Running head: ACA AND MEDICAID EXPANSION

Affordable Care Act (ACA), Medicaid Expansion, Poverty, and Health Outcomes
Savannah Byrd, Joseph Cerniglia, Chelsea Davis, and Dayonn Jackson
University of South Carolina

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Abstract

Utilizing extant literature and heavily relying on the Behavioral Risk Factors Surveillance
System survey conducted by the South Carolina Department of Health and Environmental
Control with support from the Centers for Disease Control, the research team wishes to propose
research which will determine the effects of the Affordable Care Act on persons living under the
Federal Poverty Level and not presently eligible for Medicaid. The hypotheses are that the
Affordable Care Act will not offer assistance to this vulnerable population whereas Medicaid
Expansion would offer significant assistance and additionally improve health outcomes for this
population group. This represents, for states that are considering or have already rejected
Medicaid Expansion, a significant source of data recommending expansion as a cost-effective
intervention designed to improve health outcomes for low-income individuals. In fact, our
research will hypothetically show that Medicaid Expansion, in combination with the changes
made by the Affordable Care Act, will allow for near universal health coverage for all United
States Citizens in the state of South Carolina.

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Affordable Care Act (ACA), Medicaid Expansion, Poverty, and Health Outcomes
Introduction and Research Questions
The purpose of our research is to broaden the knowledge base regarding the Affordable
Care Act (ACA) and determine possible alternative interventions for persons in South Carolina
living under the Federal Poverty Level and suffering negative health outcomes. This research
will describe the most effective interventions for persons living under the Federal Poverty Level
and demonstrate that persons living under the Federal Poverty Level could benefit from
Medicaid expansion under the Affordable Care Act. Since the Affordable Care Act is new,
complex, and expansive, measurement data is still being formulated and this research will
contribute to the growth of this data.
This research is relevant to social work in that persons living under the Federal Poverty
Level are a vulnerable population specifically targeted by the National Association of Social
Workers Code of Ethics and are in need of the services of qualified, professional social workers
to effect positive health outcomes: Social workers pursue social change, particularly with and
on behalf of vulnerable and oppressed individuals and groups[those] efforts are focused
primarily on issues of poverty (1999). The research will show that health outcomes for persons
living under the Federal Poverty Level are one cause of the continued cycle of poverty and a
population that could potentially benefit from Medicaid expansion under the Affordable Care
Act. There are an estimated 194,000 single adults between the ages of 26 and 64 living in South
Carolina under the Federal Poverty Level that are potentially affected by the research questions
addressed (Kaiser, 2014). The research will show that these individuals are not receiving services
under the Affordable Care Act because they are currently ineligible. The findings of this research
will indicate that Medicaid expansion would significantly improve health outcomes for persons

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living under the Federal Poverty Level and provide positive health outcomes and positive
second-hand economic outcomes.
The research question, therefore, is this: Does the implementation of the Affordable Care
Act improve health outcomes for persons in South Carolina living under the federal poverty
level? And if not, would Medicaid expansion improve health outcomes for the same population?
Our hypothesis is that no, the implementation of the Affordable Care Act does not
significantly improve health outcomes for persons in South Carolina living under the Federal
Poverty Level. Additionally, we hypothesize that Medicaid expansion would, in fact, improve
health outcomes for this population.
Literature Review
In pursuit of the purpose of broadening the knowledge base regarding the Affordable
Care Act (ACA) and possible interventions for persons in South Carolina living under the
Federal Poverty Level (FPL) and suffering negative health outcomes, it is necessary to explore
the available literature and determine strengths and weaknesses. This is a new, complex, and
expansive modification to the existing healthcare system in the United States. It is also important
to explore the available literature on the proposed Medicaid expansion as a possibly beneficial
intervention.
Key Concepts
Effects of Poverty on Health Outcomes
Research statistics display that many people living below poverty have worse health
outcomes because they have not had the insurance to get simple doctor visits when they are in
need of care. In particularolder people whose incomes where less than 200 percent of the
poverty level had 3.79 times higher odds of having difficulties with activities of daily living

