income adults in non-expansion states; uninsured, low-income adults in expansion states compared with each  of the four groups of insured, low-income adults—low-income adults  who had Medicaid in expansion states, low-income adults who had  Medicaid in non-expansion states, low-income adults who had private  health insurance in expansion states, and low-income adults who had  private health insurance in non-expansion states; uninsured, low-income adults in non-expansion states compared with  each of the four groups of insured, low-income adults; and uninsured, low-income adults in expansion states compared with  uninsured, low-income adults in non-expansion states.

We took steps to assess the reliability of the 2016 NHIS estimates,  including interviewing NCHS officials and checking frequency distributions  for missing estimates, outliers, and obvious errors. Based on this work,  we determined that the estimates were sufficiently reliable for the  purposes of our reporting objectives. Appendix I provides additional  information on our scope and methodology.

We conducted this performance audit from May 2017 through September  2018 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

In fiscal year 2016, Medicaid covered an estimated 72.2 million low- income and medically needy individuals in the United States, and  Medicaid estimated expenditures totaled over $575.9 billion. The federal  government matches most state expenditures for Medicaid services on  the basis of a statutory formula. States receive higher federal matching  rates for certain services or populations, including an enhanced matching  rate for Medicaid expenditures for individuals who became eligible for  Medicaid under PPACA. Of the $575.9 billion in estimated expenditures  for 2016, the federal share totaled over $363.4 billion and the states’  share totaled $212.5 billion.

The Centers for Medicare & Medicaid Services (CMS)—a federal agency  within the Department of Health and Human Services (HHS)—and states  jointly administer and fund the Medicaid program. States have flexibility  within broad federal requirements to design and implement their Medicaid  programs. States must submit a state Medicaid plan to CMS for review  and approval. A state’s approved Medicaid plan outlines the services  provided and the groups of individuals covered. While states must cover  certain mandatory populations and benefits, they have the option of  covering other categories of individuals and benefits.

PPACA permitted states to expand coverage to a new population—non- elderly, non-pregnant adults who are not eligible for Medicare and whose  income does not exceed 138 percent of the FPL. This expansion  population comprised 20 percent of total Medicaid enrollment in 2017.  (See fig. 1.)

As of December 2017, 31 states and the District of Columbia had  expanded Medicaid eligibility to the new coverage population allowed  under PPACA and 19 states had not. Figure 2, an interactive map, illustrates states’ Medicaid expansion status. See appendix II for  additional information on figure 2.

Survey Estimates Showed 5.6 Million Uninsured, Low- Income Adults Had Qualifying Incomes for Expanded Medicaid Coverage

According to the NHIS estimates, 5.6 million low-income adults were  uninsured in 2016. Of these 5.6 million, an estimated 1.9 million  uninsured, low-income adults resided in expansion states, compared with  an estimated 3.7 million in non-expansion states. Estimates of uninsured,  low-income adults comprised less than 1 percent of the total population  for all expansion states and 3 percent of the total population for all non- expansion states.

NHIS estimates also showed that over half of uninsured, low-income  adults were male, over half were employed, and over half had incomes  less than 100 percent FPL. For some demographic characteristics, there  were some statistically significant differences between uninsured, low- income adults in expansion states compared with these adults in non- expansion states. For example, expansion states had significantly larger  percentages of uninsured, low-income males than non-expansion states.  (See table 1.) See table 6 in appendix III for additional demographic  characteristics of uninsured, low-income adults.

Estimates from the 2016 NHIS showed some statistically significant  differences in the health status of uninsured, low-income adults in  expansion and non-expansion states. In particular, expansion states had  a larger percentage of these adults who reported that their health was  “good” and a smaller percentage who reported their health as “fair or  poor” than those in non-expansion states. However, the percentages of  uninsured, low-income adults with responses of “excellent or very good”  in both expansion and non-expansion states were large—47 percent or  larger, and the differences between the two groups of states were not  statistically significant. (See fig. 3.) See table 7 in appendix III for  additional information about the health status for uninsured, low-income  adults.

