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STATISTICAL BRIEF #494:
Insurance Coverage of Ambulatory Care Visits in the Last Six Months of 2011-13 and 2014, by Medicaid Expansion Status
Highlights
- In states that expanded Medicaid, the uninsured share of physician visits in the latter half of the year declined between 2011-13 and 2014, from 8.4 percent to 5.6 percent.
- In states that expanded Medicaid, the uninsured share of emergency room visits in the latter half of the year declined by approximately one-half between 2011-13 and 2014, from 19.8 percent to 10.5 percent.
- No significant reductions in uninsured shares of visits were observed for states that did not expand Medicaid.
Introduction
New pathways to insurance coverage became available in 2014, including subsidized private coverage through newly-created Marketplaces and the potential for states to expand Medicaid eligibility to include adults with incomes up to 138 percent of the federal poverty line (FPL). By April 2014, 25 states and the District of Columbia had expanded their Medicaid programs. The implementation of shared responsibility payments, beginning in 2014, may have also increased incentives for coverage.This Statistical Brief compares the insurance coverage of ambulatory care visits before and after these changes using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC). Because Marketplace enrollment lasted into Spring 2014, we compare data from the latter half of 2014 with data from the latter halves of 2011–2013 (pooling data from three years to enhance precision). Results are presented separately for physician visits (offices, clinics, and hospital outpatient), emergency room visits, and non-physician visits (offices, clinics, and hospital outpatient). Because not all states expanded Medicaid, we present results separately for “expansion” and “non-expansion” states. All differences between estimates discussed in the text are statistically significant at the 0.05 level unless otherwise noted.
Findings
Physician visits (non-ER)The public share of physician visits in expansion states was higher in the last 6 months of 2014 than in the same months of 2011–13 (figure 1, with point estimates and standard errors in table 1). The overall private (i.e., non-Marketplace plus Marketplace) share of physician visits did not change significantly in expansion states; however, the private non-Marketplace share declined, with the declines being largely offset by the introduction of Marketplace coverage. Because of these public and private changes, the uninsured share of physician visits declined in the latter half of the year, from 8.4 percent to 5.6 percent between 2011–13 and 2014.
In non-expansion states, we observed no statistically significant changes in the coverage mix of physician visits during the last 6 months of the year between 2011–13 and 2014, apart from the introduction of Marketplace coverage. As shown in the last column of table 1, the changes between 2011–13 and 2014 in public shares of physician visits were significantly different in expansion and non-expansion states.
Emergency room visits
The public share of emergency room visits in expansion states was higher in the last 6 months of 2014 than it had been in the latter halves of 2011–13 (figure 2 and table 1). The overall private share of emergency room visits did not change significantly in expansion states, though the Marketplace coverage share in 2014 was statistically significant at the 10 percent level. Because of these changes, the uninsured share of visits in expansion states declined by approximately one-half for emergency room visits between 2011–13 and 2014, from 19.8 percent to 10.5 percent.
Non-physician visits
Table 1 also presents coverage mix estimates for non-physician ambulatory visits. As for physician and ER visits, we observed an increase in the public coverage share in expansion states. Also, we observed a shift within private coverage for both groups of states toward Marketplace coverage. The uninsured share of visits declined in expansion states from 9.7 percent to 6.0 percent; whereas there was no statistically significant decline in non-expansion states in the uninsured share of visits.
Insurance
Table 2 presents insurance coverage among non-elderly adults during the last 6 months of each year in 2011-13 and 2014. To supplement our visit results we present the average percentage of months spent in each coverage category. In expansion states, declines in private non-Marketplace coverage were largely offset by the introduction of Marketplace coverage. In comparison, overall private coverage increased significantly from 2011–13 to 2014 in non-expansion states. Public coverage increased significantly between 2011–13 and 2014 in expansion states, but not in non-expansion states. Uninsurance decreased between 2011–13 and 2014 in expansion and non-expansion states. The decline in expansion states was significantly larger than the decline in non-expansion states, but only at the 10 percent level.
