Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86 percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008-13) and after (2015-17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6 percentage points), a lower proportion experienced a health status decline (-1.8 percentage points), and a higher proportion maintained their baseline health status (1.4 percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state's health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits-even for those with established access to safety-net care.
Keywords: Access to care; Affordable Care Act; Health policy; Low-income; Medicaid; Private health insurance; Uninsured; mortality.