March 2018 | Issue Brief The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Samantha Artiga A substantial body of research has investigated effects of the Medicaid expansion under the Affordable Care Act (ACA) on coverage; access to care, utilization, affordability, and health outcomes; and various economic measures. This issue brief summarizes findings from 202 studies of the impact of state Medicaid expansions under the ACA published beginning in January 2014 (when the coverage provisions of the ACA went into effect) and updates earlier versions of this brief with studies through February 2018.1 More recent studies continue to support earlier findings but provide additional findings in key areas, including expansion’s effects on health outcomes, access to services and medications for behavioral health and other needs, and providers’ financial stability. Key Findings This body of research suggests that the expansion presents an opportunity for gains in coverage, improvements in access and financial security, and economic benefits for states and providers.  Coverage: Studies show that Medicaid expansion states experienced significant coverage gains and reductions in uninsured rates, among the low-income population broadly and within specific vulnerable populations. States that implemented the expansion through a waiver have seen coverage gains, but some waiver provisions appear to compromise coverage. Data do not support a relationship between states’ expansion status and community-based services waiver waiting lists.  Access to care, utilization, affordability, and health outcomes: Most research demonstrates that Medicaid expansion has positively affected access to care, utilization of services, the affordability of care, and financial security among the low-income population. However, findings on provider capacity were mixed, with some studies suggesting that provider shortages are a challenge in certain contexts. Studies show improved self-reported health following expansion, and multiple new studies demonstrate a positive association between expansion and health outcomes. Further research is needed to more fully determine effects on outcomes given that it may take additional time for measureable changes in health outcomes to occur.  Economic measures: Analyses find positive effects of expansion on numerous economic outcomes, despite Medicaid enrollment growth initially exceeding projections in many states. Total (federal and state) Medicaid spending increased following expansion implementation, but research suggests that there were no significant increases in state spending from state funds as a result of the expansion through 2015 (although an uptick in state Medicaid spending growth was projected for 2017 and later years as the federal share for the expansion population phases down from 100% to 90%). Studies also show that Medicaid expansions result in reductions in uncompensated care costs for hospitals and clinics as well as positive or neutral effects on employment and the labor market. This literature review includes studies, analyses, and reports published by government, research, and policy organizations using data from 2014 or later. This brief only includes studies that examine impacts of the Medicaid expansion in expansion states. It excludes studies on impacts of ACA coverage expansions generally (not specific to Medicaid expansion alone), studies investigating potential effects of expansion in states that have not (or had not, at the time of the study) expanded Medicaid, and reports from advocacy organizations and media sources. Findings are separated into three broad categories: Medicaid expansion’s impact on coverage; access to care, utilization, affordability, and health outcomes; and economic outcomes for the expansion states. The Appendix at the end of the brief provides a list of citations for each of the included studies, grouped by the three categories of findings. Recently published studies from late 2017 and early 2018 have continued to support earlier findings while using the additional years of experience with expansion to deepen findings in many areas, including expansion’s effects on health outcomes, access to services and medications for behavioral health and other needs, and providers’ financial stability. Among other findings, new studies in these areas show that expansion is associated with infant mortality rate reductions, increases in cancer diagnosis rates (especially early-stage diagnosis rates), increases in prescriptions for and Medicaid coverage of medications to treat opioid use disorder and opioid overdose, and reduced probability of hospital closure (particularly in rural areas). We will continue to monitor and update these findings as additional studies and state experiences provide insight into how various factors shape coverage, access to care, and costs in Medicaid expansion states and as states continue to consider expansion and reshape Medicaid coverage. While future research will be necessary to study the effects of new waiver provisions recently approved by or pending approval from the Trump administration, findings from this literature review on states with existing expansion waivers (such as Indiana) suggest that adding new restrictions or program complexities to Medicaid through Section 1115 waivers could compromise coverage and access gains achieved under expansion or slow future progress. Impacts on Coverage Uninsured Rate and Medicaid Coverage Changes Studies show that Medicaid expansion results in significant coverage gains and reductions in uninsured rates.  States expanding their Medicaid programs under the ACA have seen large increases in Medicaid enrollment, driven by enrollment of adults made newly eligible for Medicaid as well as enrollment growth among individuals who were previously eligible for but not enrolled in Medicaid (known as the “woodwork” or “welcome mat” effect that occurred largely due to incentives to increase enrollment in coverage provided under the broader ACA). In comparison, non-expansion states have experienced slower enrollment growth.2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24  Numerous analyses demonstrate that Medicaid expansion states experienced large reductions in uninsured rates and that these reductions significantly exceed those in non-expansion states.25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 2 o Recent studies have shown that expansion-related enrollment growth in Medicaid and declines in uninsured rates in expansion states continued in 2015 and 2016, and that the gap between coverage rates in expansion and non-expansion states continued to widen after 2014. One study found that the greater uninsured rate decline in expansion compared to non-expansion states was isolated among the population that is ineligible for ACA coverage in non-expansion states (those below 100% FPL).57,58,59,60,61 ,62  The sharp declines in uninsured rates among the low-income population in expansion states are widely attributed to gains in Medicaid coverage.63,64,65,66,67,68  Research does not support a relationship between states’ Medicaid expansion status and home and community-based services (HCBS) waiver waiting lists. One study found that most expansion states either had no HCBS waiver waiting list or had a decrease in their waiting list from 2014 to 2015, and more non-expansion states than expansion states experienced an HCBS waiver waiting list increase between 2014 and 2015.69  Studies exploring the potential for Medicaid expansion to “crowd-out” private insurance have found mixed results, with most showing no evidence of “crowd-out” and some showing slight declines in private coverage in expansion states following expansion.70,71,72,73,74,75,76,77,78 Similar coverage gain patterns have occurred within specific vulnerable populations.  While many studies focused on the low-income population broadly, several studies identified larger coverage gains in expansion versus non-expansion states for specific vulnerable populations, including young adults, prescription drug users, people with HIV, veterans, parents, mothers, women of reproductive age (with and without children), children, lesbian, gay, and bisexual adults, newly diagnosed cancer patients, women diagnosed with a gynecologic malignancy, low-income workers, low-educated adults, early retirees, and childless adults with incomes under 100% FPL.79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102  Multiple recent analyses demonstrate that Medicaid expansion is having a disproportionately positive impact in rural areas in expansion states, where growth in Medicaid coverage and declines in uninsured rates have exceeded those in metropolitan areas in expansion states and both rural and metropolitan areas in non-expansion states. One study found higher Medicaid growth rates in metropolitan counties compared to rural counties in both expansion and non- expansion states, but the geographic differential in growth rates was much less dramatic in expansion states and analysis at the state level showed much variability across the states.103,104,105,106  Multiple studies showed that this trend of larger uninsured rate reductions and Medicaid coverage gains in expansion states compared to non-expansion states occurred across the major racial/ethnic categories. Additional research also suggests that Medicaid expansion has helped to reduce disparities in coverage by income and age, and research shows improvements in disparities by race/ethnicity, with mixed outcomes for some specific racial and ethnic groups.107,108,109,110,111,112,113,114,115,116 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 3  One 2017 study demonstrated a clear “welcome-mat” effect of Medicaid expansion on enrollment in public coverage among children who were already eligible for Medicaid. Enrollment increases in 2014 and 2015 among children whose parents became newly eligible for Medicaid under the expansion outpaced coverage increases among children in families without newly eligible parents by more than double.117 Coverage Effects Under Section 1115 Medicaid Expansion Waivers States implementing the expansion through a waiver have seen similar gains in coverage, but some provisions in these waivers may present barriers to coverage.  Studies show that states expanding Medicaid through Section 1115 waivers have experienced coverage gains that are similar to gains in states implementing traditional Medicaid expansions. Research comparing Arkansas (which expanded through a premium assistance model) and Kentucky (which expanded through a traditional, non-waiver model) showed no significant differences in uninsured rate declines between 2013 and 2015 in the two states. An analysis of expansion waiver programs in Michigan and Indiana showed that both states experienced uninsured rate reductions between 2013 and 2015 that were higher than the average decrease among expansion states as well as large gains in Medicaid enrollment.118,119,120,121  Data from Indiana, which implemented the expansion through a Section 1115 waiver, show that its required monthly contributions may have created an enrollment barrier for some adults. In the Healthy Indiana Plan (HIP) 2.0 Medicaid expansion program, individuals above 100% FPL are either not enrolled or disenrolled from HIP 2.0 coverage for unpaid monthly contributions. A report assessing the program showed that between February 1, 2015 and November 30, 2016, 57,189 members were disenrolled or not enrolled due do non-payment (representing 29% of those that could be affected by the policy).122,123  Evidence also suggests that beneficiaries and other stakeholders often do not fully understand complex enrollment policies such as the HIP 2.0 monthly contribution policy, and these policies can deter eligible people from enrolling in coverage. The March 2017 HIP 2.0 evaluation found that 14% of all HIP enrollees above 100% FPL, 33% of individuals who were disenrolled for not making a monthly contribution, and 40% of individuals who were not enrolled because they did not make a first monthly contribution reported being unaware that they could be disenrolled for non-payment.124,125,126 Impacts on Access to Care, Utilization, Affordability, and Health Outcomes Access to Care and Utilization Most research demonstrates that Medicaid expansion positively impacts access to care and utilization of health care services among the low-income population, but some studies have not identified significant effects in these areas.  