Medicaid expansion helped enrollees’ long-term financial health, study finds
Michigan Medicaid expansion enrollees had large drops in medical debt in collections and in rates of sub-prime credit scores
Twelve years ago this spring, the first Michiganders began getting their health care coverage from the Medicaid expansion program known as the Healthy Michigan Plan.
Today, more than 650,000 are enrolled in the program, which provides health care to individuals with low incomes. Multiple studies have already shown the program is linked to better physical and mental health, and ability to work or seek a job.
Now, a new University of Michigan study shows that enrolling also had a positive and long-lasting impact on the financial health of its first enrollees.
Over time, the study shows, those who enrolled in the first four years saw large drops in their amount of medical debt in collections – as much as 75% from the peak. That means they had fewer medical bills that were left unpaid for so long that they were turned over to a collection agency.
Medical debt kept declining for at least seven years after enrollment, according to the findings published in the journal JAMA Network Open.
Having medical bills sent to collections can lower someone’s credit score, which can make it more difficult for them to get a loan. It can also lead them to avoid needed medical care in the future.
The study also finds that the credit scores of Medicaid expansion enrollees improved, with substantial drops in the numbers who scored below 600, a number considered sub-prime or risky for lenders. The drop in rates of subprime scores was between 30% and 50% relative to the rates at the start of enrollment.
The new findings have importance for states as they implement new Medicaid requirements and funding limits signed into federal law last year. The findings can also inform policymakers and voters in the 10 states that have still not expanded Medicaid, and several states that expanded it in the past few years.
“As Medicaid changes and enrollees face new requirements for new or continued access to coverage, these findings can help to give a fuller picture of the financial benefits of these programs,” said Nora Becker, M.D., Ph.D., the U-M primary care physician and health economist who led the study. “We know that financial stress from medical debt is closely intertwined with physical and mental health, including decisions to go without health care to avoid more potential costs. People with more financial security also earn higher incomes and pay more taxes in the future, so Medicaid expansion may also have benefits for state and local government budgets as well. This is why it’s important to look at personal financial factors over time to give a full picture of Medicaid expansion’s impacts.”
Becker is part of a team from the U-M Institute for Healthcare Policy and Innovation that conducted the official evaluation of the Healthy Michigan Plan through a partnership with the Michigan Department of Health and Human Services. The evaluation was required under the state’s waiver with the Centers for Medicare and Medicaid Services that spanned the period 2019-2023, and data from the evaluation were used in the new study.
John Z. Ayanian, M.D., M.P.P., the leader of the evaluation and IHPI’s director, is the new study’s senior author.
Other financial impacts
The study looks at four kinds of financial outcomes, using anonymous data from Healthy Michigan Plan enrollees and from a major credit agency.
It focused on adults ages 26 to 62 – the years when someone can’t be covered by a parent or guardian’s insurance, and can’t receive Social Security retirement benefits or be eligible for Medicare.
To get the long-term view, the team concentrated on those who enrolled in the Healthy Michigan Plan in its first four calendar years of operation, from 2014 to 2017, and were still alive for at least three years after enrolling. In all, data on 575,283 individuals was analyzed, nearly half of whom enrolled in the program’s first year.
The researchers looked at anonymous financial information for each person, starting several years before their enrollment and for up to seven years after enrollment.
The drop in medical debt in collections really began to be seen in the third year after enrollment, and accelerated after that. Subprime credit score rates began to drop even after the first year of enrollment.
Ayanian notes that these effects may be tied to another effect already documented by previous IHPI research. On the whole, he and his colleagues showed earlier, Healthy Michigan Plan enrollees reported that the coverage increased their ability to work or seek work. Half of enrollees are employed but have incomes low enough to qualify for Medicaid coverage
However, two other financial indicators did not change after enrollment: rates of non-medical debt in collections and bankruptcy rates.
Data collection was funded by MDHHS and CMS for the purposes of the evaluation but the new paper does not represent the official views of either agency.
In addition to Becker and Ayanian, the study’s authors are Helen Levy, Ph.D., Richard A. Hirth, Ph.D., Sarah J. Clark, M.P.H. and Renuka Tipirneni, M.D., M.Sc. Becker, Ayanian and Tipirneni are faculty in the Division of General Medicine in the U-M Medical School’s Department of Internal Medicine, and Clark is faculty in the Medical School’s Department of Pediatrics. Levy is a faculty member in the U-M Institute for Social Research, and Hirth in the U-M School of Public Health, where Levy and Ayanian have joint appointments. Levy and Ayanian have joint appointments in the Ford School of Public Policy. All authors are members of the U-M Institute for Healthcare Policy and Innovation.
