title: The effect of Medicaid expansions on demand for care from the Veterans Health Administration.
abstract: BACKGROUND
  Adequate access to care at Veterans Health Administration (VA) medical centers has become a high-profile policy issue. The Affordable Care Act (ACA) could improve access to care for veterans, particularly if its Medicaid expansion is implemented in all states. The relationship between Medicaid expansion on the one hand and VA enrollment and utilization on the other has not previously been explored for all states.
  
  
  METHODS
  Using VA and other public data from 2002 to 2008, we calculated a measure of Medicaid eligibility sensitive to state-year varying policy change but not changes in demographics or economic conditions. Next, controlling for potential confounding factors, we estimated fixed effects Poisson models of VA enrollment and inpatient and outpatient utilization. We then used these estimates to simulate the effect of the ACA׳s Medicaid expansion on demand for VA care.
  
  
  RESULTS
  If the ACA׳s Medicaid expansion had been implemented in all states, enrollment for VA health coverage, acute inpatient care (days), and outpatient visits would have been 9%, 6%, and 12% lower, respectively. In states that did not expand Medicaid in 2014, VA enrollment, inpatient days, and outpatient visits were, respectively, 10, 6, and 13 percentage points higher than they would have been otherwise.
  
  
  CONCLUSIONS
  VA medical centers in states that did not expand Medicaid in 2014 are likely to have experienced a higher demand, and commensurately longer wait times. As policymakers continue to address VA capacity issues, they should be mindful of the potential role of Medicaid, and that it will change over time as more states adopt the expansion.
authors.affiliation: VA Boston Healthcare System, Department of Veterans Affairs, 150 S. Huntington Ave (152H), Boston, MA 02130, USA; Boston University, USA. Electronic address: frakt@bu.edu.
authors.forename: Austin B
authors.initials: AB
authors.lastname: Frakt
authors.affiliation: Boston University, USA.
authors.forename: Amresh
authors.initials: A
authors.lastname: Hanchate
authors.affiliation: Northeastern University, USA.
authors.forename: Steven D
authors.initials: SD
authors.lastname: Pizer
mesh_terms: D006297:Health Services Accessibility; D006787:Hospitals, Veterans; D006801:Humans; D008484:Medicaid; D058991:Patient Protection and Affordable Care Act; D014481:United States; D014493:United States Department of Veterans Affairs; D058014:Veterans Health
keywords: Affordable Care Act; Demand; Health insurance; Medicaid; Veterans Health Administration