Survey Estimates Showed Low-Income Adults in Expansion States and Those Who Were Insured Were Less Likely to Report Any Unmet Medical Needs

The 2016 NHIS estimates showed that smaller percentages of low- income adults in expansion states reported having any unmet medical  needs compared with those in non-expansion states; and smaller  percentages of those who were insured reported having any unmet  medical needs compared with those who were uninsured, regardless of  where they lived, for example:

Low-income adults in expansion and non-expansion states.

Access to Health Care: Measuring Any  Unmet Medical Needs  The National Center for Health Statistics, the  federal agency that conducts the National  Health Interview Survey (NHIS), developed a  composite measure on any unmet medical  needs, which was based on six survey  questions on respondents’ ability to afford  different types of needed health care services.  These questions asked whether in the past 12  months respondents could not afford medical  care at any time; delayed seeking medical  care due to worries about costs; or could not  afford needed prescription drugs, mental  health or counseling, dental care, or  eyeglasses. percent or less of the low-income adults who had Medicaid or private  health insurance in expansion or non-expansion states reported  having any unmet medical needs, compared with 50 percent or more  of those who were uninsured in expansion or non-expansion states.  Further, among the uninsured, 50 percent of low-income adults living  in expansion states reported any unmet medical needs, compared  with 63 percent of those in non-expansion states. (See fig. 4.) See  tables 8 and 9 in appendix IV for estimates of the composite measure  we reviewed on any unmet medical needs.

Survey Estimates Showed Low-Income Adults in Expansion States and Those Who Were Insured Were Less Likely to Report Financial Barriers to Health Care

The 2016 NHIS estimates showed that smaller percentages of low- income adults in expansion states reported financial barriers to needed  health care compared with those in non-expansion states; and smaller  percentages of those who were insured reported financial barriers to  needed health care compared with those who were uninsured, regardless  of where they lived, for example:

Low-income adults in expansion and non-expansion states. Nine  percent of low-income adults in expansion states reported that they  could not afford needed medical care, compared with 20 percent of  low-income adults in non-expansion states.

Low-income adults who were insured and uninsured. Twelve  percent or less of low-income adults who had Medicaid or private  health insurance in expansion or non-expansion states reported  financial barriers to needed medical care, compared with 27 percent  or more of those who were uninsured in expansion or non-expansion  states. In addition, among low- income adults who were uninsured,  a smaller percentage of those who lived in expansion states reported  financial barriers to two of the six needed health care services  compared with those who lived in non-expansion states. (See fig. 5.)  See tables 10 through 13 in appendix V for estimates of all survey  questions we reviewed on financial barriers to health care.

The 2016 NHIS also collected information on non-financial barriers to  health care. Specifically, the survey asked whether respondents had  delayed health care due to non-financial reasons, such as they lacked  transportation, were unable to get through on the phone, were unable to  get a timely appointment, experienced long wait time at the doctor’s  office, or were not able to get to a clinic or doctor’s office when it was  open. The 2016 NHIS showed that the same or similar percentages of  low-income adults in expansion and non-expansion states reported  delaying care due to a lack of transportation or other non-financial  reasons. Further, generally similar or larger percentages of low-income  adults with insurance reported delaying care due to non-financial reasons,  compared with those who were uninsured. See tables 14 and 15 in appendix V for estimates of low-income adults in expansion and non- expansion states and by insurance status on non-financial barriers to  health care.

Survey Estimates Showed Low-Income Adults in Expansion States and Those Who Were Insured Were Generally More Likely to Report Having a Usual Place of Care and Receiving Selected Health Care Services

The 2016 NHIS estimates showed that a larger percentage of low-income  adults in expansion states reported having a usual place of care  compared with those in non-expansion states; and larger percentages of  those who were insured reported having a usual place of care compared  with those who were uninsured, regardless of where they lived, for  example:

Low-income adults in expansion and non-expansion states.  Eighty-two percent of the low-income adults in expansion states  reported having a usual place of care when they were sick or needed  advice about their health, compared with 68 percent of those in non- expansion states.