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compared with older adults who had no history of economic hardship (Kim & Richardson,
2012). This demonstrates how people who were not provided with health care have diminishing
health outcomes in later life.
Affordable Care Act Summary
The Affordable Care Act was signed by President Barack Obama in 2010 and its aim was to
expand coverage, control healthcare costs, and improve the healthcare delivery system. This
aim is being carried out through an individual mandate to have qualifying health coverage,
employer requirements to offer coverage, the voluntary expansion of Medicaid for willing states,
subsidies to individuals between 133 to 400 percent of the Federal Poverty Level and health
insurance exchanges (Kaiser Family Foundation, 2013). In addition to this, the law purposed
changes to private insurance which offered more patient protections such as a removal of preexisting conditions, the elimination of benefit caps, and premium reimbursements (Kaiser Family
Foundation, 2013).
Despite President Obamas intention to propose a law that would universalize health
insurance the research indicates that there are individuals that have fallen in to what has become
known as the coverage gap (Buettgens, Garrett, & Holahan, 2010). This coverage gap represents
22.1 million nonelderly Americans who would be left without insurance, a quarter of whom are
undocumented immigrants, nearly 40 percent eligible for Medicaid but have not enrolled, 28
percent are subject to the mandate but chose to opt out and risk penalties, and finally 8 percent
do not qualify for Medicaid or subsidies (Buettgens, Garrett, & Holahan, 2010).
Current State of Health outcomes in South Carolina
The Behavioral Risk Factors Surveillance System (BRFSS) survey conducted by the South
Carolina Department of Health and Environmental Control (SCDHEC, 2010) provides statistical
data on numbers of individuals reported having negative health outcomes and other questions

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related to health. When asked, Would you say in general your health is excellent, very good,
good, fair, or poor? 5.6 percent of respondents answered poor. For those with household
incomes less than $15,000, 15.2 percent answered poor and those with incomes between $15,000
and $24,999, 11.1 percent answered poor. This indicates that those individuals living below the
federal poverty level in South Carolina fair much worse when it comes to their opinions of their
health status.
This BRFSS survey also attempted to determine access to health coverage including health
insurance, prepaid plans, or government plans such as Medicare. The response indicated the vast
majority did have access to care with 81.2 percent saying yes, however for those individuals
making less than $15,000 only 61.3 percent indicated having access to care and those with
household incomes between $15,000 and $24,999 indicated 69.3 percent responding yes.
Potential changes brought about by Medicaid Expansion
In 2012, the Supreme Court made Medicaid Expansion an individual state decision
(Roberts, et. al.) wherein 25 states chose to expand Medicaid and 21 chose not to expand
Medicaid and the remaining 4 states have yet to make a final decision (Glied & Ma, 2013). The
impacts of this decision vary by state. One state-by-state analysis indicated the net cost of
Medicaid expansion from a high of 11.3% increase in state funds to a low of -8.5% decrease in
state funds (Holahan, Buettgens, Caroll, & Dorn, 2012).
For South Carolina, Medicaid Expansion would be a complicated proposition. Although
state spending would increase by 7% for the period of 2013-2022, federal spending in South
Carolina would increase by 31.9%. Furthermore, because of federal efforts to enroll previously
un-enrolled but eligible individuals in Medicaid brought about by other portions of the ACA,
enrollment in South Carolinas Medicaid is expected to increase by 4% above the average 12%
annual enrollment increase. This increase represents higher costs without additional federal

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funding based on the states decision not to expand Medicaid. (Holahan, Buettgens, Caroll, &
Dorn, 2012).
One pertinent question with regards to Medicaid Expansion is what effect expansion has
on the state wherein expansion takes place. Only one such study has been done. A team of
researchers at the Oregon Health Study Group conducted a lottery with 6,387 adults who were
able to receive Medicaid and 5,842 who were not. Their conclusion was that Medicaid
coverageincrease[d] the use of health care services, raise[d] rates of diabetes detection and
management, lower[ed] rates of depression, and reduce[d] financial strain. Although this study
has only had two years of data to analyze, indications are that health outcomes in Oregon among
the study subjects are likely to continue to significantly improve (Baicker, et. al., 2013). It is
unclear what implication this study has for South Carolina or other states. Further research is
needed to bring certainty to possible health outcomes in South Carolina.
Strengths and Weaknesses
The Affordable Care Act has only been in place for four years and its full implementation
is yet to take place. For this reason, the research available is limited to the current state of
Medicaid which is quite different from the way Medicaid will function under the ACA.
Furthermore, only one study has been conducted for health outcomes of individuals newly
benefiting from Medicaid expansion and the limits of this study are specific to Oregon and
limited in scope.
However, those aspects of Medicaid that will not change under the ACA are time-tested
and well-researched. Also, the Oregon Experiment clearly marks a positive likelihood of success
for other states. The benefits to the states in the form of federal funds with minimal investment
are clearly and reasonably defined. Furthermore, the quantitative analyses presented do not
account for the multitude of human voices deeply affected by poor health outcomes, lack of