Many expansion studies point to improvements across a wide range of measures of access to care as well as utilization of some medications and services. Some of this research also shows The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 4 that improved access to care and utilization is leading to increases in diagnoses of a range of diseases and conditions and in the number of adults receiving consistent care for a chronic condition.127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157, 158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177 For example: o Two studies found that expansion was associated with significantly greater increases in cancer diagnosis rates (especially early-stage diagnosis rates), and another study showed an association of expansion with an increase in the probability of early uncomplicated presentation for patients admitted to hospitals for one of five common surgical conditions. A fourth study found that Medicaid expansion was correlated with increased heart transplant listing rates for African American patients (both overall and among Medicaid enrollees, specifically).178,179,180,181 o Recent evidence demonstrates that compared to non-expansion states, Medicaid expansion states have seen greater improvements in access to medications and services for the treatment of behavioral and mental health conditions. This evidence includes studies that have shown that Medicaid expansion is associated with increases in overall prescriptions for, Medicaid-covered prescriptions for, and Medicaid spending on medications to treat opioid use disorder and opioid overdose. Additional research found increased utilization and Medicaid coverage of evidence-based smoking cessation medications post-expansion in expansion states relative to non-expansion states.182,183,184,185,186,187,188,189,190,191,192,193 o Multiple recent studies have also found expansion to be associated with improvements in disparities by race and income, education level, and employment status in measures of access to and affordability of care.194,195,196,197 o Studies conducted in 2017 and 2018 began to explore the effect of the Medicaid expansion on quality of care. A January 2018 study found that for patients with one of five common surgical conditions admitted to an academic medical center or affiliated hospital, expansion was associated with a significantly greater probability of receiving optimal care. Another study found that at federally funded community health centers, expansion was associated with improved quality on four of eight measures examined: asthma treatment, Pap testing, body mass index assessment, and hypertension control. A third study found some improvement in perceived quality of care associated with expansion in 2015, but this result did not persist in 2016.198,199,200 o Some studies point to changes in patterns of use of emergency departments (EDs). Two recent single-state studies in Maryland and Illinois found declines in uninsured ED visits and increases in Medicaid-covered ED visits following expansion implementation. Some studies have explored expansion’s impact on total emergency department (ED) volume and utilization patterns. A single-state study in Maryland found no significant relationship between Medicaid expansion and changes in total ED volume by hospital. An Illinois study found an increase in total ED visits after ACA implementation, but this included an increase in visits by individuals with private coverage. One study in a single hospital in The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 5 Maryland found that, in the year after expansion, there was a small but statistically significant reduction in the proportion of ED patients that were high utilizers and a reduction in visits to the ED for ambulatory care sensitive conditions. However, high utilizers remained more likely than low utilizers to have ED visits for ambulatory care sensitive conditions before and after Medicaid expansion.201,202,203 o Two studies found that Medicaid expansion was associated with declines in hospital length-of-stay for Medicaid patients. Another analysis found that, contrary to past studies associating Medicaid insurance with longer hospitalizations and higher in-hospital mortality, the shift in payer mix in expansion states (increase in Medicaid discharges and decrease in uninsured discharges) did not influence length of stay or in-hospital mortality for general medicine patients at academic medical centers.204,205,206  Evidence suggests that beneficiaries and other stakeholders lack understanding of some waiver provisions designed to change utilization or improve health outcomes. Multiple studies have demonstrated confusion among beneficiaries, providers, and advocates in expansion waiver states around the basic elements of the programs or requirements for participation, as well as beneficiary reports of barriers to completion of program activities (including internet access and transportation barriers). These challenges have resulted in increased costs to beneficiaries, beneficiaries being transitioned to more limited benefit packages, low program participation, or programs not operating as intended in other ways.207,208,209,210,211  A few studies did not find significant positive effects of expansion on certain measures of access or utilization. For several of the earlier studies in this group, these results may reflect the additional time needed for persons to enroll in Medicaid and establish care following initial expansion implementation. Authors of early studies using 2014 data note that changes in utilization may take more than one year to materialize. Consistent with this premise, a longer-term study found improvements in measures of access to care and financial strain in year two of the expansion that were not observed in the first year.212,213,214,215,216,217  While some research indicates that provider shortages are a challenge in certain contexts, many studies show that providers have expanded capacity and are meeting increased demands for care.218,219,220,221,222,223,224,225,226,227,228,229,230,231,232,233,234,235,236,237 For example: o One study found that Medicaid expansion was associated with longer wait times for appointments, suggesting remaining access challenges despite improvements in coverage and access measures.238 o In contrast, another study found that Medicaid primary care appointment availability increased significantly in the five expansion states included in the analysis, whereas there were no significant changes in appointment availability in the non-expansion states studied.239 o An additional study found improvements in receipt of checkups, care for chronic conditions, and quality of care even in areas with primary care shortages, suggesting that insurance expansions can have a positive impact even in areas with relative shortages.240 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 6 Affordability and Financial Security Research suggests that Medicaid expansion improves the affordability of care and financial security among the low-income population.  Several studies show that expansion states have experienced greater reductions in unmet medical need because of cost than non-expansion states. Although a few studies did not identify statistically significant differences in changes in unmet medical need due to cost between expansion and non-expansion states, some of these findings may have been affected by study design or data limitations.241,242,243,244,245,246,247,248,249,250,251,252,253,254,255,256,257,258  Research suggests that Medicaid expansion results in significant reductions in out-of-pocket medical spending. One study found that previously uninsured prescription drug users who gained Medicaid coverage in 2014 saw, on average, a $205 reduction in annual out-of-pocket spending in 2014. The January 2018 study noted above that focused on the 100-138% FPL population in expansion and non-expansion states also found that Medicaid expansion coverage produced far greater reductions than subsidized Marketplace coverage in average total out-of-pocket spending, average out-of-pocket premium spending, and average cost-sharing spending.259,260,261,262,263  Multiple studies found larger declines in trouble paying as well as worry about paying future medical bills in expansion states relative to non-expansion states.264,265,266,267,268,269,270,271,272,273,274,275 For example: o One study found that, among those residing in areas with high shares of low-income, uninsured individuals, Medicaid expansion significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies. Similarly, other studies have found that Medicaid expansion has significantly reduced the percentage of people with medical debt, reduced the average size of medical debt, reduced the average number of collections, improved credit scores, reduced the probability of having one or more medical bills go to collections in the past 6 months, and reduced the probability of a new bankruptcy filing, among other improvements in measures of financial security.276,277,278,279 o A study of Ohio’s Medicaid expansion found that the percentage of expansion enrollees with medical debt fell by nearly half since enrolling in Medicaid (55.8% had debt prior to enrollment, 30.8% had debt at the time of the study).280 Self-Reported Health and Health Outcomes Continually emerging research has documented improvements in self-reported health and certain health outcomes measures following Medicaid expansion.  Multiple studies have found improvements in measures of self-reported health following Medicaid expansions, and additional research has documented provider reports of newly eligible adults receiving life-saving or life-changing treatments that they could not obtain prior to expansion.281,282,283,284,285,286 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 7  One 2017 study found that Medicaid expansion was associated with improved health outcomes for cardiac surgery patients, including a significant decrease in predicted preoperative risk of morbidity or mortality and a decreased risk-adjusted rate of postoperative major morbidity.287  A January 2018 study suggests that expansion may contribute to infant mortality rate reductions. While the mean infant mortality rate rose slightly in non-expansion states between 2014 and 2016, it declined in expansion states over that period. This effect was particularly pronounced among the African-American population.288  A 2018 study found no evidence of expansion affecting drug-related overdoses or fatal alcohol poisonings.289  Four analyses did not find significant changes in self-reported health status. Given that it may take additional time for measureable changes in health to occur, researchers suggest that further work is needed to provide longer-term insight into expansion’s effects on self-reported health and health outcomes.290,291,292,293 Economic Effects State Budgets and Economies Analyses find positive effects of expansion on multiple economic outcomes, despite Medicaid enrollment growth initially exceeding projections in many states and increases in total Medicaid spending, largely driven by increases in federal spending given the enhanced federal match rate for expansion population costs provided under the ACA (the federal share was 100% for 2014- 2016 and phases down to 90% for 2020 and subsequent years).  