Access to Health Care: Having a Usual  Place of Care  The 2016 National Health Interview Survey  (NHIS) asked respondents about whether  they had a place they usually go when sick or  need advice about their health.

Low-income adults who were insured and uninsured. Seventy- eight percent or more of those who had Medicaid or private health  insurance in expansion or non-expansion states reported having a  usual place of care, compared with 46 percent or less of those who  were uninsured in expansion or non-expansion states. Among the  uninsured, similar percentages of low-income adults in expansion and  non-expansion states reported having a usual place of care. (See  fig. 6.) See tables 16 through 19 in appendix VI for estimates of all  survey questions we reviewed on having a usual place of care.

Survey Estimates Showed Low-Income Adults in Expansion States and Those Who Were Insured Were Generally More Likely to Report Receiving Selected Services

The 2016 estimates showed that larger percentages of low-income adults  in expansion states reported receiving selected health care services, such  as a flu vaccine, compared with those in non-expansion states; and larger  percentages of those with insurance reported receiving selected health  care services compared with those who were uninsured, regardless of  where they lived, for example:

Thirty-one percent of low-income adults in expansion states reported  receiving flu vaccinations, compared with 24 percent of those in non- expansion states. having their blood cholesterol checked by having their blood pressure checked by a  doctor, nurse, or other health professional; visiting a hospital emergency department. percent or more of low-income adults who had Medicaid or private  health insurance in expansion or non-expansion states reported  receiving blood cholesterol checks, compared with 28 percent or less  of low-income adults who were uninsured in expansion or non- expansion states. Among the uninsured, generally similar  percentages of low-income adults in expansion and non-expansion  states reported blood cholesterol checks, flu vaccines, and other  selected services. (See fig. 7.) See tables 20 and 21 in appendix VI  for estimates of all survey questions we reviewed on selected health  care services.

The 2016 NHIS also asked respondents whether they visited or had  spoken to a health care professional about their health, including: a general doctor, such as a general practitioner, family doctor, and a nurse practitioner, physician’s assistant, or midwife; and a doctor who specializes in a particular disease, with the exception of  obstetricians, gynecologists, psychiatrists, and ophthalmologists.

See tables 22 and 23 in appendix VI for estimates of low-income adults in  expansion and non-expansion states and by insurance status on  contacting health care professionals.

We provided a draft of this report to HHS for comment. HHS provided  technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretary of Health and Human Services, the appropriate congressional  committee, and other interested parties. In addition, this report is  available at no charge on the GAO website at http://www.gao.gov.

If you are your staff members have any questions about this report,  please contact me at (202) 512-7114 or yocomc@gao.gov. Contact  points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this report. Major contributors to this report  are listed in appendix VII.

Appendix I: Objectives, Scope, and Methodology

To describe national survey estimates of (1) the number and  demographic characteristics of uninsured, low-income adults in expansion  and non-expansion states; (2) unmet medical needs for low-income  adults in expansion and non-expansion states and by insurance status;  (3) barriers to health care for low-income adults in expansion and non- expansion states and by insurance status; and (4) having a usual place of  care and receiving selected health care services for low-income adults in  expansion and non-expansion states and by insurance status, we used  data from the 2016 National Health Interview Survey (NHIS). The 2016  NHIS were the most recent data available when we conducted our  analyses. This appendix describes the data source, study population,  analyses conducted, study limitations, and data reliability assessment.

The NHIS collects demographic, health status, health insurance, health  care access, and health care service use data for the civilian,  noninstitutionalized U.S. population. It is an annual, nationally  representative, cross-sectional household interview survey. NHIS  interviews are conducted continuously throughout the year for the  National Center for Health Statistics (NCHS), which is a federal agency  within the Department of Health and Human Services that compiles  statistical information to help guide health policy decisions. Interviews are  conducted in respondents’ homes, and interviewers may conduct follow- up interviews over the telephone to complete an interview. Information  about some NHIS respondents, such as information about their health  status, may be obtained through an interview with another family member  on behalf of the respondent.

