If the ACA’s Medicaid expansion had been implemented in all states, enrollment for VA health coverage, acute inpatient care (days), and outpatient visits would have been 9%, 6%, and 12% lower, respectively. In states that did not expand Medicaid in 2014, VA enrollment, inpatient days, and outpatient visits were, respectively, 10, 6, and 13 percentage points higher than they would have been otherwise. VA medical centers in states that did not expand Medicaid in 2014 are likely to have experienced a higher demand, and commensurately longer wait times.
The VA gives excellent care, but it is not always the most convienently located care. This, I think, explains the story. Before the ACA expansion, a vet who is VA eligible and making under 138% of Federal Poverty Line and did not have employer sponsored coverage had the choice to go naked or get VA care. That VA care might be half an hour or an hour from their house. With Medicaid expansion, that same individual has more choices closer to home in most cases. Medicaid expansion is attractive as the next best alternative to it is a 30 minute drive or an hour bus ride to the VA instead of nothing.
Medicaid expansion, as well as the Exchanges with subsidies should also be a notable driver on the number of people who apply for and are later granted Social Security disability. People on Social Security disability qualify for Medicare after two years on disability. There is a good evidence that Social Security disability applications and grants go up when the labor market sucks and goes down when the labor market is good for workers. Part of that cyclical nature can be explained by the marginally attached worker who is in their mid or late 50s who has significant health conditions. That person was completely uninsurable if they were neither employed nor on Social Security disability.
Now people who have something wrong with them are insurable by either Medicaid expansion or the subsidized Exchanges. The cost of staying in the labor market is way lower and disability payments that are slightly above poverty level aren’t too attractive as medical care is no longer restricted to accepting those payments.
Anything in the US healthcare finance and delivery system has seventeen seperate threads tying it to other major parts. Austin does a nice job of outlining one of those connections.