National, multi-state, and single state studies show that states expanding Medicaid under the ACA have realized budget savings, revenue gains, and overall economic growth. A 2016 study found that growth in state Medicaid spending in expansion states has been lower relative to non- expansion states, but an uptick was predicted for state fiscal year (SFY) 2017, primarily due to the phase-down in the federal share for the expansion population from 100% to 95% in 2017. As of the end of Summer 2016, several expansion states planned to use provider taxes or fees to fund all or part of the state share of expansion costs beginning in 2017. While studies showed higher growth rates in total Medicaid spending (federal, state, and local) following initial expansion implementation in 2014 and 2015, this growth rate slowed significantly in 2016.294,295,296,297,298,299,300,301,302,303,304,305,306 o National research found that there were no significant increases in spending from state funds as a result of Medicaid expansion and no significant reductions in state spending on education, transportation, or other state programs as a result of expansion during FYs 2010-2015.307 o A Louisiana annual report on Medicaid expansion reported that expansion saved the state $199 million in FY 2017 due to multiple factors, including the higher federal match rate for Medicaid populations that were previously funded at the regular state match rate, additional revenue from a premium tax on managed care organizations, and a decrease The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 8 in state disproportionate share payments to hospitals as the uninsured population decreased.308  Multiple studies suggest that Medicaid expansion can result in state savings by offsetting state costs in other areas, including state costs related to behavioral health services, crime and the criminal justice system, and Supplemental Security Income program costs. For example, a study on Montana revealed that as Medicaid’s role in financing substance use disorder (SUD) services has grown under the state’s decision to expand Medicaid, federal Medicaid dollars have replaced federal block grant and state dollars previously used to fund services for uninsured Montanans with SUD.309,310, 311,312,313,314,315,316 Medicaid Spending Per Enrollee  National studies have found lower Medicaid spending per enrollee for the new ACA adult eligibility group compared to traditional Medicaid enrollees and that per enrollee costs for newly eligible adults have declined over time since initial implementation of the expansion.317,318,319 o One analysis found that in 2014, among those states reporting both spending and enrollment data, spending per enrollee for the new adult group was much lower than spending per enrollee for traditional Medicaid enrollees.320 o A June 2017 study showed that per enrollee Medicaid spending declined in expansion states (-5.1%) but increased in non-expansion states (5.1%) between 2013 and 2014. Researchers attributed these trends to the ACA Medicaid expansion, which increased the share of relatively less expensive enrollees in the Medicaid beneficiary population mix in expansion states.321 o The 2016 Actuarial Report on the Financial Outlook for Medicaid shows that while the average per enrollee costs for newly eligible adults in initial years following expansion were higher than for previously eligible adults, these per enrollee costs have declined over time as states have adjusted capitation rates to better reflect actual use. By 2018, the cost for newly eligible adults is projected to be less than that of previously eligible adults.322 Marketplace Effects  Research suggests that Medicaid expansion may contribute to lower Marketplace premiums— one study found that Marketplace premiums are about 7% lower in expansion compared to non- expansion states. The study authors suggested that the difference in premiums reflects a difference in risk pool between expansion and non-expansion states, where individuals between 100 and 138% FPL make up a greater share of Marketplace enrollment in non-expansion compared to expansion states. Another study found that the state average plan liability risk score was higher in non-expansion than expansion states in 2015 (higher risk scores are associated with sicker state risk pools and likely translate to higher premiums).323,324,325 o A study in Arkansas showed that the “private option” expansion has helped to boost the number of carriers offering Marketplace plans statewide, generated a younger and The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 9 relatively healthy risk pool in the Marketplace, and contributed to a 2% drop in the average rate of Marketplace premiums between 2014 and 2015. A study of New Hampshire’s Premium Assistance Program (PAP) population (Medicaid expansion population enrolled in the Marketplace), however, showed higher medical costs for the PAP population compared to other Marketplace enrollees.326,327 Impacts on Hospitals and Other Providers Medicaid expansion results in reductions in uncompensated care costs for hospitals, clinics, and other providers.  Research shows that Medicaid expansions result in reductions in uninsured hospital or other provider visits and uncompensated care costs, whereas providers in non-expansion states have experienced little or no decline in uninsured visits and uncompensated care. One study suggested that Medicaid expansion cut every dollar that a hospital in an expansion state spent on uncompensated care by 41 cents between 2013 and 2015, corresponding to a reduction in uncompensated care costs across all expansion states of $6.2 billion over that period.328,329,330,331,332,333,334,335,336,337,338,339,340,341,342,343,344,345,346,347,348,349,350,351,352,353,354,355,356,357,358,359, 360,361,362,363,364 o Some studies point to improvements in patterns of use of emergency departments (EDs), specifically. Two recent single-state studies in Maryland and Illinois, a study comparing California to Florida (a non-expansion state), and a study across 25 expansion and non- expansion states, found significant declines in uninsured ED visits and increases in Medicaid-covered ED visits following expansion implementation (the studies that included non-expansion states found much smaller changes on these measures in the non- expansion states). 365,366,367,368 o One study found that expansion significantly increased Medicaid coverage of treatment at specialty substance use disorder (SUD) treatment facilities and decreased the probability that patients at these facilities were uninsured. A second study found large shifts in sources of payment for SUD treatment among justice-involved individuals following Medicaid expansion in 2014, with significant increases in those reporting Medicaid as the source of payment.369,370 o Evidence suggests that Medicaid expansion significantly reduced variation in provision of uncompensated care between hospitals that treat a disproportionate share of low-income patients (DSH hospitals) and those that do not, with DSH hospitals experiencing significantly larger reductions in uncompensated care days per bed.371  A new study published in January 2018 found that Medicaid expansion was associated with improved hospital financial performance and significant reductions in the probability of hospital closure, especially in rural areas and areas with higher pre-ACA uninsured rates.372  Additional studies demonstrate that Medicaid expansion has significantly improved hospital operating margins. One analysis found that while all types of hospitals in expansion states experienced reductions in uncompensated care costs and increases in Medicaid revenue The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 10 compared with their counterparts in non-expansion states, expansion’s effects on margins were strongest for small hospitals, for-profit and non-federal-government-operated hospitals, and hospitals located in non-metropolitan areas.373,374,375,376 Employment and Labor Market Effects Studies find that Medicaid expansion has had positive or neutral effects on employment and the labor market.  State-specific studies have documented or predicted significant job growth resulting from expansion. A study in Colorado found that the state supports 31,074 additional jobs due to Medicaid expansion as of FY 2015-2016, and a study in Kentucky estimated that expansion would create over 40,000 jobs in the state through SFY 2021 with an average salary of $41,000.377,378,379  No studies have found negative effects of expansion on employment or employee behavior. Studies examining employment rates and other measures such as transitions from employment to non-employment, the rate of job switches, transitions from full- to part-time employment, labor force participation, and usual hours worked per week have not found significant effects of Medicaid expansion. One study showed that adults with disabilities living in expansion states are significantly more likely to be employed and less likely to be unemployed due to disability compared to adults with disabilities in non-expansion states.380,381,382,383,384  In an analysis of Medicaid expansion in Ohio, most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment. Over half of expansion enrollees who were employed reported that Medicaid enrollment made it easier to continue working.385  One study found an association between Medicaid expansion and volunteer work (both formal volunteering for organizations and informally helping a neighbor), with significant increases in volunteer work occurring among low-income individuals in expansion states in the post-expansion period (through 2015) but no corresponding increase in non-expansion states. The researchers connect this finding to previous literature showing an association between improvements in individual health and household financial stabilization and an increased likelihood of volunteering.386  An additional analysis found that Medicaid expansion is associated with increased responsiveness of the program to meet coverage needs during periods of high unemployment.387 Conclusion and Implications As a whole, the large body of research on the effects of Medicaid expansion under the ACA suggests that expansion has had largely positive impacts on coverage; access to care, utilization, and affordability; and economic outcomes, including impacts on state budgets, uncompensated care costs for hospitals and clinics, and employment and the labor market. However, findings on provider capacity are mixed, with some studies suggesting that provider shortages are a challenge in certain contexts. Overall, these findings suggest potential for gains in coverage and access as well as economic benefits to states and The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 11 providers in the remaining non-expansion states that may be considering adopting the expansion in the future. While future research will be necessary to study the effects of new waiver provisions recently approved by or pending approval from the Trump administration, findings from this literature review on states with existing expansion waivers (such as Indiana) suggest that adding new restrictions or program complexities to Medicaid through Section 1115 waivers could compromise coverage and access gains achieved under expansion or slow future progress. Key questions for future consideration include whether increased flexibility under Section 1115 waiver authority will result in roll-backs in coverage, whether additional states will adopt the expansion and under what conditions, and how new Medicaid expansion- related restrictions and requirements will impact states, beneficiaries, and providers. We will continue to monitor and update this literature review as additional studies and state experiences provide insight into how various factors shape coverage, access to care, and costs in Medicaid expansion states and as states continue to consider expansion and reshape Medicaid coverage. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 12 Endnotes 1 This is an update to three earlier versions of this issue brief that covered studies published through May 2016, January 2017, and June 2017. 