NHIS data are organized into several data files. Estimates used for our  study are based on data with the 2016 Family and Sample Adult Core  components of the 2016 NHIS. Sociodemographic, insurance, and select  health care access and utilization variables were defined using data  collected in the Family Core component of the survey, which includes  data on every household member for the families participating in NHIS.  Other measures of health care access and utilization examined in this  study are based on data collected in the Sample Adult Core component.  In this component, the respondent (i.e., the sample adult) is randomly  selected from among all adults aged ≥18 years in the family. A proxy  respondent might respond for the sample adult if, because of health  reasons, the sample adult is physically or mentally unable to respond  themselves. The 2016 imputed income files were used to define poverty  thresholds, which is based on reported and imputed family income. The  NHIS publicly released data files for 2016 include data for 40,220  households containing 97,169 persons, and the total household response  rate was 67.9 percent.

For this study we asked NCHS to provide estimates of low-income, non- elderly adults, which we defined as individuals ages 19 to 64, with family  incomes that did not exceed 138 percent of the federal poverty level  (FPL). We also requested that estimates be provided separately for  respondents based on whether they resided in an expansion or non- expansion state, and whether they were covered by private health  insurance, Medicaid, or had no insurance. We gave NCHS specifications  for the definition of low-income, non-elderly adults; the states that should  be classified as expansion or non-expansion states in calendar year  2016; and the respondents who should be classified as having private  health insurance, Medicaid, or no insurance.

We asked NCHS to exclude respondents who were noncitizens, were  covered by Medicare, only received health care services through military  health care or through the Indian Health Service, or had Supplemental  Social Security Income. We also excluded adult females from the Sample  Adult file who responded they were pregnant at the time of the interview.  In addition, we asked NCHS to exclude individuals for which information  was missing—not recorded or not provided during the interview—on  health insurance coverage (Medicaid, private health insurance, Indian  Health Service, military health care, or no health insurance), receipt of  Supplemental Social Security Income, and U.S. citizenship.

We classified individuals in our study population as residing in an  expansion or non-expansion state based on their state of residence when  they were interviewed for the 2016 NHIS. We classified the 30 states and  the District of Columbia that expanded their Medicaid eligibility before July  1, 2016, as expansion states. The remaining 20 states were classified as  non-expansion states. Louisiana expanded Medicaid coverage on July 1,  2016; therefore, we classified it as a non-expansion state. We decided  not to classify Louisiana as an expansion state because we allowed a 6- month period for the effects of expansion to appear. Therefore, for  Louisiana we only included NHIS respondents interviewed from January  through June 2016 when Louisiana was a non-expansion state. Similarly,  for two expansion states—Alaska and Montana—we only included  individuals who were interviewed March through December 2016 and July  through December 2016, respectively, after the state expanded Medicaid  to allow for a 6-month time period for the effect of expansion to take  place. (See table 2.)

Table 3 below illustrates the sample size and population estimates of low- income sample adults by expansion state, non-expansion state, and  national total.

We classified NHIS respondents as having private health insurance,  Medicaid, or no insurance based on the health insurance classification  approach used by NCHS for NHIS. NCHS assigned NHIS respondents’  health insurance classification based on a hierarchy of mutually exclusive  categories in the following order: private health insurance, Medicaid, other  coverage, and uninsured. Low-income adults with more than one  coverage type were assigned to the first appropriate category in the  hierarchy. Respondents were classified as having private health  insurance if they reported that they were covered by any comprehensive  private health insurance plan (including health maintenance and preferred  provider organizations). Private coverage excluded plans that pay for one  type of service, such as accidents or dental care. Respondents were  classified as having Medicaid if they reported they were covered by  Medicaid or by a state-sponsored health plan with no premiums or it was  not known whether a premium was charged. Respondents were classified  as being uninsured if they did not report having any private health  insurance, Medicare, Medicaid, Children’s Health Insurance Program,  state-sponsored or other government-sponsored health plan, or military  health plan. Respondents were also classified as being uninsured if they  only had insurance coverage with a private plan that paid for one type of  service, such as accidents or dental care.