Data Source
The estimates shown in this Statistical Brief are drawn from analyses of MEPS Full Year Consolidated Data Files: HC-147, HC-155, HC-163, HC-171, HC-144e-g, HC-152e-g, HC-160e-g, HC-168e-g, augmented with information on the person’s state of residence.Definitions
Population coveredPersons included in our analysis were ages 19–64 as of the end of each year. We excluded persons with Supplemental Security Income or Medicare coverage—groups that were largely outside the focus of the ACA coverage provisions. We further limited our sample to persons who were in scope during all of the last 6 months of the year.
Uninsured
People classified as uninsured during a given month were those not covered by Medicaid, Medicare, TRICARE (Armed Forces-related coverage), other public hospital/physician programs, private hospital/physician insurance (including Medigap coverage) or insurance purchased through health insurance Marketplaces established in accordance with the Affordable Care Act. People covered only by non-comprehensive State specific programs (e.g., Maryland Kidney Disease Program) or private single service plans such as coverage for dental or vision care only, or coverage for accidents or specific diseases, were considered uninsured.
Insured
People classified as insured during a given month were covered by Medicaid, Medicare, TRICARE (Armed Forces-related coverage), other public hospital/physician programs, private hospital/physician insurance (including Medigap coverage) or insurance purchased through health insurance Marketplaces established in accordance with the Affordable Care Act. People covered only by non-comprehensive State specific programs (e.g., Maryland Kidney Disease Program) or private single service plans such as coverage for dental or vision care only, or coverage for accidents or specific diseases, were not considered to be insured.
Coverage type
We grouped adults using the following hierarchy for coverage during each month: Marketplace coverage, public coverage, private (non-Marketplace) coverage (including TRICARE), and all-year uninsured. Visits were classified into coverage types based on coverage during the month in which the visit occurred.
Measures of use
We examined three visit measures in this report: (1) annual ambulatory physician visits (offices, clinics, and hospital outpatient), (2) emergency room visits (exclusive of emergency room visits that resulted in hospital stays), and (3) non-physician ambulatory visits (offices, clinics, and hospital outpatient). A small number, approximately 1 percent, of (non-ER) ambulatory visits for which type of provider was not reported were excluded from our analysis. Household-reported data on month of visit were imputed in a small number of cases using data on visit round, source of payment, and monthly coverage.
Medicaid expansion states
This analysis defined Medicaid expansion states as those states that implemented the ACA's Medicaid expansion by April 2014. Medicaid expansion states included Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia.
About MEPS-HC
MEPS-HC is a nationally representative longitudinal survey that collects detailed information on health care utilization and expenditures, health insurance, and health status, as well as a wide variety of social, demographic, and economic characteristics for the U.S. civilian noninstitutionalized population. It is co-sponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.Suggested Citation
Selden, T.M., Abdus, S., and Keenan, P.S. Insurance Coverage of Ambulatory Care Visits in the Last Six Months of 2011–13 and 2014, by Medicaid Expansion Status. Statistical Brief #494. October 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st494/stat494.shtml.AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Statistical Brief and other MEPS data and tools and to share suggestions on how MEPS products might be enhanced to further meet your needs. Please email us at MEPSProjectDirector@ahrq.hhs.gov or send a letter to the address below:
