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LTC Access Under Medicaid Expansion Improves for Newly Eligible Low-Income, Middle-Aged Adults

November 13, 2020

By Julie Gould  

van houtvenRecent research published in JAMA Network Open, shows that the Affordable Care Act (ACA) Medicaid expansion increased access to long-term care for newly eligible low-income, middle-aged adults. According to the study authors this finding suggests that the population covered by the Medicaid expansion may have had unmet long-term care (LTC) needs before expansion. 

“Although Medicaid expansion has been shown to be associated with increased access to health services, increased quality of medical care delivered, and reduced mortality, little is known about its association with individuals’ use of LTC, including use of formal home health or nursing home care,” the study authors explained. “This association is important because Medicaid finances 50% of all LTC in the US, and nearly two-thirds of all Medicaid spending focuses on older adults and adults with disability.” 

To better understand the study findings, we spoke with lead author Courtney Harold Van Houtven, PhD, professor in the Department of Population Health Science, Duke University School of Medicine and Duke-Margolis Center for Health Policy. Dr Van Houtven explains why these findings are important for LTC, as well as for medicaid managed care plans and ACOs that could also be interested if the access to long-term care helps reduce the risk of long-term nursing home care over a longer outcome window.  

What existing data led you and your co-investigators to conduct this research? 

The Health and Retirement Study is a nationally representative of middle-aged and older community-dwelling adults in the US; respondents are followed over time so we can understand their health, health care, and financial trajectories.  The study has rich information about the demographics, socio-economic status, health, and health care use.  We are able to link the HRS to state identifiers in order to accurately reflect what states people reside in at the time the answer the survey.  This is hugely important to understand the state policies that affect their lives.   

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising? 

We found that among individuals likely eligible for expanded Medicaid through health care reform, that living in an expansion state was associated with higher use of any long-term care, a 4.4 percentage point increase (on a very low pre-period mean of 2.3 percent in the expansion states). Thus, this is a very large increase in relative magnitude. Furthermore, we find that ACA-funded Medicaid expansion was associated with  a 3.8 percentage point increase in home health and a 2.1 percentage point increase in nursing home use. These are significant at standard levels. We find no spillovers to older adults who were not eligible for expanded Medicaid through ACA. 

What was a surprise?  We found it promising that the relative increase in utilization occurred due to home and community-based services rather than nursing home use, because most individuals with a need for assistance with activities of daily living (e.g. who cannot independently perform the tasks needed in everyday life) prefer to remain at home.   

What are the possible real-world applications of these findings in clinical practice? 

Clinicians who serve patients with disability and needs for long-term services and supports (eg. Older adults), especially those who are low-income, should be aware that letting them know about and enrolling in ACA-Medicaid will increase their ability to receive needed LTSS. This study emphasizes that ACA-Medicaid expansion has direct effects on low-income middle aged adults through increasing their access to LTSS.  As such, state health departments and public health agencies, as well as state and local agencies serving disabled adults can also be an important pipeline for ensuring that qualifying individuals obtain Medicaid in expansion states by increasing applications to Medicaid.   

Do you and your co-investigators intend to expand upon this research? 

Not immediately.  The next obvious step would be to link the survey data to Medicaid claims and Medicare claims in order to understand what type of nursing home use was affected.  We know from other research using the Health and Retirement Study data that we may have been undercounting the total nursing home use across both the groups (those in expansion states and those in non-expansion states).  So linking to Medicare and Medicaid claims would be important to capture post-acute nursing home use (skilled nursing facility benefit paid for by Medicare) as well as long-term custodial nursing home use (paid by Medicaid).  It is important to understand whether the nursing home increase came from short-stayers for temporary problems like recovering from an accident (e.g. paid by Medicare), versus long-stayers, such as those who need nursing home level care for a long-period and maybe permanently.  We are unable to say with the self-reported data who paid for the long-term care types, and this too is important to understand for policy decision-making.    

Medicaid managed care plans and ACOs could also be interested in the findings if the access to long-term care helps reduce the risk of long-term nursing home care over a longer outcome window.  

Is there anything else pertaining to your research and findings that you would like to add?

Given that we were able to quantify the fact that unpaid care from family members and friends did not go down, our findings imply that total unmet needs for Long-term services and supports may have fallen. 

There are important caveats too. Our sample size was relatively small and our study only examines the immediate effects on LTSS use.  Understanding longer term effects will be important using data through 2020 and beyond.  

About Dr Van Houtven:

Dr. Courtney Van Houtven is a Professor in The Department of Population Health Science, Duke University School of Medicine and Duke-Margolis Center for Health Policy.  She is also a Research Scientist in Health Services Research and Development in Primary Care at the Durham Veteran’s Administration. Dr. Van Houtven’s aging and economics research interests encompass long-term care financing, intra-household decision-making, informal care, and end-of-life care. She examines how family caregiving affects health care utilization, expenditures, health and work outcomes of care recipients and caregivers. She is also interested in understanding how best to support family caregivers to optimize caregiver and care recipient outcomes. 


Van Houtven CH, McGarry BE, Jutkowitz E, Grabowski DC. 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. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.18728

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