Association for Public Policy Analysis & Management

Background and Rationale:Prior to the health insurance marketplace implementation under the Affordable Care Act, a majority of uninsured people in the United States struggled with one or more key health insurance terms. Many of the same consumers prefer in-person assistance with health plan shopping to electronic resources. In-person assistance with plan selection may be important not only to increase insurance enrollment in the health insurance marketplaces, but also to reduce "churn" out of insurance and ensure that access to insurance translates to access to care.

Research Objective:To study how the increases and subsequent cuts in in-person consumer assistance funding on the state-level over 2010-2014 were associated with uptake of health insurance marketplace insurance coverage, churn out of such insurance coverage, and use of such insurance coverage for routine care and prescription fills.

Identifying Variation:We exploit variation in consumer assistance funding over geography and time. Due to discrepancies in federal funding mechanisms available to each state, funds per eligible uninsured person varied more than four-fold across states in 2014; state-based marketplaces also received lump sums of funds earlier than other states.

Data Sources:The authors have created a new dataset on consumer assistance funding by state by combining available sources including in-person assistance grants, navigator grants, and community health center assistance grants. These data are being merged onto restricted access MEPS data, which have detailed information on care for conditions of high policy relevance: hypertension, heart disease, high cholesterol, emphysema, chronic bronchitis, diabetes, cancer, arthritis, asthma, and stroke. The MEPS data are also ideal for achieving our research objectives because they distinguish between health insurance marketplace coverage vs. other coverage and follow individuals over time, enabling measures of individual-level changes in health insurance status and health care use.

Measurement Strategy:We will conduct panel data models in which our outcomes of interest – health insurance marketplace health insurance uptake, "churn" out of health insurance, and health care utilization - are modeled as a function of prior and current funding for consumer assistance on the state-level over 2006-2014. Because generosity of assistance funding was correlated with Medicaid expansion status, we will run models separately for states with vs. without Medicaid expansions. All models will have state and year fixed effects. We will also examine heterogeneity of findings by conducting a separate investigation of populations with chronic conditions and health disparities populations.

Policy Impact: Federal funding to states for consumer assistance programs in the United States has declined since 2014. Advocates of the program require evidence as to the program’s impact.