Medicaid expansion increased access to nursing home care for people younger than 65, but it’s unclear whether those patients would have been treated more adequately in other post-acute settings.

That’s according to researchers from the University of Pennsylvania and the Duke Margolis Center for Health Policy, who set out to study the effect of Medicaid eligibility expansion under the Affordable Care Act on the nation’s nursing homes.

The team reviewed more than 15 million admissions, including those of about 2.5 million of residents younger than 65, between 2009 and 2016.

Ashley Z. Ritter, Ph.D.

Facilities in expansion states that previously had an occupancy rate of more than 70% saw their share of under-65 residents grow by 2.74% more than similar facilities in non-expansion states, the team reported Monday in JAMDA, The Journal of Post-Acute and Long-Term Care Medicine.

The authors hypothesized that skilled nursing facilities with “greater bed availability” might pursue these new Medicaid patients as a way to fill beds amid a decade-long occupancy decline that pre-dated COVID-19.

Instead, lead author and geriatric nurse practitioner Ashley Z. Ritter, Ph.D., told McKnight’s Long-Term Care News, they found more of the under-65 population went to facilities reporting 70% to 90% occupancy before the Affordable Care Act. That may be a sign that those with higher occupancy tend to work harder to maintain census as a business practice.

Shorter stays, but why?

Among residents younger than 65, the average length of stay decreased compared to non-expansion states, leading to concerns about how much and what kinds of post-acute care these patients need. While the study did not track patient conditions or expected length of stay, Ritter said the downward trend could be connected to payers pressing for faster hospital discharges, the socio-economic status of patients living near the poverty line or even mental health conditions.

“With preferred partners and contracts, it might be cheaper to give care in a nursing home (than in a hospital), but the nursing home might not have the skillset or the desirability for a younger person to remain in that setting,” said Ritter, director of Clinical Care Research, NewCourtland Center for Transitions and Health and an adjunct professor at the UPenn School of Nursing. “There are a ton of questions as to what is the best place to take care of these individuals (and) what competencies does a nursing home have to deliver that care?”

The study used nursing-home level data from LTCFocus, patient-level data from the Minimum Data Set, and Medicaid expansion information from the Kaiser Family Foundation. According to Kaiser, 38 states and Washington, D.C., have expanded eligibility for Medicaid since 2014. 

The Affordable Care Act, passed in 2010, allows states to receive federal support for expanded Medicaid eligibility up to 138% of the federal poverty level for adults.

A previous study published in JAMA Network Open found Medicaid expansion was associated with increased access to long-term care — including home care — for low-income, middle-aged adults, suggesting that the newly eligible population may have had unmet long-term care needs before expansion. Expansion has also increased access to acute care, which could ultimately feed more patients to the post-acute system.

In this study, researchers found Medicaid expansion significantly drove down the average age of newly admitted nursing home patients in affected states — by nearly eight months in one scenario.

Those younger patients come with different needs and expectations, a reality nursing homes still mostly familiar with long-stay Medicaid patients may not be adequately prepared for, Ritter said.