2 Frederic Blavin, Michael Karpman, Genevieve Kenney, and Benjamin Sommers, “Medicaid Versus Marketplace Coverage for Near-Poor Adults: Effects on Out-Of-Pocket Spending and Coverage,” Health Affairs 37 no. 2 (January 2018), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.1166 3 Sarah Miller and Laura Wherry, “Health and Access to Care During the First 2 Years of the ACA Medicaid Expansions,” The New England Journal of Medicine 376 no. 10 (March 2017), http://www.nejm.org/doi/full/10.1056/NEJMsa1612890 4 Louisiana Department of Health, Medicaid Expansion 2016/17 (Baton Rouge, Louisiana Department of Health, June 2017), http://dhh.louisiana.gov/assets/HealthyLa/Resources/MdcdExpnAnnlRprt_2017_WEB.pdf 5 Jack Hoadley, Karina Wagnerman, Joan Alker, and Mark Holmes, Medicaid in Small Towns and Rural America: A Lifeline for Children, Families, and Communities (Washington, DC: Georgetown Center for Children and Families, June 2017), https://ccf.georgetown.edu/wp-content/uploads/2017/06/Rural-health-final.pdf 6 Sandra Decker, Brandy Lipton, and Benjamin Sommers, “Medicaid Expansion Coverage Effects Grew in 2015 With Continued Improvements in Coverage Quality,” Health Affairs 36 no. 5 (May 2017): 819-825, http://content.healthaffairs.org/content/36/5/819.full 7 Abigail Barker, Kelsey Huntzberry, Timothy McBride, and Keith Mueller, Changing Rural and Urban Enrollment in State Medicaid Programs (Iowa City, IA: Rural Policy Research Institute, May 2017), https://cph.uiowa.edu/rupri/publications/policybriefs/2017/Changing%20Rural%20and%20Urban%20Enrollment%20in %20State%20Medicaid%20Programs.pdf 8 George Wehby and Wei Lyu, “The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12711/abstract 9 Robin Rudowitz, Laura Snyder, and Vernon Smith, Medicaid Enrollment & Spending Growth: FY 2015 & 2016 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2015), http://kff.org/medicaid/issue- brief/medicaid-enrollment-spending-growth-fy-2015-2016/ 10 Deloitte Development LLC, Commonwealth of Kentucky Medicaid Expansion Report, (Deloitte Development LLC, February 2015), http://jointhehealthjourney.com/images/uploads/channel-files/Kentucky_Medicaid_Expansion_One- Year_Study_FINAL.pdf 11 Samantha Artiga, Jennifer Tolbert, and Robin Rudowitz, Year Two of the ACA Coverage Expansions: On-the- Ground Experiences from Five States (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2015), http://kff.org/health-reform/issue-brief/year-two-of-the-aca-coverage-expansions-on-the-ground-experiences- from-five-states/ 12 Laura Wherry and Sarah Miller, “Early Coverage, Access, Utilization, and Health Effects Associated with the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study,” Annals of Internal Medicine, Epub ahead of print (April 2016), http://annals.org/article.aspx?articleid=2513980 13 Anne Martin et al., “National Health Spending: Faster Growth in 2015 As Coverage Expands and Utilization Increases,” Health Affairs 36 no. 1 (January 2017): 166-176, http://content.healthaffairs.org/content/36/1/166.full?sid=982b20c0-0a17-4dc4-a35a-b0302d4ec289 14 Benjamin Sommers, Robert Blendon, and E. John Orav, “Both the ‘Private Option’ And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults,” Health Affairs 35, no. 1 (January 2016): 96-105, http://content.healthaffairs.org/content/35/1/96.abstract 15 Robin Rudowitz, Allison Valentine, and Vernon Smith, Medicaid Enrollment and Spending Growth: FY 2016 & 2017 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2016), http://kff.org/medicaid/issue- brief/medicaid-enrollment-spending-growth-fy-2016-2017/ The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 13 16 Jessica Vistnes and Joel Cohen, “Gaining Coverage in 2014: New Estimates of Marketplace and Medicaid Transitions,” Health Affairs 35 no. 10 (October 2016): 1825-1829, http://content.healthaffairs.org/content/35/10/1825.full?sid=cc385dd5-9c95-4ee1-9c58-888408d49c54 17 Pauline Leung and Alexandre Mas, Employment Effects of the ACA Medicaid Expansions (Working Paper No. 22540, National Bureau of Economic Research, August 2016), http://www.nber.org/papers/w22540 18 Kamyar Nasseh and Marko Vujicic, Early Impact of the Affordable Care Act’s Medicaid Expansion on Dental Care Use (Health Services Research, November 2016), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12606/full 19 Christopher Truffer, Christian Wolfe, and Kathryn Rennie, 2016 Actuarial Report on the Financial Outlook for Medicaid, (Office of the Actuary, Centers for Medicare and Medicaid Services, 2016), https://www.cms.gov/Research- Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2016.pdf 20 Aparna Soni, Michael Hendryx, and Kosali Simon, “Medicaid Expansion under the Affordable Care Act and Insurance Coverage in Rural and Urban Areas,” The Journal of Rural Health epub ahead of print (January 2017), http://onlinelibrary.wiley.com/doi/10.1111/jrh.12234/full 21 Molly Frean, Jonathan Gruber, and Benjamin Sommers, Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the Affordable Care Act (Working Paper No. 22213, National Bureau of Economic Research, April 2016), http://www.nber.org/papers/w22213?utm_campaign=ntw&utm_medium=email&utm_source=ntw 22 Stan Dorn, Norton Francis, Laura Snyder, and Robin Rudowitz, The Effects of the Medicaid Expansion on State Budgets: An Early Look in Select States (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2015), http://kff.org/medicaid/issue-brief/the-effects-of-the-medicaid-expansion-on-state-budgets-an-early-look- in-select-states/ 23 Stacey McMorrow, Genevieve Kenney, Sharon Long, and Nathaniel Anderson, “Uninsurance Among Young Adults Continues to Decline, Particularly in Medicaid Expansion States,” Health Affairs 34, no. 4 (April 2015): 616-620, http://content.healthaffairs.org/content/34/4/616.full 24 Brendan Saloner, Sachini Bandara, Emma McGinty, and Colleen Barry, “Justice-Involved Adults With Substance Use Disorders: Coverage Increased but Rates of Treatment Did Not in 2014,” Health Affairs 35 no. 6 (June 2016), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0005 25 Frederic Blavin, Michael Karpman, Genevieve Kenney, and Benjamin Sommers, “Medicaid Versus Marketplace Coverage for Near-Poor Adults: Effects on Out-Of-Pocket Spending and Coverage,” Health Affairs 37 no. 2 (January 2018), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.1166 26 Thomas Selden, Brandy Lipton, and Sandra Decker, “Medicaid Expansion and Marketplace Eligibility Both Increased Coverage, With Trade-Offs in Access, Affordability,” Health Affairs 36 no. 12 (December 2017), https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0830 27 Susan Hayes, Sara Collins, David Radley, and Douglas McCarthy, What’s at Stake: States’ Progress on Health Coverage and Access to Care, 2013-2016 (The Commonwealth Fund, December 2017), http://www.commonwealthfund.org/publications/issue-briefs/2017/dec/states-progress-health-coverage-and-access 28 Sharon Long, Lea Bart, Michael Karpman, Adele Shartzer, and Stephen Zuckerman, “Sustained Gains in Coverage, Access, and Affordability Under the ACA: A 2017 Update,” Health Affairs 36 no. 9 (September 2017), https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0798 29 Kevin Griffith, Leigh Evans, and Jacob Bor, “The Affordable Care Act Reduced Socioeconomic Disparities in Health Care Access,” Health Affairs 36 no. 8 (August 2017), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0083 30 Aaron Sojourner and Ezra Golberstein, “Medicaid Expansion Reduced Unpaid Medical Debt and Increased Financial Satisfaction,” Health Affairs (July 2017), https://www.healthaffairs.org/do/10.1377/hblog20170724.061160/full/ 31 Sunha Choi, Sungkyu Lee, and Jason Matejkowski, “The Effects of State Medicaid Expansion on Low-Income Individuals’ Access to Health Care: Multilevel Modeling,” Population Health Management epub ahead of print (September 2017), http://online.liebertpub.com/doi/abs/10.1089/pop.2017.0104 32 Dahai Yue, Petra Rasmussen, and Ninez Ponce, “Racial/Ethnic Differential Effects of Medicaid Expansion on Health Care Access,” Health Services Research (February 2018), http://onlinelibrary.wiley.com/doi/10.1111/1475- 6773.12834/abstract The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 14 33 Sarah Miller and Laura Wherry, “Health and Access to Care During the First 2 Years of the ACA Medicaid Expansions,” The New England Journal of Medicine 376 no. 10 (March 2017), http://www.nejm.org/doi/full/10.1056/NEJMsa1612890 34 Benjamin Sommers, Bethany Maylone, Robert Blendon, E. John Orav, and Arnold Epstein, “Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults,” Health Affairs epub ahead of print (May 2017), http://content.healthaffairs.org/content/early/2017/05/15/hlthaff.2017.0293 35 Jack Hoadley, Karina Wagnerman, Joan Alker, and Mark Holmes, Medicaid in Small Towns and Rural America: A Lifeline for Children, Families, and Communities (Washington, DC: Georgetown Center for Children and Families, June 2017), https://ccf.georgetown.edu/wp-content/uploads/2017/06/Rural-health-final.pdf 36 Decker, Lipton, and Sommers, “Medicaid Expansion Coverage Effects Grew in 2015 With Continued Improvements in Coverage Quality,” Health Affairs 36 no. 5 (May 2017): 819-825. 37 Sandra Decker and Brandy Lipton, “Most Newly Insured People in 2014 Were Long-Term Uninsured,” Health Affairs 36 no. 1 (January 2017): 16-20, http://content.healthaffairs.org/content/36/1/16.full?sid=982b20c0-0a17-4dc4- a35a-b0302d4ec289 38 George Wehby and Wei Lyu, “The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12711/abstract 39 Kelsey Avery, Kenneth Finegold, and Amelia Whitman, Affordable Care Act Has Led to Historic, Widespread Increase in Health Insurance Coverage (Office of the Assistant Secretary for Planning and Evaluation, September 2016), https://aspe.hhs.gov/sites/default/files/pdf/207946/ACAHistoricIncreaseCoverage.pdf 40 Eric Seiber and Micah Berman, “Medicaid Expansion and ACA Repeal: Evidence from Ohio,” “American Journal of Public Health epub ahead of print (April 2017), http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2017.303722 41 Office of the Assistant Secretary for Planning and Evaluation (ASPE), Impacts of the Affordable Care Act’s Medicaid Expansion on Insurance Coverage and Access to Care (Office of the Assistant Secretary for Planning and Evaluation, June 2016), https://aspe.hhs.gov/sites/default/files/pdf/205141/medicaidexpansion.pdf 42 Benjamin Sommers, Robert Blendon, E. John Orav, and Arnold Epstein, “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” The Journal of the American Medical Association 176 no. 10 (October 2016): 1501-1509, http://jamanetwork.com/journals/jamainternalmedicine/article- abstract/2542420 43 Joseph Benitez, Liza Creel, and J’Aime Jennings, “Kentucky’s Medicaid Expansion Showing Early Promise on Coverage and Access to Care,” Health Affairs (February 2016), http://content.healthaffairs.org/content/early/2016/02/16/hlthaff.2015.1294 44 Robin Cohen and Michael Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2014 (National Center for Health Statistics, June 2015), http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201506.pdf 45 Sara Collins, Petra Rasmussen, Michelle Doty, and Sophie Beutel The Rise in Health Care Coverage and Affordability Since Health Reform Took Effect: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014 (The Commonwealth Fund, January 2015), http://www.commonwealthfund.org/~/media/files/publications/issue- brief/2015/jan/1800_collins_biennial_survey_brief.pdf?la=en 46 Sommers, Blendon, and Orav, “Both the ‘Private Option’ And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults,” Health Affairs 35, no. 1 (January 2016): 96-105. 47 Benjamin Sommers, Munira Gunja, Kenneth Finegold, and Thomas Musco, “Changes in Self-Reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act,” The Journal of the American Medical Association 314 no. 4 (July 2015): 366-374, http://jama.jamanetwork.com/article.aspx?articleid=2411283&resultClick=3 48 McMorrow, Kenney, Long, and Anderson, “Uninsurance Among Young Adults Continues to Decline, Particularly in Medicaid Expansion States,” Health Affairs 34, no. 4 (April 2015): 616-620. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 15 49 Barbara DiPietro, Samantha Artiga, and Alexandra Gates, Early Impacts of the Medicaid Expansion for the Homeless Population (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2014), http://kff.org/uninsured/issue-brief/early-impacts-of-the-medicaid-expansion-for-the-homeless-population/ 50 Benjamin Sommers, Thomas Musco, Kenneth Finegold, Munira Gunja, Amy Burke, and Audrey McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014” The New England Journal of Medicine 371 (August 2014): 867-874, http://www.nejm.org/doi/full/10.1056/NEJMsr1406753 51 Jessica Smith and Carla Medalia, Health Insurance Coverage in the United States: 2014 (U.S. Census Bureau, September 2015), https://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf 52 Thomas Buchmueller, Zachary Levinson, Helen Levy, and Barbara Wolfe, “Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage,” American Journal of Public Health (May 2016), http://www.ncbi.nlm.nih.gov/pubmed/27196653 53 Avery, Finegold, and Whitman, Affordable Care Act Has Led to Historic, Widespread Increase in Health Insurance Coverage (Office of the Assistant Secretary for Planning and Evaluation, September 2016). 