Comparing the Impacts of Alternative Approaches in Medicaid

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A survey of low-income nonelderly people in Ohio, Indiana, and Kansas explored how alternative approaches to Medicaid can impact access, coverage, and healthcare satisfaction, as well as what effect implementing work requirements in Kansas would have.

With the Trump administration indicating a greater willingness to allow more flexibility in state Medicaid programs, more states are proposing alternative approaches to the program. A new report published in Health Affairs surveyed low-income nonelderly people in Ohio, Indiana, and Kansas and explored several new approaches being implemented or proposed in Medicaid.

The 3 states were chosen to assess different approaches. Ohio expanded Medicaid in 2014 without a waiver; Indiana expanded coverage in 2015 with a waiver to create a plan that featured premiums, health savings accounts, and a lockout period for beneficiaries who failed to make required payments; and Kansas has not expanded Medicaid, but it is considering work requirements for both expansion and traditional Medicaid populations.

Researchers from the Harvard T.H. Chan School of Public Health interviewed 2739 people (1007 in Indiana, 1000 in Kansas, and 732 in Ohio) to assess differences in coverage, access, and healthcare satisfaction, as well as experiences with Indiana’s program, and attitudes about expanding Medicaid and the possible impact of work requirements in Kansas.


Ohio and Indiana have similar rates of Medicaid coverage and uninsured rates, and they had both had significantly higher rates of coverage and lower rates of uninsured compared with Kansas. However, Ohio had lower rates of delaying care due to costs than both Kansas and Indiana.

The researchers also found a lack of knowledge among Indiana respondents about their coverage. Indiana requires beneficiaries to pay premiums that go into their health savings accounts, called Personal Wellness and Responsibility (POWER) accounts. Only 36% were making regular payments to their health savings accounts; 39% said they hadn’t heard of the POWER accounts, and 26% had heard of them but were not consistently making required payments.

Overall, 9% of uninsured respondents in Indiana said they had been locked out of benefits because they did not make payments into their POWER account.

Respondents from Kansas largely supported Medicaid expansion in their state (77%), with two-thirds saying they would receive higher-quality care under Medicaid compared with having no insurance. Only 11% of current Medicaid recipients and those who would likely be eligible under expansion who are currently unemployed said they would look for a job if there was a work requirement.

According to the authors, the implementation of a work requirement in Kansas would have “modest impacts on job-searching behavior,” but the likelihood of looking for employment would not change for 90% of people who might enroll in Medicaid.

“These findings suggest that current Medicaid innovations may lead to unintended consequences for coverage and access and that ongoing independent monitoring of their effects is essential,” the authors concluded.


Sommers BD, Fry CE, Blendon RJ, Epstein AM. New approaches in Medicaid: work requirements, health savings accounts, and health care access. Health Aff (Millwood). 2018;37(7):1099-1108. doi: 10.1377/hlthaff.2018.0331.