Abstract
Objectives. To examine the joint impact of states’ Medicaid expansion and participation in Medicaid enrollment outreach at the take-up of other means-tested public programs (Women, Infants, and Children [WIC], Supplemental Nutrition Assistance Program [SNAP]).
Methods. Data were used from the American Community Survey, WIC, and SNAP. We used difference-in-differences analyses to compare the combined impact of Medicaid expansion and enrollment outreach on program enrollment.
Results. Enrollment in means-tested programs decreased after 2014, regardless of Medicaid expansion and outreach status. However, gaps in enrollment among states that both expanded Medicaid and conducted outreach, compared with states that did neither, increased after expansion of SNAP and WIC enrollment (10.15% and 4.57%, respectively) and favored those states that did both.
Conclusions. States that both expanded Medicaid and conducted Medicaid enrollment outreach experienced smaller decreases in SNAP and WIC enrollment in comparison with other states. Moreover, enrollment in SNAP has shown to reduce health care expenditures. Greater collaboration among public programs, such as streamlining eligibility data and concerted outreach efforts, is one of the achievements of the Affordable Care Act that should be continued.
By September 2015, a total of 30 states and Washington, DC, had expanded Medicaid eligibility, as a result of the Affordable Care Act (ACA).1 (States that had adopted the Medicaid expansion as of January 1, 2014, were AZ, AR, CA, CO, CT, DE, DC, HI, IL, IA, KY, MD, MA, MN, NV, NJ, NM, NY, ND, OH, OR, RI, VT, WA, WV.) In addition, ACA provisions called for greater integration of public programs to aid with enrollment, retention, and eligibility determination.2 Efforts were made to improve customer experience, lower administrative costs, and improve program integrity by streamlining enrollment processes.2 After the ACA, Medicaid enrollment increased in both expansion and nonexpansion states; however, the increase was much greater in expansion states.3 This overall increase was likely caused by the “woodwork” or “welcome-mat” effect because nonexpansion states had no change in eligibility. The increase was attributed to several factors, including streamlining of eligibility determination and the application process, as well as an increase in outreach, which led to greater public awareness.4 Did Medicaid expansion and outreach have a similar effect on existing means-tested programs that experienced low take-up?
We examined the impact of outreach, in concert with Medicaid expansion, on enrollment in the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC). SNAP offers nutrition assistance to low-income individuals and families, and is available for nearly all low-income households, but the program has take-up problems.5 However, a study of SNAP indicated that when information and transaction cost barriers were reduced, there was a statistically significant increase in take-up.5 WIC provides nutrition services and education for low-income pregnant, breastfeeding, and nonbreastfeeding women, as well as infants and children aged up to 5 years. WIC also has a lower rate of take-up than eligible recipients, which has been addressed via outreach and partnerships with Medicaid and other agencies.6 Although eligibility requirements and enrollment for SNAP and WIC vary across states, they both have the potential for increased take-up from improved awareness and integration with other social programs. Both expansion states and nonexpansion states could use outreach strategies that include other public program data to increase Medicaid enrollment. Consequently, we examined whether Medicaid expansion states had differences in take-up in other public programs compared with nonexpansion states when factoring in outreach efforts.
METHODS
The data included the American Community Survey and the Annual Social and Economic Supplement to the Current Population Survey 2011 to 2016, Small Area Income and Poverty Estimates data, and SNAP and WIC Monthly Benefit Summary data sets. The outreach efforts for the states came from Centers for Medicare and Medicaid guidelines. As of August 2014, states could
implement modified adjusted gross income rules (15 states),
extend the renewal period for certain individuals (36 states),
facilitate enrollment through administrative transfers from other programs (7 states),
enroll parents based on children’s eligibility (4 states), and
adopt 12 months of continuous eligibility for parents and other adults (0 states).7
We included states in the outreach efforts analysis if they participated in at least 1 of the methods; some states used more than 1 strategy.
We used difference-in-differences analyses to examine the impact of both Medicaid expansion and Medicaid enrollment outreach on state-level enrollment in SNAP and WIC. We created a categorical variable to represent the 4 possible Medicaid expansion and outreach combinations. We also used a dichotomous time variable to capture data before and after Medicaid expansion. After meeting parallel trends assumptions, we performed multivariate regressions that included covariates, main effects, and the interaction of expansion and outreach condition by time to represent the difference-in-differences effect using Stata version 15 (StataCorp, College Station, TX).
RESULTS
Table 1 provides the results of the difference-in-differences analyses that examined the impact of Medicaid expansion and Medicaid enrollment outreach on state-level take-up of WIC and SNAP programs. For both means-tested programs, the differences in enrollment before expansion in states that both expanded Medicaid and conducted outreach, including all other combinations of expansion and outreach, was compared before and after expansion. Although take-up of means-tested programs decreased over time, states that both expanded Medicaid and conducted Medicaid enrollment outreach had higher rates of enrollment relative to those that did not expand or conduct outreach before expansion; this gap in enrollment increased after expansion.8 Specifically, this gap increased in SNAP and WIC take-up 10.15% and 4.57%, respectively. States that did not expand Medicaid but conducted Medicaid enrollment outreach had higher rates of enrollment relative to those that both expanded and conducted outreach before expansion, but this gap decreased after expansion by 6.21%, which further illustrated the combined effect of expansion and outreach.