We gave NCHS officials specifications to calculate estimates from the  2016 NHIS for demographic characteristics, access to care, as well as  composite measures of access to health care based on selected survey  questions. Composite measures are NCHS-developed measures based  on responses to NHIS questions covering related topics. The analysis  included two composite measures:  1.  any unmet medical needs, which is based on responses to six  underlying survey questions that asked respondents about whether  during the past 12 months they needed medical care but did not get it  because they could not afford it; delayed seeking medical care  because of worry about the cost; or did not get prescription medicines,  mental health care or counseling, eyeglasses, or dental care due to  cost; and  2.  any non-financial barriers to health care, which is based on five  underlying questions that asked respondents whether they delayed  care in the past 12 months for any of the following reasons: could not  get through on the telephone; could not get an appointment soon  enough; waited too long to see the doctor after arriving at the doctor’s  office; the clinic/doctor’s office was not open when respondent could  get there; and did not have transportation.

NCHS officials calculated our requested estimates of groups within our  study population based on whether respondents resided in an expansion  or non-expansion state and whether they had private health insurance,  Medicaid, or were uninsured at the time of the interview. For each  comparison—such as comparisons of access to health care for  respondents in expansion versus non-expansion states—we asked  NCHS to test for statistically significant differences. We identified a  statistically significant difference when the p-value from a t-test of the  difference in the estimated proportions between two study subgroups had  a value of less than 0.05.

To describe the number and demographic characteristics of uninsured,  low-income adults, we compared estimates of selected demographic  characteristics (race and ethnicity, gender, poverty status, and  employment status) and reported health status for this group in expansion  and non-expansion states. These and other estimates of demographic  characteristics and reported health status from the 2016 NHIS for  uninsured, low-income adults by expansion states, non-expansion states,  and all states are provided in tables 6 and 7 in appendix III.

To describe unmet medical needs, barriers to health care, and having a  usual place of care and receiving selected services for all low-income  adults in expansion and non-expansion states and by insurance status,  we asked NCHS to calculate estimates based on responses to selected  NHIS questions and NCHS composite measures. We selected these  survey questions and composite measures from the Family and Adult  Access to Health Care and Utilization and Adult Health Behaviors  sections of the 2016 NHIS. To summarize estimates of low-income adults  in expansion and non-expansion states and by insurance status,  responses to selected survey questions and composite measures were  calculated as an estimated percentage of the relevant group’s total  population for eight groups of low-income adults: (1) those in expansion  states, (2) those in non-expansion states, (3) those who had Medicaid in  expansion states, (4) those who had Medicaid in non-expansion states,  (5) those who had private health insurance in expansion states, (6) those  who had private health insurance in non-expansion states, (7) those who  were uninsured in expansion states, and (8) those who were uninsured in  non-expansion states.

We asked NCHS to test for statistically significant differences for the  estimates of access to care between selected groups of low-income  adults. (See table 4.) The results of the tests for statistically significant  differences for these comparison groups are in appendixes IV through VI.

Study Limitations and Data Reliability Assessment

Our study has some limitations. First, our study did not examine whether  statistically significant differences in estimates of access to health care  between respondents in expansion and non-expansion states were  associated with the choice to expand Medicaid. Second, NHIS data are  based on respondent-reported data, which may be subject to potential  biases and recall of participants’ use of health services and may be less  accurate than administrative data or clinical data. Third, we could not  report estimates of access to health care that did not meet NCHS’s  standards of reliability or precision.

We assessed the reliability of NHIS data by reviewing NHIS data  documentation; interviewing knowledgeable NCHS officials and academic  researchers; and examining the data for logical errors, missing values,  and values outside of expected ranges. We determined that the data  were sufficiently reliable for the purposes of these analyses.

