The Effects of Medicaid Expansion on the Racial/ethnic Composition Within Nursing Home Residents

Overview

Journal Health Econ Rev

Publisher Biomed Central

Specialty Public Health

Date 2024 Jun 20

PMID 38902384

Authors

Fernando Loaiza

Affiliations

Soon will be listed here.

Abstract

Background: The Affordable Care Act (ACA), enacted in 2010, aimed to improve healthcare coverage for American citizens. This study investigates the impact of Medicaid expansion (ME) under the ACA on the racial and ethnic composition of nursing home admissions in the U.S., focusing on whether ME has led to increased representation of racial/ethnic minorities in nursing homes.

Methods: A difference-in-differences estimation methodology was employed, using U.S. county-level aggregate data from 2000 to 2019. This approach accounted for multiple time periods and variations in treatment timing to analyze changes in the racial and ethnic composition of nursing home admissions post-ME. Additionally, two-way fixed effects (TWFE) regression was utilized to enhance robustness and validate the findings.

Results: The analysis revealed that the racial and ethnic composition of nursing home admissions has become more homogeneous following Medicaid expansion. Specifically, there was a decline in Black residents and an increase in White residents in nursing homes. Additionally, significant differences were found when categorizing states by income inequality, and poverty rate levels. These findings remain statistically significant even after controlling for additional variables, indicating that ME influences the racial makeup of nursing home admissions.

Conclusions: Medicaid expansion has not diversified nursing home demographics as hypothesized; instead, it has led to a more uniform racial composition, favoring White residents. This trend may be driven by nursing home preferences and financial incentives, which could favor residents with private insurance or higher personal funds. Mechanisms such as payment preferences and local cost variations likely contribute to these shifts, potentially disadvantaging Medicaid-reliant minority residents. These findings highlight the complex interplay between healthcare policy implementation and racial disparities in access to long-term care, suggesting a need for further research on the underlying mechanisms and implications for policy refinement.

References

Miller S, Wherry L . Health and Access to Care during the First 2 Years of the ACA Medicaid Expansions. N Engl J Med. 2017; 376(10):947-956. DOI: 10.1056/NEJMsa1612890. View

Musa D, Schulz R, Harris R, Silverman M, Thomas S . Trust in the health care system and the use of preventive health services by older black and white adults. Am J Public Health. 2008; 99(7):1293-9. PMC: 2696665. DOI: 10.2105/AJPH.2007.123927. View

Smith D, Feng Z, Fennell M, Zinn J, Mor V . Racial disparities in access to long-term care: the illusive pursuit of equity. J Health Polit Policy Law. 2008; 33(5):861-81. DOI: 10.1215/03616878-2008-022. View

Ortega A . Medicaid Expansion and mental health treatment: Evidence from the Affordable Care Act. Health Econ. 2022; 32(4):755-806. DOI: 10.1002/hec.4633. View

Kaestner R, Garrett B, Chen J, Gangopadhyaya A, Fleming C . Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply. J Policy Anal Manage. 2017; 36(3):608–42. DOI: 10.1002/pam.21993. View

Sommers B, Gunja M, Finegold K, Musco T . Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act. JAMA. 2015; 314(4):366-74. DOI: 10.1001/jama.2015.8421. View

Simon K, Soni A, Cawley J . The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions. J Policy Anal Manage. 2017; 36(2):390-417. DOI: 10.1002/pam.21972. View

Van Houtven C, McGarry B, Jutkowitz E, Grabowski D . Association of Medicaid Expansion Under the Patient Protection and Affordable Care Act With Use of Long-term Care. JAMA Netw Open. 2020; 3(10):e2018728. PMC: 7530637. DOI: 10.1001/jamanetworkopen.2020.18728. View

Wang S, Hsu S, Huang S, Doan K, Gross C, Ma X . Regional Practice Patterns and Racial/Ethnic Differences in Intensity of End-of-Life Care. Health Serv Res. 2018; 53(6):4291-4309. PMC: 6232508. DOI: 10.1111/1475-6773.12998. View

10.

Andersen R, NEWMAN J . Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973; 51(1):95-124. View

11.

Smith D . The racial integration of health facilities. J Health Polit Policy Law. 1993; 18(4):851-69. DOI: 10.1215/03616878-18-4-851. View

12.

Doty M, Blumenthal D, Collins S . The Affordable Care Act and health insurance for Latinos. JAMA. 2014; 312(17):1735-6. DOI: 10.1001/jama.2014.13841. View

13.

Courtemanche C, Marton J, Ukert B, Yelowitz A, Zapata D . Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States. J Policy Anal Manage. 2016; 36(1):178-210. DOI: 10.1002/pam.21961. View

14.

Frean M, Gruber J, Sommers B . Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act. J Health Econ. 2017; 53:72-86. DOI: 10.1016/j.jhealeco.2017.02.004. View

15.

Smith D, Feng Z, Fennell M, Zinn J, Mor V . Separate and unequal: racial segregation and disparities in quality across U.S. nursing homes. Health Aff (Millwood). 2007; 26(5):1448-58. DOI: 10.1377/hlthaff.26.5.1448. View

16.

Mack D, Jesdale B, Ulbricht C, Forrester S, Michener P, Lapane K . Racial Segregation Across U.S. Nursing Homes: A Systematic Review of Measurement and Outcomes. Gerontologist. 2019; 60(3):e218-e231. PMC: 7117622. DOI: 10.1093/geront/gnz056. View

17.

Zhang X, Lin D, Pforsich H, Lin V . Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resour Health. 2020; 18(1):8. PMC: 7006215. DOI: 10.1186/s12960-020-0448-3. View

18.

Bradley E, Curry L, McGraw S, Webster T, Kasl S, Andersen R . Intended use of informal long-term care: the role of race and ethnicity. Ethn Health. 2004; 9(1):37-54. DOI: 10.1080/13557850410001673987. View

19.

Beland L, Huh J, Kim D . The effect of Affordable Care Act Medicaid expansions on foster care admissions. Health Econ. 2021; 30(11):2943-2951. DOI: 10.1002/hec.4419. View

20.

Weech-Maldonado R, Morales L, Elliott M, Spritzer K, Marshall G, Hays R . Race/ethnicity, language, and patients' assessments of care in Medicaid managed care. Health Serv Res. 2003; 38(3):789-808. PMC: 1360917. DOI: 10.1111/1475-6773.00147. View