54 Sommers, Blendon, Orav, and Epstein, “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” The Journal of the American Medical Association 176 no. 10 (October 2016): 1501-1509. 55 DiPietro, Artiga, and Gates, Early Impacts of the Medicaid Expansion for the Homeless Population (Kaiser Commission on Medicaid and the Uninsured, November 2014). 56 Sommers, Musco, Finegold, Gunja, Burke, and McDowell, “Health Reform and Changes in Health Insurance Coverage in 2014” The New England Journal of Medicine 371 (August 2014): 867-874. 57 Benjamin Sommers, Bethany Maylone, Robert Blendon, E. John Orav, and Arnold Epstein, “Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults,” Health Affairs epub ahead of print (May 2017), http://content.healthaffairs.org/content/early/2017/05/15/hlthaff.2017.0293 58 Decker, Lipton, and Sommers, “Medicaid Expansion Coverage Effects Grew in 2015 With Continued Improvements in Coverage Quality,” Health Affairs 36 no. 5 (May 2017): 819-825. 59 Sarah Miller and Laura Wherry, “Health and Access to Care During the First 2 Years of the ACA Medicaid Expansions,” The New England Journal of Medicine 376 no. 10 (March 2017), http://www.nejm.org/doi/full/10.1056/NEJMsa1612890 60 George Wehby and Wei Lyu, “The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12711/abstract 61 Anne Martin et al., “National Health Spending: Faster Growth in 2015 As Coverage Expands and Utilization Increases,” Health Affairs 36 no. 1 (January 2017): 166-176, http://content.healthaffairs.org/content/36/1/166.full?sid=982b20c0-0a17-4dc4-a35a-b0302d4ec289 62 Thomas Selden, Brandy Lipton, and Sandra Decker, “Medicaid Expansion and Marketplace Eligibility Both Increased Coverage, With Trade-Offs in Access, Affordability,” Health Affairs 36 no. 12 (December 2017), https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0830 63 Benitez, Creel, and Jennings, “Kentucky’s Medicaid Expansion Showing Early Promise on Coverage and Access to Care,” Health Affairs (February 2016). 64 Arkansas Health Reform Legislative Task Force, Health Care Task Force Preliminary Report, (Arkansas Health Reform Legislative Task Force, December 2015), http://www.arkleg.state.ar.us/assembly/2015/Meeting%20Attachments/836/I14218/Task%20Force%20report%2012- 17-15%20sent%20to%20Jill.pdf 65 Deloitte Development LLC, Commonwealth of Kentucky Medicaid Expansion Report (February 2015). 66 Charles Courtemanche, James Marton, Benjamin Ukert, Aaron Yelowitz, and Daniela Zapata, Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States (Working Paper No. 22182, The National Bureau of Economic Research, April 2016), http://www.nber.org/papers/w22182 67 Frean, Gruber, and Sommers, Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the Affordable Care Act (Working Paper No. 22213, National Bureau of Economic Research, April 2016). The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 16 68 Brendan Saloner, Sachini Bandara, Emma McGinty, and Colleen Barry, “Justice-Involved Adults With Substance Use Disorders: Coverage Increased but Rates of Treatment Did Not in 2014,” Health Affairs 35 no. 6 (June 2016), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0005 69 MaryBeth Musumeci, Data Note: Data Do Not Support Relationship Between States’ Medicaid Expansion Status and Community-Based Services Waiver Waiting Lists (Washington, DC: Kaiser Family Foundation, February 2017), https://www.kff.org/medicaid/issue-brief/data-note-data-do-not-support-relationship-medicaid-expansion-hcbs-waiver- waiting-lists/ 70 Molly Frean, Jonathan Gruber, and Benjamin Sommers, Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the Affordable Care Act (Working Paper No. 22213, National Bureau of Economic Research, April 2016), http://www.nber.org/papers/w22213?utm_campaign=ntw&utm_medium=email&utm_source=ntw 71 Robin Cohen and Michael Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2014 (National Center for Health Statistics, June 2015), http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201506.pdf 72 Stacey McMorrow, Genevieve Kenney, Sharon Long, and Nathaniel Anderson, “Uninsurance Among Young Adults Continues to Decline, Particularly in Medicaid Expansion States,” Health Affairs 34, no. 4 (April 2015): 616-620, http://content.healthaffairs.org/content/34/4/616.full 73 Sandra Decker, Brandy Lipton, and Benjamin Sommers, “Medicaid Expansion Coverage Effects Grew in 2015 With Continued Improvements in Coverage Quality,” Health Affairs 36 no. 5 (May 2017): 819-825, http://content.healthaffairs.org/content/36/5/819.full 74 Sarah Miller and Laura Wherry, “Health and Access to Care During the First 2 Years of the ACA Medicaid Expansions,” The New England Journal of Medicine 376 no. 10 (March 2017), http://www.nejm.org/doi/full/10.1056/NEJMsa1612890 75 Pauline Leung and Alexandre Mas, Employment Effects of the ACA Medicaid Expansions (Working Paper No. 22540, National Bureau of Economic Research, August 2016), http://www.nber.org/papers/w22540 76 George Wehby and Wei Lyu, “The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12711/abstract 77 Charles Courtemanche, James Marton, Benjamin Ukert, Aaron Yelowitz, and Daniela Zapata, Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States (Working Paper No. 22182, The National Bureau of Economic Research, April 2016), http://www.nber.org/papers/w22182 78 Vivian Wu et al, “Early Impact of the Affordable Care Act Coverage Expansion on Safety-Net Hospital Inpatient Payer Mix and Market Shares,” Health Services Research (January 2018), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12812/full 79 Lindsey Dawson, Jennifer Kates, and Anthony Damico, The Affordable Care Act and Insurance Coverage Changes by Sexual Orientation (Washington, DC: Kaiser Family Foundation, January 2018), https://www.kff.org/disparities- policy/issue-brief/the-affordable-care-act-and-insurance-coverage-changes-by-sexual-orientation/ 80 Aparna Soni, Lindsay Sabik, Kosali Simon, and Benjamin Sommers, “Changes in Insurance Coverage Among Cancer Patients Under the Affordable Care Act,” Journal of the American Medical Association 4, no. 1 (January 2018): 122-124, https://jamanetwork.com/journals/jamaoncology/article-abstract/2657670?redirect=true&redirect=true 81 Fumiko Chino, Gita Suneja, Haley Moss, S. Yousuf Zafar, Laura Havrilesky, and Junzo Chino, “Healthcare Disparities in Cancer Patients Receiving Radiation: Changes in Insurance Status After Medicaid Expansion Under the Affordable Care Act,” International Journal of Radiation Oncology (December 2017), http://www.sciencedirect.com/science/article/pii/S0360301617341883 82 Emily Johnston, Andrea Strahan, Peter Joski, Anne Dunlop, and E. Kathleen Adams, “Impacts of the Affordable Care Act’s Medicaid Expansion on Women of Reproductive Age,” Women’s Health Issues, 28, no. 2 (February 2018), http://www.whijournal.com/article/S1049-3867(17)30242-6/pdf 83 Ahmedin Jemal, Chun Chieh Lin, Amy Davidoff, and Xuesong Han, “Changes in Insurance Coverage and Stage at Diagnosis Among Nonelderly Patients with Cancer after the Affordable Care Act,” Journal of Clinical Oncology 35, no. 35 (December 2017), http://ascopubs.org/doi/pdf/10.1200/JCO.2017.73.7817 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 17 84 Haley Moss, Laura Havrilesky, and Junzo Chino, “Insurance Coverage Among Women Diagnosed with a Gynecologic Malignancy Before and After Implementation of the Affordable Care Act,” Gynecologic Oncology 146, no. 3 (September 2017), https://www.ncbi.nlm.nih.gov/pubmed/28641821 85 Samantha Artiga, Barbara DiPietro, and Petry Ubri, The Role of Medicaid and the Impact of the Medicaid Expansion for Veterans Experiencing Homelessness, (Washington, DC: Kaiser Family Foundation, October 2017), https://www.kff.org/medicaid/issue-brief/the-role-of-medicaid-and-impact-of-the-medicaid-expansion-for-veterans- experiencing-homelessness/ 86 Michael Dworsky, Carrie Farmer, and Mimi Shen, Veterans’ Health Insurance Coverage Under the Affordable Care Act and Implications of Repeal for the Department of Veterans Affairs, (RAND Corporation, 2017), https://www.rand.org/pubs/research_reports/RR1955.html 87 Jennifer Haley, Robin Wang, Matthew Buettgens, and Genevieve Kenney, Health Insurance Coverage among Children Ages 3 and Younger and Their Parents in 2016 (The Urban Institute, January 2018), https://www.urban.org/research/publication/health-insurance-coverage-among-children-ages-3-and-younger-and- their-parents-2016 88 Kevin Griffith, Leigh Evans, and Jacob Bor, “The Affordable Care Act Reduced Socioeconomic Disparities in Health Care Access,” Health Affairs 36 no. 8 (August 2017), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0083 89 Jennifer Kates and Lindsey Dawson, Insurance Coverage Changes for People with HIV Under the ACA (Washington, DC: Kaiser Family Foundation, February 2017), http://kff.org/health-reform/issue-brief/insurance- coverage-changes-for-people-with-hiv-under-the-aca/ 90 Jennifer Haley, Genevieve Kenney, and Jason Gates, Veterans Saw Broad Coverage Gains Between 2013 and 2015 (Washington, DC: The Urban Institute, April 2017), http://www.urban.org/research/publication/veterans-saw- broad-coverage-gains-between-2013-and-2015 91 Stacey McMorrow, Jason Gates, Sharon Long, and Genevieve Kenney, “Medicaid Expansion Increased Coverage, Improved Affordability, and Reduced Psychological Distress for Low-Income Parents,” Health Affairs 36 no. 5 (May 2017): 808-818, http://content.healthaffairs.org/content/36/5/808.full?sid=29f7e3de-89cd-489f-9fe0-18f04188d8a4 92 Stacey McMorrow, Genevieve Kenney, Sharon Long, and Jason Gates, The ACA Medicaid Expansion Led to Widespread Reductions in Uninsurance Among Poor Childless Adults (The Urban Institute, April 2017), http://www.urban.org/sites/default/files/publication/89536/2001222- aca_medicaid_expansion_led_to_widespread_reductions_in_uninsurance_among_poor_childless_adults.pdf 93 George Wehby and Wei Lyu, “The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12711/abstract 94 McMorrow, Kenney, Long, and Anderson, “Uninsurance Among Young Adults Continues to Decline, Particularly in Medicaid Expansion States,” Health Affairs 34, no. 4 (April 2015): 616-620. 95 Andrew W. Mulcahy, Christine Eibner, and Kenneth Finegold, “Gaining Coverage Through Medicaid Or Private Insurance Increased Prescription Use and Lowered Out-Of-Pocket Spending,” Health Affairs 35, no. 9 (September 2016), http://content.healthaffairs.org/content/early/2016/08/16/hlthaff.2016.0091.full 96 Michael Karpman, Jason Gates, Genevieve Kenney, Stacey McMorrow, “How Are Moms Faring under the Affordable Care Act? Evidence Through 2014,” (The Urban Institute, May 2016), http://www.urban.org/research/publication/how-are-moms-faring-under-affordable-care-act-evidence-through-2014 97 Genevieve Kenney, Jennifer Haley, Clare Pan, Victoria Lynch, and Matthew Buettgens, Children’s Coverage Climb Continues: Uninsurance and Medicaid/CHIP Eligibility and Participation Under the ACA, (Washington, DC: The Urban Institute, May 2016), http://www.urban.org/research/publication/childrens-coverage-climb-continues-uninsurance-and- medicaidchip-eligibility-and-participation-under-aca 98 Joan Alker and Alisa Chester, Children’s Health Insurance Rates in 2014: ACA Results in Significant Improvements (Washington, DC: Georgetown Center for Children and Families, October 2015), http://ccf.georgetown.edu/wp-content/uploads/2015/10/ACS-report-2015.pdf 99 Alanna Williamson, Larisa Antonisse, Jennifer Tolbert, Rachel Garfield, and Anthony Damico, ACA Coverage Expansions and Low-Income Workers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2016), http://kff.org/report-section/aca-coverage-expansions-and-low-income-workers-issue-brief/ The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 18 100 Helen Levy, Thomas Buchmueller, and Sayeh Nikpay, Health Reform and Health Insurance Coverage of Early Retirees (Ann Arbor, MI: University of Michigan Retirement Research Center Working Paper, September 2016), http://www.mrrc.isr.umich.edu/publications/papers/pdf/wp345.pdf 101 Simon, Soni, and Cawley, The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the 2014 ACA Medicaid Expansions (Working Paper 22265, National Bureau of Economic Research, May 2016). 