TABLE 1—
Tests Examining the Impact of Medicaid Expansion and Medicaid Enrollment Outreach Status on Changes in Enrollment in Two Means-Tested Programs: United States, 2010–2016
| Median Enrollment Frequencies 2010–2013 | Median Enrollment Frequencies 2014–2016 | Adjusted Coefficient for Interactiona (95% CI) | Percent DiD | |
| SNAP | ||||
| Yes expansion/yes outreach (n = 25) | 523 401 | 505 169 | 0 (Ref) | — |
| No expansion/no outreach (n = 6) | 250 372 | 219 252 | 0.042 (0.006, 0.077) | 10.15 |
| No expansion/yes outreach (n = 13) | 872 833 | 826 790 | 0.026 (0.007, 0.045) | 6.21 |
| Yes expansion/no outreach (n = 7) | 429 298 | 453 146 | 0.016 (−0.015, 0.046) | 3.73 |
| WIC | ||||
| Yes expansion/yes outreach (n = 25) | 111 590 | 98 304 | 0 (Ref) | — |
| No expansion/no outreach (n = 6) | 55 996 | 47 898 | 0.019 (0.009, 0.029) | 4.57 |
| No expansion/yes outreach (n = 13) | 141 360 | 129 160 | 0.003 (−0.011, 0.018) | 0.80 |
| Yes expansion/no outreach (n = 7) | 70 044 | 63 481 | 0.013 (−0.003, 0.029) | 2.96 |
Note. CI = confidence interval; DiD = difference-in-differences; SNAP = Supplemental Nutrition Assistance Program; WIC = Women, Infants, and Children. Reference condition: states that both expanded Medicaid and conducted Medicaid enrollment outreach. SEs were clustered within states and examined using bootstrapping.
Source. ACS, CPS, SAIPE 2011-2016; SNAP and WIC benefit reports; CMS guidelines. Data were collected March 2017.
The DiD interaction was adjusted for covariates: state population, Gini coefficient, poverty and unemployment rates. The coefficients represent the impact of “Medicaid Expansion and Medicaid Enrollment Outreach Status” and “Time” on log10 transformed SNAP and WIC enrollment data. The time variable accounted for differences in year of expansion.
DISCUSSION
Nearly every public assistance program has more eligible beneficiaries than it enrolls. With expansion of Medicaid, there was not only an increase in enrollment for newly eligible participants, but also previously eligible but not enrolled participants, which was likely caused by increased awareness.9 We found increased Medicaid awareness and outreach, coupled with expansion, which might have spilled over to affect take-up of other public programs. Findings from previous single state expansion suggested this. Research from the Oregon Medicaid lottery experiment examined Medicaid enrollment, the labor market, and take-up of other social safety net programs and discovered enrolling in Medicaid had a statistically significant impact on SNAP enrollment.5 Greater awareness, access, and information could affect the take-up of other social programs.
Many outreach programs were set up after the ACA to help the newly eligible get insurance (e.g., Enroll America). They launched a major campaign called “Get Covered America” that provided outreach, education, training, and data-backed resources for communities and individuals.4 Also, as previously stated, the Centers for Medicare and Medicaid issued several strategies for states to streamline enrollment processes. Strategy 3 allowed Medicaid enrollment using SNAP application information, making the enrollment process more efficient. Household income data used for SNAP eligibility are often less than 6 months old and rigorously verified.7 As shown in Table 1, the gaps in enrollment increased, favoring states that both expanded Medicaid and engaged in outreach, which highlighted the association between enrollment strategies to a specific program and streamlined eligibility data. Our findings supported the notion that overt outreach can be linked to greater take-up in public assistance programs.
There were several limitations of the present research. The number of years included in the post-Medicaid expansion timeframe was limited. With likely changes to the ACA, it is possible that states will continue Medicaid expansion; future research could contain more years of data. Policy changes other than Medicaid expansion were not accounted for and could affect the findings and changes in the general economy and program-specific policies.
PUBLIC HEALTH IMPLICATIONS
All states saw a decline in the number of uninsured, with Medicaid expansion states experiencing higher rates of decline.9 Policy decisions at the state level determine eligibility standards, participation rates, benefits, and numerous other less visible decisions. Food insecurity is linked to higher health care costs.10 Recent research related to SNAP enrollment has indicated that low-income Americans who receive SNAP benefits have lower health care expenditures.11 This finding supports the importance of outreach efforts of enrollment in SNAP programs because it could lead to reduced overall health care costs in the United States.
A major effect of the ACA implementation is the considerable modernization of the eligibility and enrollment systems for Medicaid across the states.12 The Urban Institute’s report on integrating health and humanservice programs states that “The single greatest success achieved by integration under the ACA thus far probably involves states’ use of SNAP data.”2(p24) The report also confirms that doing this decreases the administrative burden on state health officials.2
HUMAN PARTICIPANT PROTECTION
Institutional review board approval was not needed for this project because the data were de-identified and publicly available.
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