Joel W. Cohen, PhD, Director
Center for Financing, Access, and Cost Trends
Agency for Healthcare Research and Quality
5600 Fishers Lane, Mailstop 07W41A
Rockville, MD 20857
| Expansion Status | Expansion States | Non-Expansion States | ||
|---|---|---|---|---|
| Year | 2011-2013 | 2014 | 2011-2013 | 2014 |
| Uninsured | 8.4% | 5.6% | 13.2% | 12.8% |
| Public | 13.4% | 16.7% | 10.4% | 10.1% |
| Marketplace | 0.0% | 3.1% | 0.0% | 3.5% |
| Private (non-Marketplace) | 78.2% | 74.6% | 76.4% | 73.6% |
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2014
| Expansion Status | Expansion States | Non-Expansion States | ||
|---|---|---|---|---|
| Year | 2011-2013 | 2014 | 2011-2013 | 2014 |
| Uninsured | 19.8% | 10.5% | 29.8% | 29.6% |
| Public | 22.2% | 34.8% | 15.1% | 12.4% |
| Marketplace | 0.0% | 1.9% | 0.0% | 4.4% |
| Private (non-Marketplace) | 58.0% | 52.7% | 55.1% | 53.6% |
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2014
| Coverage Type | Share in Expansion Statesa (%) | Share in Non-Expansion Statesa (%) | Change in Expansion States Minus Change in Non-Expansion Statesb | ||
|---|---|---|---|---|---|
| Year | 2011-13 | 2014 | 2011-13 | 2014 | |
| Non-ER Physician Visits | |||||
| Uninsured | 8.4 | 5.6*** | 13.2 | 12.8 | -2.5 |
| Standard Error | (0.5) | (0.6) | (0.8) | (1.9) | (2.0) |
| Public | 13.4 | 16.7*** | 10.4 | 10.1 | 3.6** |
| Standard Error | (0.8) | (1.2) | (0.9) | (1.0) | (1.7) |
| Private | 78.2 | 77.7 | 76.4 | 77.1 | -1.2 |
| Standard Error | (1.0) | (1.3) | (1.3) | (2.1) | (2.6) |
| Non-Marketplace | 78.2 | 74.6** | 76.4 | 73.6 | -0.9 |
| Standard Error | (1.0) | (1.5) | (1.3) | (2.1) | (2.7) |
| Marketplace | 0.0 | 3.1*** | 0.0 | 3.5*** | -0.3 |
| Standard Error | (0.0) | (0.6) | (0.0) | (0.5) | (0.8) | ER Visits |
| Uninsured | 19.8 | 10.5*** | 29.8 | 29.6 | -9.2** |
| Standard Error | (1.3) | (1.5) | (1.6) | (2.8) | (3.6) |
| Public | 22.2 | 34.8*** | 15.1 | 12.4 | 15.3*** |
| Standard Error | (1.7) | (2.9) | (1.2) | (1.6) | (3.6) |
| Private | 58.0 | 54.7 | 55.1 | 58.0 | -6.2 |
| Standard Error | (2.0) | (2.9) | (1.8) | (3.2) | (4.3) |
| Non-Marketplace | 58.0 | 52.7 | 55.1 | 53.6 | -3.7 |
| Standard Error | (2.0) | (2.9) | (1.8) | (3.2) | (4.3) |
| Marketplace | 0.0 | 1.9* | 0.0 | 4.4*** | -2.5 |
| Standard Error | (0.0) | (1.1) | (0.0) | (1.5) | (1.8) | Non-ER, Non-Physician Visits |
| Uninsured | 9.7 | 6.0** | 11.7 | 10.8 | -2.8 |
| Standard Error | (1.5) | (1.4) | (1.1) | (1.5) | (2.7) |
| Public | 8.4 | 17.6*** | 6.8 | 8.7 | 7.3* |
| Standard Error | (0.9) | (2.9) | (1.0) | (2.1) | (3.9) |
| Private | 81.8 | 76.4** | 81.5 | 80.6 | -4.5 |
| Standard Error | (1.7) | (3.1) | (1.5) | (2.4) | (3.6) |
| Non-Marketplace | 81.8 | 73.1*** | 81.5 | 75.9* | -3.1 |
| Standard Error | (1.7) | (3.1) | (1.5) | (2.6) | (3.6) |
| Marketplace | 0.0 | 3.3*** | 0.0 | 4.7*** | -1.3 |
| Standard Error | (0.0) | (0.7) | (0.0) | (1.1) | (1.3) |
Notes: Authors' calculation from AHRQ's Medical Expenditure Panel Survey (MEPS) Household Component data on adults ages 19 to 64 who were not on Medicare and who did not have Supplemental Security Income. Standard errors are in parentheses and have been adjusted for the complex survey design of the MEPS. The hierarchical coverage categories are: Marketplace coverage during the event month, else public coverage during event month, else private (non-Marketplace) coverage during event month, or else uninsured during event month. Service use is from any time during the last 6 months of the calendar year.
