Impact of the Affordable Care Act on participation in the Supplemental Nutrition Assistance Program among low-income older Medicare beneficiaries

(2023) 23:509 Kim et al. BMC Health Services Research https://doi.org/10.1186/s12913-023-09557-7 BMC Health Services Research Open Access RESEARCH Impact of the Affordable Care Act on participation in the Supplemental Nutrition Assistance Program among low‑income older Medicare beneficiaries Hyunmin Kim1* , Asos Mahmood2,3 , Cyril F. Chang4, Noah E. Hammarlund5   and Aram Dobalian6    Abstract Background The Affordable Care Act (ACA) provisions, especially Medicaid expansion, are believed to have “spillover effects,” such as boosting participation in the Supplemental Nutrition Assistance Program (SNAP) among eligible individuals in the United States (US). However, little empirical evidence exists about the impact of the ACA, with its focus on the dual eligible population, on SNAP participation. The current study investigates whether the ACA, under an explicit policy aim of enhancing the interface between Medicare and Medicaid, has improved participation in the SNAP among low-income older Medicare beneficiaries. Methods We extracted 2009 through 2018 data from the US Medical Expenditure Panel Survey (MEPS) for lowincome (≤ %138 Federal Poverty Level [FPL]) older Medicare beneficiaries (n = 50,466; aged ≥ 65), and low-income (≤ %138 FPL) younger adults (aged 20 to < 65 years, n = 190,443). MEPS respondents of > %138 FPL incomes, younger Medicare and Medicaid beneficiaries, and older adults without Medicare were excluded from this study. Using a quasiexperimental comparative interrupted time-series design, we examined (1) whether ACA’s support for the MedicareMedicaid dual-eligible program, through facilitating the online Medicaid application process, was associated with an increase in SNAP uptake among low-income older Medicare beneficiaries, and (2) in the instance of an association, to assess the magnitude of SNAP uptake that can be explicitly attributed to the policy’s implementation. The outcome, SNAP participation, was measured annually from 2009 through 2018. The year 2014 was set as the intervention point when the Medicare-Medicaid Coordination Office started facilitating Medicaid applications online for eligible Medicare beneficiaries. Results Overall, the change in the probability of SNAP enrollment from the pre- to post-intervention period was 17.4 percentage points higher among low-income older Medicare enrollees, compared to similarly low-income, SNAP-eligible, younger adults (β = 0.174, P < .001). This boost in SNAP uptake was significant and more apparent among older White (β = 0.137, P = .049), Asians (β = 0.408, P = .047), and all non-Hispanic adults (β = 0.030, P < .001). Conclusions The ACA had a positive, measurable effect on SNAP participation among older Medicare beneficiaries. Policymakers should consider additional approaches that link enrollment to multiple programs to increase SNAP participation. Further, there may be a need for additional, targeted efforts to address structural barriers to uptake among African Americans and Hispanics. *Correspondence: Hyunmin Kim Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kim et al. BMC Health Services Research (2023) 23:509 Page 2 of 14 Keywords Supplemental Nutrition Assistance Program, Health Care Reform, Affordable Care Act, Medicare and Medicaid, Dually eligible beneficiaries, Low-income, Older adults Background The Supplemental Nutrition Assistance Program (SNAP) is a federally funded and state-supervised nutrition program. It has played a critical role in reducing food insecurity among low-income households in the United States (US) by providing a monthly cash benefit for purchasing eligible food items [1]. As the nation’s largest anti-hunger program, an estimated 40 million Americans received SNAP benefits among the 47 million people who were eligible in 2016 [2]. SNAP is considered to be one of the most effective federal anti-poverty programs in reducing poverty and in alleviating food insecurity for millions of low-income Americans [3]. To date, however, SNAP participation among a particularly needy population, i.e. eligible low-income seniors, remains low. In 2017, for example, 82% of the general population eligible for SNAP participated in this program, while only 42% of eligible older adults did [4]. The Affordable Care Act (ACA) implementation is believed to have direct or spillover implications for reducing food insecurity and boosting SNAP participation in the US, particularly, through the expansion of health insurance coverage [5, 6]. Generally, the ACA aimed to achieve the triple aims of better healthcare, better health outcomes, and better value by providing increased access to healthcare for the US population [7]. It included several measures targeted at older Medicare populations with a focus on those who were eligible for both Medicare and Medicaid, the so-called “dual eligibles.” It specifically included a set of options to provide enhanced care to dual eligibles such as improved care coordination, increased access to long-term care services, and enhanced performance measures to monitor progress. To achieve these aims, the ACA constructed two entities: The Center for Medicare and Medicaid Innovation (CMMI) and the Medicare-Medicaid Coordination Office (MMCO) or “Duals Office.” The Duals Office has several programmatic goals[8] including offering dually eligible individuals full access to Medicare and Medicaid benefits and simplifying associated processes. Dual eligibles are defined as Medicare enrollees who are also eligible for Medicaid either due to their income status or because of costly medical bills upon which they can have full or partial dual benefits. It is estimated that about 12 million people, or about 19% of Medicare and 14% of Medicaid enrollees are dually eligible [9]. Dual eligibles are considered the most vulnerable patient population in the US public health system [1 (...truncated)