Medicaid Expansion Associated with Increased, But Not High Quality, Screening for Alcohol Use

People living in states with expanded Medicaid access were more likely to be screened by their doctor for alcohol use compared to people who lived in states that did not expand Medicaid access, but they did not necessarily receive effective interventions. A study published in Alcohol: Clinical and Experimental Research found that living in a state with expanded Medicaid access was associated with a higher prevalence of lower-income adults’ receiving some alcohol screening at a recent checkup but not receiving higher quality screening or brief counseling. The authors suggest that expanded Medicaid access may increase screening via increased access to primary care but that policies that target healthcare provider constraints are also needed to increase high-quality, evidence-based screening and counseling around alcohol use.

The study is the first to examine whether an increased likelihood of receiving alcohol screening and brief counseling among nonelderly low-income adults was associated with living in a state that expanded Medicaid eligibility under the Affordable Care Act (ACA). After the passage of the ACA, the federal government offered states subsidies to expand eligibility for Medicaid to include all nonelderly adults with incomes up to 138% of the federal poverty level. Researchers reviewed responses to the 2017 and 2019 National Behavioral Risk Factor Surveillance System from nearly 16,000 low-income adults aged 18 to 64 living in 14 states that expanded Medicaid eligibility before 2017 and nine states that did not.

Researchers found that living in a state that expanded Medicaid eligibility is associated with a slightly higher prevalence of receiving general alcohol screening at a primary care checkup within the past two years. However, it found no significant associations between living in Medicaid expansion states and evidence-based interventions for alcohol misuse, including being asked about the quantity of drinking and, among respondents who drank heavily, receiving advice about what harmful drinking is or how to reduce or quit drinking.

The study also explored the relationship between expanded access to Medicaid and alcohol interventions for people with chronic health conditions caused or worsened by moderate or heavy alcohol use, such as high blood pressure and diabetes. For these adults, living in a state with expanded Medicaid eligibility was associated with a greater prevalence of receiving more thorough alcohol screening, such as being asked how much they drink and being screened for binge drinking. Expanded access to Medicaid was not associated with an increased prevalence of receiving brief counseling about reducing or stopping drinking.

The researchers noted that the rates of receiving screening and counseling were low across the study sample, with only 60 percent of respondents reporting being asked whether they drink and, of people who reported drinking within the last month, only half reported being asked how much they drank and a third were asked about binge drinking. Of people who reported drinking heavily, less than a third had been offered advice about what constitutes risky drinking, and less than 20 percent were advised to reduce or quit drinking. The authors suggest that healthcare provider and system barriers, such as limited training, lack of tools for screening and referral, and time constraints, may be responsible for the low rates of screening and counseling and should be addressed.

Residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling by adults with lower incomes: Is increased access to primary care enough? A. Phillips, K. Karriker-Jaffe, K. Bensley, M. Subbaraman, J. Delk, N. Mulia. (p. x-xx)

ACER-23-5604.R2