102 Robert Kaestner, Bowen Garrett, Anuj Gangopadhyaya, and Caitlyn Fleming, Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply (Working Paper No. 21836, National Bureau of Economic Research, December 2015), http://www.nber.org/papers/w21836 103 Jack Hoadley, Karina Wagnerman, Joan Alker, and Mark Holmes, Medicaid in Small Towns and Rural America: A Lifeline for Children, Families, and Communities (Washington, DC: Georgetown Center for Children and Families, June 2017), https://ccf.georgetown.edu/wp-content/uploads/2017/06/Rural-health-final.pdf 104 Julia Foutz, Samantha Artiga, and Rachel Garfield, The Role of Medicaid in Rural America (Washington, DC: Kaiser Family Foundation, April 2017), http://kff.org/medicaid/issue-brief/the-role-of-medicaid-in-rural-america/ 105 Aparna Soni, Michael Hendryx, and Kosali Simon, “Medicaid Expansion under the Affordable Care Act and Insurance Coverage in Rural and Urban Areas,” The Journal of Rural Health epub ahead of print (January 2017), http://onlinelibrary.wiley.com/doi/10.1111/jrh.12234/full 106 Abigail Barker, Kelsey Huntzberry, Timothy McBride, and Keith Mueller, Changing Rural and Urban Enrollment in State Medicaid Programs (Iowa City, IA: Rural Policy Research Institute, May 2017), https://cph.uiowa.edu/rupri/publications/policybriefs/2017/Changing%20Rural%20and%20Urban%20Enrollment%20in %20State%20Medicaid%20Programs.pdf 107 Fumiko Chino, Gita Suneja, Haley Moss, S. Yousuf Zafar, Laura Havrilesky, and Junzo Chino, “Healthcare Disparities in Cancer Patients Receiving Radiation: Changes in Insurance Status After Medicaid Expansion Under the Affordable Care Act,” International Journal of Radiation Oncology (December 2017), http://www.sciencedirect.com/science/article/pii/S0360301617341883 108 Susan Hayes, Pamela Riley, David Radley, and Douglas McCarthy, Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference? (The Commonwealth Fund, August 2017), http://www.commonwealthfund.org/publications/issue-briefs/2017/aug/racial-ethnic-disparities-care 109 Avery, Finegold, and Whitman, Affordable Care Act Has Led to Historic, Widespread Increase in Health Insurance Coverage (Office of the Assistant Secretary for Planning and Evaluation, September 2016). 110 George Wehby and Wei Lyu, “The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12711/abstract 111 Dahai Yue, Petra Rasmussen, and Ninez Ponce, “Racial/Ethnic Differential Effects of Medicaid Expansion on Health Care Access,” Health Services Research (February 2018), http://onlinelibrary.wiley.com/doi/10.1111/1475- 6773.12834/abstract 112 Courtemanche, Marton, Ukert, Yelowitz, and Zapata, Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States (Working Paper No. 22182, The National Bureau of Economic Research, April 2016). 113 Buchmueller, Levinson, Levy, and Wolfe, “Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage,” American Journal of Public Health (May 2016). 114 Sergio Gonzales and Benjamin Sommers, “Intra-Ethnic Coverage Disparities among Latinos and the Effects of Health Reform” Health Services Research epub ahead of print (June 2017), http://onlinelibrary.wiley.com/wol1/doi/10.1111/1475-6773.12733/full 115 John Heintzman, Steffani Bailey, Jennifer DeVoe, Stuart Cowburn, Tanya Kapka, Truc-Vi Duong, and Miguel Marino, “In Low-Income Latino Patients, Post-Affordable Care Act Insurance Disparities May Be Reduced Even More than Broader National Estimates: Evidence from Oregon,” Journal of Racial and Ethnic Health Disparities (April 2016), http://www.ncbi.nlm.nih.gov/pubmed/27105630 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 19 116 Kevin Griffith, Leigh Evans, and Jacob Bor, “The Affordable Care Act Reduced Socioeconomic Disparities in Health Care Access,” Health Affairs 36 no. 8 (August 2017), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0083 117 Julie Hudson and Asako Moriya, “Medicaid Expansion for Adults Had Measureable ‘Welcome Mat’ Effects on Their Children,” Health Affairs, 36 no. 9 (September 2017), https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0347 118 Benjamin Sommers, Robert Blendon, E. John Orav, and Arnold Epstein, “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” The Journal of the American Medical Association 176 no. 10 (October 2016): 1501-1509, http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2542420 119 Benjamin Sommers, Robert Blendon, and E. John Orav, “Both the ‘Private Option’ And Traditional Medicaid Expansions Improved Access To Care For Low-Income Adults,” Health Affairs 35, no. 1 (January 2016): 96-105, http://content.healthaffairs.org/content/35/1/96.abstract 120 Jocelyn Guyer, Naomi Shine, MaryBeth Musumeci, and Robin Rudowitz, A Look at the Private Option in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, August 2015), http://kff.org/medicaid/issue- brief/a-look-at-the-private-option-in-arkansas/ 121 MaryBeth Musumeci, Robin Rudowitz, Petry Ubri, and Elizabeth Hinton, An Early Look at Medicaid Expansion Waiver Implementation in Michigan and Indiana (Washington, DC: The Kaiser Family Foundation, January 2017), http://kff.org/medicaid/issue-brief/an-early-look-at-medicaid-expansion-waiver-implementation-in-michigan-and- indiana/ 122 The Lewin Group, Healthy Indiana Plan 2.0: POWER Account Contribution Assessment, (The Lewin Group, prepared for the Indiana Family and Social Services Administration, March 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy- Indiana-Plan-2/in-healthy-indiana-plan-support-20-POWER-acct-cont-assesmnt-03312017.pdf 123 Emily Zylla, Colin Planalp, Elizabeth Lukanen, and Lynn Blewett, “Section 1115 Medicaid Expansion Waivers: Implementation Experiences,” (Medicaid and CHIP Payment and Access Commission, February 2018), https://www.macpac.gov/publication/section-1115-medicaid-expansion-waivers-implementation-experiences/ 124 MaryBeth Musumeci, Robin Rudowitz, Petry Ubri, and Elizabeth Hinton, An Early Look at Medicaid Expansion Waiver Implementation in Michigan and Indiana (Washington, DC: The Kaiser Family Foundation, January 2017), http://kff.org/medicaid/issue-brief/an-early-look-at-medicaid-expansion-waiver-implementation-in-michigan-and- indiana/ 125 The Lewin Group, Healthy Indiana Plan 2.0: POWER Account Contribution Assessment, (The Lewin Group, prepared for the Indiana Family and Social Services Administration, March 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy- Indiana-Plan-2/in-healthy-indiana-plan-support-20-POWER-acct-cont-assesmnt-03312017.pdf 126 Emily Zylla, Colin Planalp, Elizabeth Lukanen, and Lynn Blewett, “Section 1115 Medicaid Expansion Waivers: Implementation Experiences,” (Medicaid and CHIP Payment and Access Commission, February 2018), https://www.macpac.gov/publication/section-1115-medicaid-expansion-waivers-implementation-experiences/ 127 Nicolas Ajkay et al, “Early Impact of Medicaid Expansion and Quality of Breast Cancer Care in Kentucky,” Journal of the American College of Surgeons, epub ahead of print, February 2018, https://www.sciencedirect.com/science/article/pii/S107275151830022X 128 Sunha Choi, Sungkyu Lee, and Jason Matejkowski, “The Effects of State Medicaid Expansion on Low-Income Individuals’ Access to Health Care: Multilevel Modeling,” Population Health Management epub ahead of print (September 2017), http://online.liebertpub.com/doi/abs/10.1089/pop.2017.0104 129 Aparna Soni, Kosali Simon, John Cawley, and Lindsay Sabik, “Effect of Medicaid Expansions of 2014 on Overall and Early-Stage Cancer Diagnoses,” American Journal of Public Health epub ahead of print (December 2017), http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.304166 130 Tyler Winkelman and Virginia Chang, “Medicaid Expansion, Mental Health, and Access to Care Among Childless Adults With and Without Chronic Conditions,” Journal of General Internal Medicine epub ahead of print (November 2017), https://www.ncbi.nlm.nih.gov/pubmed/29181792 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 20 131 Andrew Loehrer et al., “Association of the Affordable Care Act Medicaid Expansion with Access to and Quality of Care for Surgical Conditions,” Journal of the American Medical Association Surgery, epub ahead of print (January 2018), https://jamanetwork.com/journals/jamasurgery/article-abstract/2670459?redirect=true 132 Susan Hayes, Pamela Riley, David Radley, and Douglas McCarthy, Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference? 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James Kirby and Jessica Vistnes, “Access to Care Improved for People Who Gained Medicaid or Marketplace Coverage in 2014,” Health Affairs 35 no. 10 (October 2016): 1830-1834, http://content.healthaffairs.org/content/35/10/1830.full 144 Khadijah Breathett et al., “The Affordable Care Act Medicaid Expansion Correlated with Increased Heart Transplant Listings in African Americans but Not Hispanics or Caucasians,” JACC: Heart Failure 5 no. 2 (January 2017): 136-147, https://www.ncbi.nlm.nih.gov/pubmed/28109783 145 United States Government Accountability Office (GAO), Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014 (Washington, DC: GAO Report to Congressional Requesters, June 2017), https://www.gao.gov/assets/690/685415.pdf 146 Lisa Clemens-Cope, Marni Epstein, and Genevieve Kenney, Rapid Growth in Medicaid Spending on Medications to Treat Opioid Use Disorder and Overdose (Washington, DC: The Urban Institute, June 2017), 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John Orav, and Arnold Epstein, “Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults,” Health Affairs epub ahead of print (May 2017), http://content.healthaffairs.org/content/early/2017/05/15/hlthaff.2017.0293 270 Stacey McMorrow, Jason Gates, Sharon Long, and Genevieve Kenney, “Medicaid Expansion Increased Coverage, Improved Affordability, and Reduced Psychological Distress for Low-Income Parents,” Health Affairs 36 no. 5 (May 2017): 808-818, http://content.healthaffairs.org/content/36/5/808.full?sid=29f7e3de-89cd-489f-9fe0- 18f04188d8a4 271 Sommers, Blendon, Orav, and Epstein, “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” The Journal of the American Medical Association 176 no. 10 (October 2016): 1501-1509. 272 Luojia Hu, Robert Kaestner, Bhashkar Mazumder, Sarah Miller, and Ashley Wong, The Effect of the Patient Protection and Affordable Care Act Medicaid Expansions on Financial Well-Being (Working Paper No. 22170, National Bureau of Economic Research, April 2016), http://www.nber.org/papers/w22170?utm_campaign=ntw&utm_medium=email&utm_source=ntw 273 The Ohio Department of Medicaid, Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly (The Ohio Department of Medicaid, January 2017), http://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Assessment.pdf 274 Sarah Miller and Laura Wherry, “Health and Access to Care During the First 2 Years of the ACA Medicaid Expansions,” The New England Journal of Medicine 376 no. 10 (March 2017), http://www.nejm.org/doi/full/10.1056/NEJMsa1612890 275 David Slusky and Donna Ginther, Did Medicaid Expansion Reduce Medical Divorce? (Working Paper No. 23139, National Bureau of Economic Research, February 2017), http://www.nber.org/papers/w23139?utm_campaign=ntw&utm_medium=email&utm_source=ntw 276 Luojia Hu, Robert Kaestner, Bhashkar Mazumder, Sarah Miller, and Ashley Wong, The Effect of the Patient Protection and Affordable Care Act Medicaid Expansions on Financial Well-Being (Working Paper No. 22170, National Bureau of Economic Research, April 2016), http://www.nber.org/papers/w22170?utm_campaign=ntw&utm_medium=email&utm_source=ntw 277 Kenneth Brevoort, Daniel Grodzicki, and Martin Hackmann, Medicaid and Financial Health (National Bureau of Economic Research, Working Paper No. 24002, November 2017), http://www.nber.org/papers/w24002 278 Aaron Sojourner and Ezra Golberstein, “Medicaid Expansion Reduced Unpaid Medical Debt and Increased Financial Satisfaction,” Health Affairs (July 2017), https://www.healthaffairs.org/do/10.1377/hblog20170724.061160/full/ 279 Kyle Caswell and Timothy Waidmann, The Affordable Care Act Medicaid Expansions and Personal Finance (Washington, DC: The Urban Institute, September 2017), https://www.urban.org/research/publication/affordable-care- act-medicaid-expansions-and-personal-finance 280 The Ohio Department of Medicaid, Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly (The Ohio Department of Medicaid, January 2017), http://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Assessment.pdf 281 Benjamin Sommers, Bethany Maylone, Robert Blendon, E. John Orav, and Arnold Epstein, “Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults,” Health Affairs epub ahead of print (May 2017), http://content.healthaffairs.org/content/early/2017/05/15/hlthaff.2017.0293 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 29 282 Sommers, Blendon, Orav, and Epstein, “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” The Journal of the American Medical Association 176 no. 10 (October 2016): 1501-1509. 