Among the many goals of the Affordable Care Act (ACA) was expanded Medicaid coverage. In theory, adults with incomes up to 138 percent of the federal poverty level would be eligible to be covered. Pre-ACA standards were more stringent and excluded non-disabled adults with no dependent children.
Medicaid expansion was supposed to be a mandatory component of Obamacare. But a Supreme Court ruling made it optional, and each state could decide whether to accept the expansion.
Studies show that people in states with Medicaid expansion have benefitted significantly. More people in those states got insured. And, according to a recent overview, Medicaid expansion “improved access to care, utilization, affordability, and health outcomes.”
But did eligible unmarried people benefit as much as eligible married people from Medicaid expansion? That’s what Jim P. Stimpson of Drexel University, and two of his colleagues, wanted to know. In a study published in the journal Plos One in 2019, and summarized here, they compared the rates of Medicaid coverage before and after the ACA was passed, in states that did and did not have Medicaid expansion.
The Medicaid-eligible adults in their study were nearly 4 million people between the ages of 19 and 64 with incomes up to 138% of the federal poverty level. Data came from the American Community Survey between 2010 and 2016.
The Findings
First, for the nearly 4 million Medicaid-eligible people in the study, the ACA improved their access to health insurance. More had health insurance after ACA was passed than before it was passed. More were covered by Medicaid after ACA than before.
Every group benefited from the ACA. Between 2010 and 2016, the percentage of people in the study who had health insurance and who were covered by Medicaid increased for people who were married and for people who were not married; for women and for men; for states with Medicaid expansion and for states without Medicaid expansion.
The gains were not uniform. People in states with Medicaid expansion did far better than those without. And, Medicaid expansion improved coverage for married people more than unmarried people.
Consider, for example, the results for the most recent year for which data were available: 2016 (shown below). In states with Medicaid expansion, half of the married people eligible for Medicaid, 50%, were actually covered by Medicaid. That was a big improvement over the 23% of eligible adults who were covered by Medicaid in the states without Medicaid expansion – an increase of 27 percentage points.
Now look at the results for the unmarried (also shown below). Of those eligible for Medicaid, 43% were actually covered by Medicaid in states with Medicaid expansion. That’s less than the 50% of married people who were covered. It also represents an increase of only 19 percentage points over states without Medicaid expansion, compared to an increase of 27 percentage points for married people.
PEOPLE COVERED BY MEDICAID, 2016
Married (men and women)
50% Medicaid expansion states
23% States without Medicaid expansion
27% DIFFERENCE: more married people covered in expansion states than states without expansion
Unmarried (men and women)
43% Medicaid expansion states
24% States without Medicaid expansion
19% DIFFERENCE: more unmarried people covered in expansion states than states without expansion
I’ve also shown the 2016 results separately for the men and the women (below). In the states with Medicaid expansion, more of the eligible married men than unmarried men were covered by Medicaid, 48% vs. 38%. More of the married women than unmarried women were covered, too, 51% vs. 48%.
MEN
Married men
48% Medicaid expansion states
23% States without Medicaid expansion
Unmarried men
38% Medicaid expansion states
20% States without Medicaid expansion
WOMEN
Married women
51% Medicaid expansion states
24% States without Medicaid expansion
Unmarried women
48% Medicaid expansion states
28% States without Medicaid expansion
For just the year 2016, it looks like being in a Medicaid expansion state benefitted married men (over unmarried men) to about the same extent as it benefitted married women (over unmarried women). If I had kept the decimal places instead of rounding to the nearest whole numbers, then married women would have benefitted a bit more than married men.
The authors did not just look at one year. They compared the years post-ACA (2014-2016) to the years before (2010-2013), then calculated the extent of the improvement in coverage in the same way I did for 2016: comparing married and unmarried men, and married and unmarried women, in states with and without Medicaid expansion. With that more comprehensive analysis, they found that both married men and married women benefitted more than their unmarried counterparts, but that the married women benefitted more. Being married translated into a bigger improvement in coverage for women than for men.
Why Is This Happening?
In a way, these findings are an extension of what we already know about adults generally, and not just those eligible for Medicaid. Married people are typically advantaged in health insurance coverage – they are more likely to have coverage than unmarried people are. One reason is that married people can sometimes access coverage through their spouse’s plan at work.
The authors do not know for sure why fewer unmarried than married people benefitted from Medicaid expansion. For previously married people, they suggest the possibility that “marital disruption complicates the eligibility criteria and Medicaid application.”
As for unmarried people (and not just the previously married), the authors hypothesize that they “may have limited time to apply for benefits or lower awareness of eligibility for benefits.”
Before the ACA was passed, adults who were not disabled and who did not have dependent children were generally excluded from eligibility for Medicaid. The ACA expanded coverage to include them. For that reason, the authors thought that the unmarried might actually benefit more than the married people from Medicaid expansion. But that didn’t happen.
Having more inclusive laws on the books is a great step forward but it is not enough. Equal access to the benefits afforded by the laws is necessary, too.
[Notes: (1) The opinions expressed here do not represent the official positions of Unmarried Equality. (2) I’ll post all these blog posts at the UE Facebook page; please join our discussions there. (3) For links to previous columns, click here.]
About Bella DePaulo