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access to affordable health care, and freedom from the crippling debt of medical bills. Qualitative
research could be useful in offering insight into their states of mind.
Summary
Within the available research on the subject of the Affordable Care Act and its effect on
health outcomes for poor individuals living in South Carolina there exists gaps. It is, then,
necessary to pursue the purpose of broadening the knowledge base on the ACA and possible
interventions. For counties that face high unemployment and severe poverty, the existing
evidence has demonstrated negative outcomes. The Affordable Care Act may improve those
outcomes. The literature shows that in South Carolina, many residents consider themselves to be
in poor health. Some conclude this is due to poor health decisions such as poor diet,
unwillingness to seek care, or smoking, but the literature indicates affordability of health care
may be a more complete explanation. The necessity of further research demands a more
complete picture of the effect of the ACA and possible Medicaid expansion on poor individuals
in South Carolina.
Research Question
Does the implementation of the Affordable Care Act improve health outcomes for
persons in South Carolina living under the federal poverty level? And if not, would Medicaid
expansion improve health outcomes for the same population?

Methods
Research Design
The researchers will conduct a quantitative analysis of survey data collected in the South
Carolina Behavioral Risk Factors Surveillance System (BRFSS) annual surveys from 2014
through 2019. BRFSS is a powerful tool which, in its current form, measures a variety of health

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outcomes which meets with the purpose of the desired research. The research will demonstrate
any measured change in the variables of interest but most relevant is the change in health
outcomes for individuals who receive Medicaid measured against individuals who do not have
access to health coverage.
The strengths of this experimental research design are that it uses a measure that has a
high historical sample size of more than 9,000 respondents which allows for validity and
transferability (Babin & Rubin, 2011). Additionally, this design utilizes information easily
accessible, cost efficient, and conducted by a reliable third party. However, the design does have
the weaknesses of qualitative assessment. Individuals are asked how they feel about their health
status rather than using quantitative measures of their health status. Also, this represents a
corollary approach and does not necessarily infer causality.
This research is adequately suitable to the South Carolina Department of Health and
Human Services in that it offers measurements for potential benefits of Medicaid and the inferred
benefits of expanding Medicaid in the state of South Carolina. This research will also be helpful
in allowing lawmakers to make informed decisions about the expansion of Medicaid under the
Patient Protection and Affordable Care Act of 2010 and could lead to a more accurate costbenefit analysis.
The research design utilized in this study is optimal for a variety of factors most prevalent
of which is the cost effectiveness. The BRFSS includes all the qualitative measures necessary to
draw research conclusions that answer the research question of Does the implementation of the
Affordable Care Act improve health outcomes for persons in South Carolina living under the
federal poverty level? And if not, would Medicaid expansion improve health outcomes for the
same population?

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Data Collection/Measurement
The measurement intended for use by the researchers will be the Behavioral Risk Factors
Surveillance System annual questionnaire conducted by the South Carolina Department of
Health and Environmental Control Division of Biostatistics and Health GIS. The target
dependent variables from the SC BRFSS are as follows: Health Status, Healthy Days HealthRelated Quality of Life and, Health Care Access.
Because the SC BRFSS so adequately measures the desired variables, it is logical to use
this measure to conduct the research. The SC BRFSS also breaks down relevant demographic
information that allows for a deeper qualitative analysis.
The researchers will use this survey to gather more information about the Affordable Care
Act and, more specifically, the potential effects of Medicaid expansion on health outcomes of
individuals in South Carolina.
According to the South Carolina Department of Health and Environmental Control
(2014): The Behavior Risk Factor Surveillance System is the world's largest random
telephone survey of non-institutionalized population aged 18 or older that is used to track
health risks in the United States. In 1981, the Centers for Disease Control and Prevention
(CDC), in collaboration with selected states, initiated a telephone based behavioral risk
factor surveillance system to monitor health risk behaviors. As of 1993, participation in
the BRFSS has expanded to include all 50 States, the District of Columbia, Guam, Puerto
Rico, and the Virgin Islands. South Carolina began administering BRFSS since 1984. The
basic philosophy is to collect data on actual behaviors, rather than on attitudes or
knowledge, that would be especially useful for planning, initiating, supporting, and
evaluating health promotion and disease prevention programs. South Carolina has used