aCategory comprises the 26 states that expanded on or before June 2014: AZ, AR, CO, CT, CA, DE, DC, HI, IL, IA, KY, MD, MA, MI, MN, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, and WV.
bDifferences between the expansion and the non-expansion states in the increases in the percentages from 2011–13 to 2014.
* Statistically significantly different from 2011-13 (uninsured, public, private, non-Marketplace) or from zero (Marketplace coverage and net change measures) at the 10% level.
** Statistically significantly different from 2011-13 (uninsured, public, private, non-Marketplace) or from zero (Marketplace coverage and net change measures) at the 5% level.
*** Statistically significantly different from 2011-13 (uninsured, public, private, non-Marketplace) or from zero (Marketplace coverage and net change measures) at the 1% level.
| Percentage of last 6 months with: | Expansion Statesa(%) | Non-Expansion Statesa(%) | Change in Expansion States Minus Change in Non-Expansion Statesb | ||
|---|---|---|---|---|---|
| Year | 2011-13 | 2014 | 2011-13 | 2014 | |
| No coverage | 21.3 | 15.9*** | 27.4 | 23.8*** | -1.8* |
| Standard Error | (0.5) | (0.6) | (1.1) | (1.0) | (0.9) | Public coverage | 9.2 | 14.5*** | 5.2 | 5.3 | 5.1*** |
| Standard Error | (0.5) | (0.8) | (0.3) | (0.3) | (0.7) | Private coverage | 69.4 | 69.6 | 67.4 | 71.0*** | -3.3*** |
| Standard Error | (0.8) | (0.9) | (1.2) | (1.2) | (1.2) |
| Non-Marketplace coverage | 69.4 | 67.3** | 67.4 | 67.7 | -2.5** |
| Standard Error | (0.8) | (1.0) | (1.2) | (1.3) | (1.2) |
| Marketplace coverage | 0.0 | 2.4*** | 0.0 | 3.2*** | -0.9** |
| Standard Error | (0.0) | (0.3) | (0.0) | (0.3) | (0.4) |
Notes: Authors' calculation from AHRQ's Medical Expenditure Panel Survey (MEPS) Household Component data on adults ages 19 to 64 who were not on Medicare and who did not have Supplemental Security Income. Standard errors are in parentheses and have been adjusted for the complex survey design of the MEPS. Within each month, the hierarchical coverage categories are: Marketplace coverage, else public coverage, else private (non-Marketplace) coverage, or else uninsured. A person with 3 uninsured months during last 6 months of year was counted as being uninsured 50 percent of the time.
aCategory comprises the 26 states that expanded on or before June 2014: AZ, AR, CO, CT, CA, DE, DC, HI, IL, IA, KY, MD, MA, MI, MN, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, and WV.
bDifferences between the expansion and the non-expansion states in the increases in the percentages from 2011-13 to 2014.
* Statistically significantly different from 2011-13 (uninsured, public, private, non-Marketplace) or from zero (Marketplace coverage and net change measures) at the 10% level.
** Statistically significantly different from 2011-13 (uninsured, public, private, non-Marketplace) or from zero (Marketplace coverage and net change measures) at the 5% level.
*** Statistically significantly different from 2011-13 (uninsured, public, private, non-Marketplace) or from zero (Marketplace coverage and net change measures) at the 1% level.