Appendix II: Status of Medicaid Eligibility Expansion by States, as of 2017

Under the Patient Protection and Affordable Care Act (PPACA), states  may opt to expand their Medicaid programs’ eligibility to cover certain  low-income adults beginning January 2014. As of December 2017, 31  states and the District of Columbia had expanded their Medicaid  programs as permitted under PPACA and 19 states had not. Table 5 lists  the states that expanded Medicaid eligibility and those that did not. It also  includes state population and other Medicaid data, which is presented in  the roll-over information in interactive figure 2.

Appendix III: Estimates of Demographic Characteristics and Health Status in Expansion and Non-Expansion States

This appendix provides additional 2016 National Health Interview Survey  (NHIS) estimates we obtained from the National Center for Health  Statistics (NCHS). Table 6 presents estimates of selected demographic  characteristics for low-income adults who were uninsured at the time of  the survey interview. The table provides estimates for these adults based  on whether they resided in states that expanded Medicaid eligibility as  permitted under the Patient Protection and Affordable Care Act (PPACA)  (referred to as expansion states) or states that did not (referred to as non- expansion states). We report statistically significant differences when  comparing the responses of uninsured, low-income adults in expansion  and non-expansion states.

Table 7 shows estimates of the reported health status of uninsured, low- income adults based on whether they resided in an expansion or non- expansion state. The table provides the number and percent of these  adults who reported that at the time of the interview their health status  was excellent or very good; good; or fair or poor. The table also shows  the extent to which these adults reported whether their health status was  different at the time of the interview compared to the previous year. We  report statistically significant differences when comparing the responses  of uninsured, low-income adults in expansion and non-expansion states.

Appendix IV: Estimates of Any Unmet Medical Needs in Expansion and Non- Expansion States and by Insurance Status

This appendix provides estimates of any unmet medical needs for low- income adults—individuals ages 19 to 64, with family incomes that did not  exceed 138 percent of the federal poverty level (FPL)—from the 2016  National Health Interview Survey (NHIS), which were produced by the  National Center for Health Statistics (NCHS). Estimates are based on a  composite measure of any unmet medical needs. Table 8 shows  estimates of all low-income adults in expansion and non-expansion  states. We also report statistically significant differences between low- income adults in expansion and non-expansion states.

Table 9 shows estimates of six groups of low-income adults: (1) low- income adults who were uninsured in expansion states; (2) low-income  adults who were uninsured in non-expansion states; (3) low-income  adults who had Medicaid in expansion states; (4) low-income adults who  had Medicaid in non-expansion states; (5) low-income adults who had  private health insurance in expansion states; and (6) low-income adults  who had private health insurance in non-expansion states. We also  report any statistically significant differences when comparing the six  groups of low-income adults, specifically:  low-income adults who were uninsured in expansion states compared  with each of the four groups of low-income adults who were insured— low-income adults who had Medicaid in expansion states, low-income  adults who had Medicaid in non-expansion states, low-income adults  who had private health insurance in expansion states, and low-income  adults who had private insurance in non-expansion states;  low-income adults who were uninsured in non-expansion states  compared with each of the four groups of low-income adults who were  insured;  low-income adults who were uninsured in expansion states compared  with low-income adults who were uninsured in non-expansion states;  low-income adults who had Medicaid in expansion states compared  with low-income adults who had Medicaid in non-expansion states;  and  low-income adults who had private health insurance in expansion  states compared with low-income adults who had private health  insurance in non-expansion states.

Appendix V: Estimates of Barriers to Health Care in Expansion and Non-Expansion States and by Insurance Status

This appendix provides estimates of barriers to health care for low- income adults—individuals ages 19 to 64, with family incomes that did not  exceed 138 percent of the federal poverty level (FPL)—from the 2016  National Health Interview Survey (NHIS), which we obtained from the  National Center for Health Statistics (NCHS). Estimates of financial  barriers to needed medical, specialty, and other types of health care and  prescription drugs are based on selected survey questions. Estimates of  non-financial barriers to health care are based on responses to selected  survey questions and a composite measure. Estimates are reported for:

All low-income adults in expansion and non-expansion states. We  also report statistically significant differences between low-income  adults in expansion and non-expansion states.