283 The Ohio Department of Medicaid, Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly (The Ohio Department of Medicaid, January 2017). 284 Simon, Soni, and Cawley, The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the 2014 ACA Medicaid Expansions (Working Paper 22265, National Bureau of Economic Research, May 2016). 285 DiPietro, Artiga, and Gates, Early Impacts of the Medicaid Expansion for the Homeless Population (Kaiser Commission on Medicaid and the Uninsured, November 2014). 286 Tyler Winkelman and Virginia Chang, “Medicaid Expansion, Mental Health, and Access to Care Among Childless Adults With and Without Chronic Conditions,” Journal of General Internal Medicine epub ahead of print (November 2017), https://www.ncbi.nlm.nih.gov/pubmed/29181792 287 Eric Charles et al., “Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes,” The Annals of Thoracic Surgery (June 2017), http://www.annalsthoracicsurgery.org/article/S0003-4975(17)30552-0/pdf 288 Chintan Bhatt and Consuelo Beck-Sague, “Medicaid Expansion and Infant Mortality in the United States,” American Journal of Public Health (January 2018) e1-e3, http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2017.304218 289 Johanna Maclean and Brendan Saloner, The Effect of Public Insurance Expansions on Substance Use Disorder Treatment: Evidence from the Affordable Care Act (National Bureau of Economic Research Working Paper No. 23342, April 2017), http://www.nber.org/papers/w23342.pdf 290 Wherry and Miller, “Early Coverage, Access, Utilization, and Health Effects Associated with the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study,” Annals of Internal Medicine, (April 2016). 291 Sommers et al., “Changes in Self-Reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act,” The Journal of the American Medical Association 314 no. 4 (July 2015): 366-374. 292 Sarah Miller and Laura Wherry, “Health and Access to Care During the First 2 Years of the ACA Medicaid Expansions,” The New England Journal of Medicine 376 no. 10 (March 2017), http://www.nejm.org/doi/full/10.1056/NEJMsa1612890 293 Charles Courtemanche, James Marton, Benjamin Ukert, Aaron Yelowitz, Daniela Zapata, Early Effects of the Affordable Care Act on Health Care Access, Risky Health Behaviors, and Self-Assessed Health (National Bureau of Economic Research, Working Paper no. 23269, March 2017), http://www.nber.org/papers/w23269 294 Louisiana Department of Health, Medicaid Expansion 2016/17 (Baton Rouge, Louisiana Department of Health, June 2017), http://dhh.louisiana.gov/assets/HealthyLa/Resources/MdcdExpnAnnlRprt_2017_WEB.pdf 295 April Grady, Deborah Bachrach, and Patti Boozang, Medicaid’s Role in the Delivery and Payment of Substance Use Disorder Services in Montana, (Manatt Health, March 2017), http://mthcf.org/wp- content/uploads/2017/03/Medicaid-Role-in-Substance-Use-Disorder-Services-in-Montana_Final.pdf 296 The Colorado Health Foundation, Assessing the Economic and Budgetary Impact of Medicaid Expansion in Colorado, (The Colorado Health Foundation, March 2016), http://www.coloradohealth.org/studies.aspx 297 Lee A. Reynis, Economic and Fiscal Impacts of the Medicaid Expansion in New Mexico, (The University of New Mexico Bureau of Business and Economic Research, February 2016), http://bber.unm.edu/media/publications/Medicaid_Expansion_Final2116R.pdf 298 Benjamin Sommers and Jonathan Gruber, “Federal Funding Insulated State Budgets From Increased Spending Related To Medicaid Expansion,” Health Affairs epub ahead of print (April 2017), https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.1666 299 Abby Evans, John Folkemer, Joel Menges, Amira Mouna, Nick Pantaleo, Emily Ricci, and Poornima Sigh, Assessment of Medicaid Expansion and Reform, Initial Analysis (The Menges Group, January 2016), http://lba.akleg.gov/download/publications/Initial%20Analysis%20Assessment%20of%20Medicaid%20Expansion%20 and%20Reform,%20January%2015,%202016%20Prepared%20by%20The%20Menges%20Group.pdf The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 30 300 Chris Brown and John Bennett, Economic Impacts of the Arkansas Private Option (Regional Economic Models, Inc., August 2015), http://www.arkhospitals.org/Misc.%20Files/August2015APOEconomicImpacts.pdf 301 Rudowitz, Snyder, and Smith, Medicaid Enrollment and Spending Growth: FY 2015 & 2016 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2015). 302 Deborah Bachrach, Patricia Boozang, Avi Herring, and Dori Glanz Reyneri, States Expanding Medicaid See Significant Budget Savings and Revenue Gains, (Manatt Health Solutions, prepared by the Robert Wood Johnson Foundation’s State Health Reform Assistance Network, March 2016), http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf419097 303 Dorn, Francis, Snyder, and Rudowitz, The Effects of the Medicaid Expansion on State Budgets: An Early Look in Select States (Kaiser Commission on Medicaid and the Uninsured, March 2015). 304 Deloitte Development LLC, Commonwealth of Kentucky Medicaid Expansion Report (February 2015). 305 Robin Rudowitz, Allison Valentine, and Vernon Smith, Medicaid Enrollment and Spending Growth: FY 2016 & 2017 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2016), http://kff.org/medicaid/issue-brief/medicaid-enrollment-spending-growth-fy-2016-2017/ 306 Micah Hartman et al., “National Health Care Spending in 2016: Spending and Enrollment Growth Slow After Initial Coverage Expansions,” Health Affairs epub ahead of print (December 2017), https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.1299 307 Benjamin Sommers and Jonathan Gruber, “Federal Funding Insulated State Budgets From Increased Spending Related To Medicaid Expansion,” Health Affairs epub ahead of print (April 2017), http://content.healthaffairs.org/content/early/2017/04/10/hlthaff.2016.1666.full 308 Louisiana Department of Health, Medicaid Expansion 2016/17 (Baton Rouge, Louisiana Department of Health, June 2017), http://dhh.louisiana.gov/assets/HealthyLa/Resources/MdcdExpnAnnlRprt_2017_WEB.pdf 309 April Grady, Deborah Bachrach, and Patti Boozang, Medicaid’s Role in the Delivery and Payment of Substance Use Disorder Services in Montana, (Manatt Health, March 2017), http://mthcf.org/wp- content/uploads/2017/03/Medicaid-Role-in-Substance-Use-Disorder-Services-in-Montana_Final.pdf 310 Aparna Soni, Marguerite Burns, Laura Dague, and Kosali Simon, “Medicaid Expansion and State Trends in Supplemental Security Income Program Participation,” Health Affairs 36 no. 8, (August 2017): 1485-1488, http://content.healthaffairs.org/content/36/8/1485.full?sid=982b20c0-0a17-4dc4-a35a-b0302d4ec289 311 Jacob Vogler, Access to Health Care and Criminal Behavior: Short-Run Evidence from the ACA Medicaid Expansions (University of Illinois at Urbana-Champaign, November 2017), https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3042267 312 Deborah Bachrach, Patricia Boozang, Avi Herring, and Dori Glanz Reyneri, States Expanding Medicaid See Significant Budget Savings and Revenue Gains, (Manatt Health Solutions, prepared by the Robert Wood Johnson Foundation’s State Health Reform Assistance Network, March 2016), http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf419097 313 Dorn, Francis, Snyder, and Rudowitz, The Effects of the Medicaid Expansion on State Budgets: An Early Look in Select States (Kaiser Commission on Medicaid and the Uninsured, March 2015). 314 Lee A. Reynis, Economic and Fiscal Impacts of the Medicaid Expansion in New Mexico, (The University of New Mexico Bureau of Business and Economic Research, February 2016), http://bber.unm.edu/media/publications/Medicaid_Expansion_Final2116R.pdf 315 Deloitte Development LLC, Commonwealth of Kentucky Medicaid Expansion Report (February 2015). 316 Abby Evans, John Folkemer, Joel Menges, Amira Mouna, Nick Pantaleo, Emily Ricci, and Poornima Sigh, Assessment of Medicaid Expansion and Reform, Initial Analysis (The Menges Group, January 2016), http://lba.akleg.gov/download/publications/Initial%20Analysis%20Assessment%20of%20Medicaid%20Expansion%20 and%20Reform,%20January%2015,%202016%20Prepared%20by%20The%20Menges%20Group.pdf 317 David Lassman et al., “Health Spending by State 1991-2014: Measuring Per Capita Spending by Payers and Programs,” Health Affairs epub ahead of print (June 2017), http://content.healthaffairs.org/content/early/2017/06/13/hlthaff.2017.0416 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 31 318 Laura Snyder, Katherine Young, Robin Rudowitz, and Rachel Garfield, Medicaid Expansion Spending and Enrollment in Context: An Early Look at CMS Claims Data for 2014 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, January 2016), http://kff.org/medicaid/issue-brief/medicaid-expansion-spending-and- enrollment-in-context-an-early-look-at-cms-claims-data-for-2014/ 319 Christopher Truffer, Christian Wolfe, and Kathryn Rennie, 2016 Actuarial Report on the Financial Outlook for Medicaid, (Office of the Actuary, Centers for Medicare and Medicaid Services, 2016), https://www.cms.gov/Research- Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2016.pdf 320 Laura Snyder, Katherine Young, Robin Rudowitz, and Rachel Garfield, Medicaid Expansion Spending and Enrollment in Context: An Early Look at CMS Claims Data for 2014 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, January 2016), http://kff.org/medicaid/issue-brief/medicaid-expansion-spending-and- enrollment-in-context-an-early-look-at-cms-claims-data-for-2014/ 321 David Lassman et al., “Health Spending by State 1991-2014: Measuring Per Capita Spending by Payers and Programs,” Health Affairs epub ahead of print (June 2017), http://content.healthaffairs.org/content/early/2017/06/13/hlthaff.2017.0416 322 Christopher Truffer, Christian Wolfe, and Kathryn Rennie, 2016 Actuarial Report on the Financial Outlook for Medicaid, (Office of the Actuary, Centers for Medicare and Medicaid Services, 2016), https://www.cms.gov/Research- Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/MedicaidReport2016.pdf 323 Aditi Sen and Thomas DeLeire, The Effect of Medicaid Expansion on Marketplace Premiums (Office of the Assistant Secretary for Planning and Evaluation, August 2016), https://aspe.hhs.gov/sites/default/files/pdf/206761/McaidExpMktplcPrem.pdf 324 Jocelyn Guyer, Naomi Shine, MaryBeth Musumeci, and Robin Rudowitz, A Look at the Private Option in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, August 2015), http://kff.org/medicaid/issue- brief/a-look-at-the-private-option-in-arkansas/ 325 Ashley Semanskee, Cynthia Cox, and Larry Levitt, Data Note: Effect of State Decisions on State Risk Scores (Kaiser Family Foundation, October 2016), https://www.kff.org/health-reform/issue-brief/data-note-effect-of-state- decisions-on-state-risk-scores/ 326 Jocelyn Guyer, Naomi Shine, MaryBeth Musumeci, and Robin Rudowitz, A Look at the Private Option in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, August 2015), http://kff.org/medicaid/issue- brief/a-look-at-the-private-option-in-arkansas/ 327 Bela Gorman and Jenn Smagula, 2016 Actuarial Analysis of NH Premium Assistance Program, (Gorman Actuarial, Inc., August 2017), https://www.nh.gov/insurance/reports/documents/08-28-17-ga-nh-pap-analysis-final.pdf 328 Kurt Gillis, Physicians’ Patient Mix – A Snapshot from the 2016 Benchmark Survey and Changes Associated