The goal of the 2010 Affordable Care Act (ACA) was to achieve nearly universal health insurance coverage in the United States through a combination of insurance market reforms, mandates, subsidies, health insurance Marketplaces, and Medicaid expansions (Obama, 2016). Most major components of the ACA took effect in 2014. A growing literature has evaluated the impact of these reforms on insurance coverage. At the national level, pre-post comparisons find increases in insurance coverage of between 2.8 and 6.9 percentage points, depending on the time frame, dataset, and population group (Long et al., 2014; Smith and Medalia, 2015; Courtemanche et al., 2016; Obama, 2016; Barnett and Vornovitsky, 2016). State-level studies reach similar conclusions (Sommers et al., 2014, Sommers et al., 2016, Golberstein et al., 2015; Benitez, 2016). Other work uses more sophisticated econometric techniques to isolate the impact of different components of the ACA on coverage. Kaestner et al. (2015) and Wherry and Miller (2016) focus on the effect of the Medicaid expansions, while Frean et al., (2016) focus on the Medicaid expansions, subsidized premiums for Marketplace coverage, and the individual mandate. All of these studies use either the Current Population Survey (CPS), American Community Survey (ACS), National Health Interview Survey (NHIS), or Urban Institute Health Reform Monitoring Survey. Courtemanche et al. (2017) develop an identification strategy to estimate the causal effect of the ACA more generally. Using ACS data, the authors conclude that the ACA increased coverage by an average of 5.9 percentage points in Medicaid expansion states compared to 2.8 percentage points in non-expansion states in 2014.
The natural next step in the evaluation of the ACA is to examine the impact of these public and private coverage gains on health care utilization and spending, which we do in this paper using the Medical Expenditure Panel Survey (MEPS). Examining changes in utilization allows for a more direct measurement of changes in access than studying subjective survey responses about, for instance, cost being a barrier to care. The MEPS data also allow for an examination of substitution between different types and locations of services. If the newly insured transition from using the emergency room for their primary source of care to the doctor’s office, this could reduce the consumption of hospital care and overall health care spending. The data also allow for evaluation of changes in total spending, out-of-pocket (OOP) spending, and exposure to catastrophic OOP costs. A few recent studies have analyzed changes in health care utilization and spending in 2014, though none of them estimate the causal impact of the full ACA.
