Medicaid expansion and potential effects on Veterans Health Administration inpatient utilization

Abstract Background The Affordable Care Act (ACA) allowed states to expand Medicaid to adults under 138 percent of the federal poverty line. Questions remain about how expansion influences health care utilization by Veterans already enrolled in the Veterans Health Administration (VHA). Objective To understand changes in VHA share of inpatient utilization among VHA‐enrolled Veterans after Medicaid expansion. Methods Sample included Veterans aged 18–64 from 2011 to 2016 enrolled in VHA. Outcomes included changes in VHA share of total VHA + Medicaid inpatient days, proportion with VHA and Medicaid inpatient dual use, total per‐capita inpatient days, and likelihood of any inpatient visits, moderated by VHA priority group and race. We controlled for sex, age, year, health status, ethnicity, and VHA distance. Results Population included 17,573,731 person years, 1,808,321 with inpatient days. Expansion was associated with relative decreases in VHA share of inpatient days (−2.60 percentage points [95% confidence interval −3.38 to −1.81]) and increases in proportion of VHA‐enrollees using both VA and Medicaid for inpatient care (1.17 pp [0.89 to 1.43]). While both per‐capita inpatient days and proportion of VHA enrollees with at least one hospitalization decreased from 2011 to 2016, no statistically significant differences existed between expansion and non‐expansion states. Low‐income Veterans had larger decreases in the VHA share of inpatient days (−6.27 pp [−7.32 to −5.21]) associated with Medicaid expansion. No racial groups exhibited statistically significant differences. Conclusions Medicaid expansion is associated with reductions in VHA share and increase in dual use of VHA‐Medicaid inpatient services, but no changes in overall utilization.