Six groups of low-income adults: (1) low-income adults who were  uninsured in expansion states; (2) low-income adults who were  uninsured in non-expansion states; (3) low-income adults who had  Medicaid in expansion states; (4) low-income adults who had  Medicaid in non-expansion states; (5) low-income adults who had  private health insurance in expansion states; and (6) low-income  adults who had private health insurance in non-expansion states. We  also report any statistically significant differences when comparing the  six groups of low-income adults, specifically:  low-income adults who were uninsured in expansion states  compared with each of the four groups of low-income adults who  were insured—low-income adults who had Medicaid in expansion  states, low-income adults who had Medicaid in non-expansion  states, low-income adults who had private health insurance in  expansion states, and low-income adults who had private  insurance in non-expansion states;  low-income adults who were uninsured in non-expansion states  compared with each of the four groups of low-income adults who  were insured;  low-income adults who were uninsured in expansion states  compared with low-income adults who were uninsured in non- expansion states;  low-income adults who had Medicaid in expansion states  compared with low-income adults who had Medicaid in non- expansion states; and  low-income adults who had private health insurance in expansion  states compared with low-income adults who had private health  insurance in non-expansion states.

Financial barriers to medical, specialty, and other types of health  care. Tables 10 and 11 present estimates and differences in estimates of  responses to survey question that asked whether respondents did not  obtain different types of needed health care services in the past 12  months because they could not afford it.

Financial barriers to prescription drugs. Tables 12 and 13 present  estimates and differences in estimates of survey question that asked  respondents who had been prescribed medications whether they had  taken actions during the past 12 months to save money on medications.

Non-financial barriers to health care. Tables 14 and 15 present  estimates and differences in estimates of the NCHS composite measure  on any non-financial barriers to health care, which was based on  responses to five survey questions on whether respondents delayed care  in the past 12 months due to long wait times, a lack of transportation, and  other non-financial reasons. Additionally, these tables present estimates  and differences in estimates of responses to the composite measure’s  five underlying survey questions.

Appendix VI: Estimates on Place of Care and Services in Expansion and Non- Expansion States and by Insurance Status

This appendix provides estimates on having a usual place of care and  receiving selected health care services for adults—individuals ages 19 to  64, with family incomes that did not exceed 138 percent of the federal  poverty level (FPL)—from the 2016 National Health Interview Survey  (NHIS), which we obtained from the National Center for Health Statistics  (NCHS). Estimates are based on responses to selected survey  questions on having a usual place of care, receiving selected health care  services, and contacting health care professionals. Estimates are  reported for:

Having a usual place of care. Tables 16 through 19 present estimates  and differences in estimates of survey questions that asked respondents  about the place of care they usually go to when sick or need advice about  their health and the type of place that respondents most often went.

Receiving selected health care services. Tables 20 and 21 present  estimates and differences in estimates of survey questions that asked  respondents whether they had received a blood cholesterol check, flu  vaccine, or other selected services.

Contacting health care professionals. Tables 22 and 23 present  estimates and differences in estimates of survey questions that asked  respondents whether they had visited or spoken to a general doctor,  specialist, or other health care professionals about their health in the past  12 months.

Appendix VII: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Katherine M. Iritani (Director),  Tim Bushfield (Assistant Director), Deitra H. Lee (Analyst-in-Charge),  Kristin Ekelund, Laurie Pachter, Vikki Porter, Merrile Sing, and Emily  Wilson made key contributions to this report.

As of December 2017, 31 states and the District of Columbia have expanded access to Medicaid for low-income adults under the Patient Protection and Affordable Care Act. In 2017, these adults made up 20% of all Medicaid recipients.

We reviewed available survey results and found that low-income adults in states that expanded Medicaid generally reported better access to health care. For example, they were less likely to report having unmet medical needs (such as not being able to afford their prescriptions)—whether or not they were insured.