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the BRFSS system to: Document the need for and monitor the progress of prevention
programs, including those targeting tobacco use, breast and cervical cancer, injury
prevention, cardiovascular disease, and populations with disparate disease (rural,
minority). Identify the prevalence of a sedentary lifestyle as a significant risk factor in the
state and develop programs within counties to encourage fitness activities through
environmental and policy changes at the community level. Strengthen and promote
communication and collaboration among other agencies and organizations to support
community efforts to improve health. Assess the quality of life of South Carolina
residents and determine the distribution of these indicators across subgroups in the
population. Provide data for the development of educational and environmental policy
change efforts. (SC DHEC, 2014)
Sample Design
For this study, the researchers have decided to the same methods as used by the Center of
Disease Controls Behavioral Risk Factors Surveillance System or BRFSS, for short. The
sampling design is based on the data collected from the South Carolina Department of Health
and Environmental Control.
The researchers will use the BRFSS to track trends for the next five years, which is from
2014 among individuals that have enrolled into Medicaid until the conclusion of the term which
will be 2019. The strengths of this method will be for convenience of the participants. Since most
of the participants have their mobile/cell number on record. The survey can be conducted from
the place of the participants choosing. The very same strength can also be the weakness. The
sampling choice can also be of a convenience of the participant. The participants also have the
right to refuse to answer any questions or none at all just by not answering the call.

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The sample design is the best choice because of the cost and effectiveness of this style of
survey. The sample design is cost effective because there will be no need of actual home visits or
use of any services or manpower from the Department of Health and Human Services.
The ideal sample size for the control group will be above 9,000 individuals as is the
historical trend of the SC BRFSS. For the explanatory group, who are enrolled in Medicaid, the
researchers have established an ideal sample size of 300 individuals.
Using probability sampling will allow the researchers to use the sample group to make
statements relative to other South Carolinians who could potentially benefit from Medicaid
expansion.
Protection of Research Subjects
Voluntary Response
Voluntary participation happens over the phone, only if the participant wants to answer
the questions. With the voluntary response, this will allow participants not to feel like they have
to participant. Also, since this research is voluntary, it will protect the research from receiving
any backlash if a participant were to get hurt. The participants will be informed that the questions
they will be answering will be anonymous. The participants will not receive any incentives for
their participation in the study.
Informed Consent
Before asking the questions, we must inform them on why we our conducting the
research. This consent would inform them that the information they give us will be used
anonymously, and inform them on why we are doing research. Another aspect that is important is
why we chose to call them, and how they ended up on our call list.
Risks vs. Benefits

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Risk that could occur in relation to research subjects is you may hurt their feelings or they
could become embarrassed that you are reaching out to them because of their lack of insurance.
Benefit in relation to the research is you can inform them on why they study is happening and
how it could change their future if they become involved.
Confidentiality
When reaching out to participants, we first inform them and receive consent that they are
okay with participating. When there is an agreement, the researcher can inform them that all
information received is confidential and will not be passed along to others.

References
Baicker, K., Taubman, S., Allen, H., Bernstein, M., Gruber, J., Newhouse, J., Finkelstein, A.,
(2013). The Oregon experiment Effects of Medicaid on clinical outcomes. The New
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Buettgens, M., Garrett, B., & Holahan, J. (2010). America under the Affordable Care Act.
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Collins, S., Rasmussen, P., Doty, M., Garber, T., & Blumenthal, D. (2014). Americans'
experiences in the health insurance marketplaces: Results from the first three months.

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Retrieved from The Commonwealth Fund website:

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s_tracking_survey.pdf
Glied, S., & Ma, S. (2013). How states stand to gain or lose federal funds by opting in or out of
the Medicaid expansion. Retrieved from The Commonwealth Fund website:
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%20Brief/2013/Dec/1718_Glied_how_states_stand_gain_lose_Medicaid_expansion_ib_
v2.pdf
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http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8384.pdf
Kaiser Family Foundation, (2014). How will the uninsured in South Carolina fare under the
affordable care act? Retrieved from website:
http://kaiserfamilyfoundation.files.wordpress.com/2013/12/8531-sc.pdf
Kaiser Family Foundation, (2013). Summary of the Affordable Care Act (8061-02). Retrieved
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National Association of Social Workers. (1999). Code of ethics of the National Association of
Social Workers. Washington, DC. NASW Press. Retrieved from website:
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Roberts, J., et. al. (2012). National Federation of Independent Business, et. al. versus Sebelius,
Secretary of Health and Human Services, et. al. Supreme Court of the United States.
Retrieved from: http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf
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