], but neither assessed changes in spillover of the value of care. To address this evidence gap, we sought to assess the effects of Medicaid expansion on the overall accessibility and quality of care for Medicaid, Medicare, and commercially insured patients.
A DinD analysis using only NAMCS would not be able to account for changes in the underlying state population size as a potential confounder associated with changes in access to care unrelated to Medicaid expansion among expansion and non-expansion states. Therefore, we used U.S. Census Bureau state-level population estimates for 2012–2015 to account for time-varying population changes.NAMCS provides state-level estimates for only years 2012–2015 and only for the most populous U.S. states .
Because Medicaid expansion was limited to the low-income adult population, we expected that this would be less likely to differentially affect visit rates or visit-level quality for older adults in the Medicare population or for the commercially-insured population in expansion vs. non-expansion states.
]. Our treatment group included 8 expansion states, with 5 non-expansion states in the control group . We defined the pre-expansion period to include visits in years 2012 and 2013 and post-expansion for visits in 2014 and 2015.Our analysis had two categories of outcomes: access to care measured by physician office visit volume and quality of care measured by widely accepted high- and low-value care metrics.
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