Medicaid expansion represents an enormous use of resources that could have been expended in many ways to promote health and well-being. While the Medicaid expansion has produced benefits, particularly for those near retirement age, Americans’ health has worsened overall since the implementation of the Affordable Care Act. Targeted health efforts aimed at the most vulnerable likely would have been more efficient.

Key points:

  • The ACA significantly expanded insurance coverage between 2013 and 2017, but Americans’ health worsened during this period as life expectancy declined for three consecutive years from 2014 to 2017.
  • States that did not adopt Medicaid expansion had favorable mortality trends from 2013 to 2017 compared with states that adopted the expansion, in part because they had fewer people die from opioid overdoses.
  • Medicaid expansion was associated with improvements in self-reported health and greater financial peace of mind, with mixed evidence on physical health benefits. It was associated with a decline in mortality for those near retirement age.
  • The bulk of the evidence suggests that targeted health programs, including those geared toward children, prove to be far better public investments than does a massive Medicaid expansion.
  • Large coverage expansions disappoint for several reasons: the uninsured receive nearly 80 percent as much care as similar insured people, the crowd-out of private coverage, and indirect effects on others such as longer wait times for care.