Learn more about the IHPI evaluation of the Healthy Michigan Plan here: https://ihpi.umich.edu/featured-work/healthy-michigan-plan-evaluation
See summaries of past research showing links between Healthy Michigan Plan enrollment and impacts on health and work here: https://ihpi.umich.edu/featured-work/healthy-michigan-plan-evaluation/news
Financial Outcomes Among Medicaid Expansion Enrollees Nora V. Becker, MD, PhD; Helen Levy, PhD; Richard A. Hirth, PhD; Sarah J. Clark, MPH; Renuka Tipirneni, MD, MSc; John Z. Ayanian, MD, MPP, JAMA Network Open, doi:10.1001/jamanetworkopen.2026.9328
Journal
JAMA Network Open
Method of Research
Data/statistical analysis
Subject of Research
People
Article Title
Financial Outcomes Among Medicaid Expansion Enrollees
Article Publication Date
27-Apr-2026
Grant supports efforts to create atlas of Medicaid spending
image:
Dr. William Schpero
view moreCredit: Weill Cornell Medicine
Researchers from Weill Cornell Medicine and Boston University School of Public Health have been awarded more than $950,000 from Arnold Ventures to create a “Medicaid Atlas” — a national, data-driven web platform that will illuminate how health care use and spending vary across Medicaid programs, plans and populations. The project will be one of the first major efforts of the Medicaid Policy Impact Initiative, a new cross-campus Cornell program aimed at supporting evidence-based policymaking in Medicaid.
The project launches at a moment of growing urgency for Medicaid policymakers. As states face increasing fiscal pressure due funding cuts enacted under the One Big Beautiful Bill Act, leaders need actionable data to understand where spending is high, why it varies and where opportunities exist to improve care.
“Medicaid is a massive program. It’s one of the biggest line items in states’ budgets. And yet we still lack great visibility into what drives spending variation,” said Dr. William Schpero, an assistant professor of population health sciences at Weill Cornell Medicine and co-lead on the project.
Understanding those drivers has been difficult for researchers because Medicaid is highly fragmented across states and often delivered through private managed care plans. Two patients with similar health needs may generate very different spending depending on where they live and which plan they are enrolled in. At the same time, information about health care spending, use and quality has historically been siloed across states and insurers, forcing policymakers to rely on time-intensive, custom analyses to answer even basic questions.
This approach does not always support the rapid-cycle policy environment many Medicaid programs operate in. “With the atlas, we want to make it possible to go from months-long studies to making helpful data insights one click away,” said atlas co-lead Dr. Sarah Gordon, associate professor of health law, policy & management at Boston University School of Public Health and co-director of the BU Medicaid Policy Lab.
That goal has become more feasible in recent years with the release of high-quality national Medicaid claims data from the federal government, which for the first time enable consistent analysis across states. In 2022, Drs. Gordon and Schpero helped start the Medicaid Data Learning Network, a national consortium of researchers dedicated to developing best practices for analyzing federal Medicaid claims data. The research produced by this network has demonstrated the potential impact of national Medicaid data analyses to inform policy.
“These data have proved to be a major catalyst for conducting timely Medicaid research that can directly inform state decision-making,” said Dr. Schpero, who is also an associate director at the Cornell Health Policy Center, which houses the Medicaid Policy Impact Initiative. “Our hope is that this tool can be a valuable resource for Medicaid leaders to understand variation within their state and benchmark to other states, all in a one-stop, easy-to-use dashboard.”
Over the first two years, the research team will develop a set of 10–15 measures capturing major drivers of Medicaid spending and utilization. These measures will be selected in collaboration with state Medicaid leaders to ensure they help answer high-priority policy questions.
“The goal of this project is to put Medicaid policy and financing insights at the fingertips of policymakers, researchers, journalists and the public,” Dr. Gordon said.
The atlas will allow users to examine variation across states, counties, plans and enrollee populations — and to identify patterns that may signal opportunities to improve efficiency and care delivery. States could use the atlas to benchmark spending, evaluate managed care plans and identify high-value models of care.
There’s precedent to think this approach will work, Dr. Schpero said. A decades-long project called the Dartmouth Atlas of Health Care used claims data to identify opportunities to lower spending while maintaining or improving quality in the Medicare program. Some of the project’s findings laid the groundwork for components of the Affordable Care Act.
“There’s a rich history of using national claims data to inform policymaking,” Dr. Schpero said. “To date, much less of this has happened in Medicaid. There is a lot that we can learn about Medicaid policy from these data and that states can learn from each other.”
The atlas is part of a broader effort at Cornell to strengthen the role of data and evidence in Medicaid policymaking. The Medicaid Policy Impact Initiative, directed by Dr. Schpero, brings together Cornell faculty, data infrastructure and state partnerships to produce research designed for real-world decision-making. The initiative focuses on how Medicaid programs are designed, financed and delivered — and translates those insights into practical guidance for policymakers, health plans and providers.
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