with the ACA (American Medical Association, October 2017), https://www.ama-assn.org/sites/default/files/media- browser/public/health-policy/PRP-2017-physician-benchmark-survey-patient-mix.pdf 329 Seth Freedman, Sayeh Nikpay, Aaron Carroll, and Kosali Simon, “Changes in inpatient payer-mix and hospitalizations following Medicaid expansion: Evidence from all-capture hospital discharge data,” Plos One 12 no. 9, http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183616 330 Allen Dobson, Joan DaVanzo, Randy Haught, and Phap Hoa Luu, Comparing the Affordable Care Act’s Financial Impact on Safety-Net Hospitals in States that Expanded Medicaid and Those That Did Not (The Commonwealth Fund, November 2017), http://www.commonwealthfund.org/~/media/files/publications/issue- brief/2017/nov/dobson_impact_medicaid_expanion_safety_net_hosps_ib.pdf 331 Richard Lindrooth, Marcelo Perraillon, Rose Hardy, and Gregory Tung, “Understanding the Relationship Between Medicaid Expansions and Hospital Closures,” Health Affairs epub ahead of print (January 2018), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0976 332 Heather Angier et al., “Uninsured Primary Care Visit Disparities under the Affordable Care Act,” Annals of Family Medicine, 15 no. 5 (September 2017): 434-442, http://www.annfammed.org/content/15/5/434.full.pdf+html 333 Andrew Loehrer et al., “Association of the Affordable Care Act Medicaid Expansion with Access to and Quality of Care for Surgical Conditions,” Journal of the American Medical Association Surgery, epub ahead of print (January 2018), https://jamanetwork.com/journals/jamasurgery/article-abstract/2670459?redirect=true The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 32 334 Sayeh Nikpay, Seth Freedman, Helen Levy, and Tom Buchmueller, “Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases,” Annals of Emergency Medicine 70, no.2 (August 2017), http://www.annemergmed.com/article/S0196-0644(17)30319- 0/pdf 335 Johanna Maclean and Brendan Saloner, The Effect of Public Insurance Expansions on Substance Use Disorder Treatment: Evidence from the Affordable Care Act (National Bureau of Economic Research Working Paper No. 23342, April 2017), http://www.nber.org/papers/w23342.pdf 336 Monique Barakat et al., “Affordable Care Act and Healthcare Delivery: A Comparison of California and Florida Hospitals and Emergency Departments,” PLoS ONE 12 no. 8 (August 2017), http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0182346 337 Eili Klein et al., “The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments,” Annals of Emergency Medicine epub ahead of print (June 2017), http://www.annemergmed.com/article/S0196-0644(17)30784- 9/pdf 338 Aabha Sharma, Scott Dresden, Emilie Powell, Raymond Kang, Joe Feinglass, “Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion,” Journal of Community Health 42 no. 3 (June 2017): 591-597, https://link.springer.com/article/10.1007/s10900-016-0293-4 339 Vivian Wu et al, “Early Impact of the Affordable Care Act Coverage Expansion on Safety-Net Hospital Inpatient Payer Mix and Market Shares,” Health Services Research (January 2018), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12812/full 340 David Dranove, Craig Garthwaite, and Christopher Ody, The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal, (The Commonwealth Fund, May 2017), http://www.commonwealthfund.org/publications/issue-briefs/2017/may/aca-medicaid-expansion-hospital- uncompensated-care 341 Fredric Blavin, How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data (The Urban Institute, April 2017), http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf436310 342 Craig Garthwaite, Tal Gross, Matthew Notowidigdo, and John Graves, “Insurance Expansion and Hospital Emergency Department Access: Evidence from the Affordable Care Act,” Annals of Internal Medicine 166 no. 3 (February 2017): 172-179, http://annals.org/aim/article/2593599/insurance-expansion-hospital-emergency- department-access-evidence-from-affordable-care 343 Nathalie Huguet et al., “Medicaid Expansion Produces Long-Term Impact on Insurance Coverage Rates in Community Health Centers,” Journal of Primary Care & Community Health epub ahead of print (May 2017), http://journals.sagepub.com/doi/full/10.1177/2150131917709403 344 Susan Camilleri, “The ACA Medicaid Expansion, Disproportionate Share Hospitals, and Uncompensated Care” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475- 6773.12702/abstract 345 Adam Searing and Jack Hoadley, Beyond the Reduction in Uncompensated Care: Medicaid Expansion is Having a Positive Impact on Safety Net Hospitals and Clinics (Washington, DC: Georgetown University Center for Children and Families, June 2016), http://ccf.georgetown.edu/wp-content/uploads/2016/05/Medicaid_hospitals-clinics-June- 2016.pdf 346 Natalia Chalmers, Jane Grover, and Rob Compton, “After Medicaid Expansion in Kentucky, Use of Hospital Emergency Departments for Dental Conditions Increased,” Health Affairs 35, no. 12 (December 2016), http://content.healthaffairs.org/content/35/12/2268.full#xref-ref-32-1 347 Arkansas Health Reform Legislative Task Force, Health Care Task Force Preliminary Report, (December 2015). 348 Arkansas Hospital Association, “Survey Reveals Private Option Impact on Hospitals,” The Notebook 21, no. 33 (November 2014), http://www.arkhospitals.org/archive/notebookpdf/Notebook_11-03-14.pdf 349 Mary Anderson, Jeffrey Glasheen, and Debra Anoff, “Impact of State Medicaid Expansion Status on Length of Stay and In-Hospital Mortality for General Medicine Patients at US Academic Medical Centers,” Journal of Hospital Medicine Epub ahead of print (August 2016), http://onlinelibrary.wiley.com/wol1/doi/10.1002/jhm.2649/citedby The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 33 350 The University of Michigan Institute for Healthcare Policy & Innovation, The Healthy Michigan Plan: 2015 Report on Uncompensated Care and Insurance Rates (The University of Michigan Institute for Healthcare Policy & Innovation, prepared for the Michigan Department of Health and Human Services and the Michigan Department of Insurance and Financial Services, December 2016), http://www.michigan.gov/documents/mdhhs/2015_Report_on_Uncompensated_Care_and_Insurance_Rates- HMP_547720_7.pdf 351 Laurie Felland, Peter Cunningham, Annie Doubleday, and Cannon Warren, Effects of the Affordable Care Act on Safety Net Hospitals (Washington, DC: Mathematica Policy Research, prepared for the Assistant Secretary for Planning and Evaluation, November 2016), https://aspe.hhs.gov/sites/default/files/pdf/255491/SafetyNetHospital.pdf 352 Sayeh Nikpay, Thomas Buchmueller, and Helen Levy. “Affordable Care Act Medicaid Expansion Reduced Uninsured Hospital Stays in 2014,” Health Affairs 35, no.1 (January 2016): 106-110, http://content.healthaffairs.org/content/35/1/106.full 353 Fred Hellinger, “In Four ACA Expansion States, The Percentage of Uninsured Hospitalizations for People With HIV Declined, 2012-14,” Health Affairs 34, no. 12 (December 2015): 2061-2068, http://search.proquest.com/docview/1749932806/627DA95CDEA44BE7PQ/77?accountid=39486# 354 Deborah Bachrach, Patricia Boozang, and Mindy Lipson, The Impact of Medicaid Expansion on Uncompensated Care Costs: Early Results and Policy Implications for States, (Manatt Health Solutions, prepared by the Robert Wood Johnson Foundation’s State Health Reform Assistance Network, June 2015), https://www.manatt.com/uploadedFiles/Content/5_Insights/White_Papers/State-Network-Manatt-Impact-of-Medicaid- Expansion-on-Uncompensated-Care-Costs-June-2015.pdf 355 Peter Cunningham, Rachel Garfield, and Robin Rudowitz, How Are Hospitals Faring Under the Affordable Care Act? 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http://www.cha.com/documents/press- releases/cha-medicaid-expansion-study-june-2014.aspx 359 Fredric Blavin, “Association Between the 2014 Medicaid Expansion and US Hospital Finances,” The Journal of the American Medical Association 316 no. 14 (October 2016): 1475-1483, http://jamanetwork.com/journals/jama/article- abstract/2565750 360 David Dranove, Craig Garthwaite, and Christopher Ody, “Uncompensated Care Decreased At Hospitals In Medicaid Expansion States But Not At Hospitals In Nonexpansion States,” Health Affairs 35 no. 8 (August 2016): 1471-1479, http://content.healthaffairs.org/content/35/8/1471.full 361 Peter Cunningham, Robin Rudowitz, Katherine Young, Rachel Garfield, and Julia Foutz, Understanding Medicaid Hospital Payments and the Impact of Recent Policy Changes (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2016), http://kff.org/medicaid/issue-brief/understanding-medicaid-hospital-payments-and-the- impact-of-recent-policy-changes/ 362 Christine Jones, Serena Scott, Debra Anoff, Read Pierce, and Jeffrey Glasheen, “Changes in Payer Mix and Physician Reimbursement After the Affordable Care Act and Medicaid Expansion,” Inquiry: The Journal of Health Care Organization, Provision, and Financing 52 (August 2015), http://inq.sagepub.com/content/52/0046958015602464.full 363 Deloitte Development LLC, Commonwealth of Kentucky Medicaid Expansion Report (February 2015). 364 Robin Rudowitz and Rachel Garfield, New Analysis Shows States with Medicaid Expansion Experienced Declines in Uninsured Hospital Discharges (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, September 2015), http://kff.org/health-reform/issue-brief/new-analysis-shows-states-with-medicaid-expansion-experienced- declines-in-uninsured-hospital-discharges/ The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review 34 365 Sayeh Nikpay, Seth Freedman, Helen Levy, and Tom Buchmueller, “Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases,” Annals of Emergency Medicine 70, no.2 (August 2017), http://www.annemergmed.com/article/S0196-0644(17)30319- 0/pdf 366 Monique Barakat et al., “Affordable Care Act and Healthcare Delivery: A Comparison of California and Florida Hospitals and Emergency Departments,” PLoS ONE 12 no. 8 (August 2017), http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0182346 367 Eili Klein et al., “The Effect of Medicaid Expansion on Utilization in Maryland Emergency Departments,” Annals of Emergency Medicine epub ahead of print (June 2017), http://www.annemergmed.com/article/S0196-0644(17)30784- 9/pdf 368 Aabha Sharma, Scott Dresden, Emilie Powell, Raymond Kang, Joe Feinglass, “Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion,” Journal of Community Health 42 no. 3 (June 2017): 591-597, https://link.springer.com/article/10.1007/s10900-016-0293-4 369 Johanna Maclean and Brendan Saloner, The Effect of Public Insurance Expansions on Substance Use Disorder Treatment: Evidence from the Affordable Care Act (National Bureau of Economic Research Working Paper No. 23342, April 2017), http://www.nber.org/papers/w23342.pdf 370 Brendan Saloner, Sachini Bandara, Emma McGinty, and Colleen Barry, “Justice-Involved Adults With Substance Use Disorders: Coverage Increased but Rates of Treatment Did Not in 2014,” Health Affairs 35 no. 6 (June 2016), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0005 371 Susan Camilleri, “The ACA Medicaid Expansion, Disproportionate Share Hospitals, and Uncompensated Care” Health Services Research epub ahead of print (May 2017), http://onlinelibrary.wiley.com/doi/10.1111/1475- 6773.12702/abstract 372 Richard Lindrooth, Marcelo Perraillon, Rose Hardy, and Gregory Tung, “Understanding the Relationship Between Medicaid Expansions and Hospital Closures,” Health Affairs epub ahead of print (January 2018), https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0976 373 Allen Dobson, Joan DaVanzo, Randy Haught, and Phap Hoa Luu, Comparing the Affordable Care Act’s Financial Impact on Safety-Net Hospitals in States that Expanded Medicaid and Those That Did Not (The Commonwealth Fund, November 2017), http://www.commonwealthfund.org/~/media/files/publications/issue- brief/2017/nov/dobson_impact_medicaid_expanion_safety_net_hosps_ib.pdf 374 Fredric Blavin, How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report Data (The Urban Institute, April 2017), http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf436310 375 Peter Cunningham, Rachel Garfield, and Robin Rudowitz, How Are Hospitals Faring Under the Affordable Care Act? 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