Panel: Evaluating the Impacts of Affordable Care Act Health Insurance Expansions: What Are the Implications for Future Health Policies?

Thursday, November 7, 2019: 8:30 AM-10:00 AM
I.M Pei Tower: Majestic Level, Vail (Sheraton Denver Downtown)

*Names in bold indicate Presenter

Organizer:  Heidi Allen, Columbia University
Panel Chair:  Timothy McBride, Washington University in St. Louis
Discussants:  Naomi Zewde, CUNY Graduate Center and Abigail Barker, Washington University in St. Louis

This panel provides rigorous evidence from three interrelated papers that collectively explore wide-ranging impacts of the 2014 Affordable Care Act (ACA) health insurance expansions. The three papers will provide fodder for a nuanced panel discussion on possible repercussions of contemporary state policy proposals concerning Medicaid and Marketplace coverage.

The first paper asks the question, which program serves low-income adults better: Medicaid or Marketplace coverage? Using a novel all-payer claims data source merged with enrollee income and a regression discontinuity design, this paper found meaningful differences in the health care experiences of low-income adults in public vs. private coverage. Medicaid enrollees had higher emergency department and lower office visit rates than Marketplace enrollees, which could reflect lower cost-sharing barriers to ED care as well as greater difficulty in accessing outpatient providers in Medicaid compared to private insurance. Meanwhile, the study found Medicaid resulted in more coverage and was substantially less costly both to enrollees and society. 

The second paper examines the differential impact of Medicaid and Marketplace coverage growth on the financial performance of hospitals. The authors hypothesize that Medicaid expansions may differentially affect hospital finances compared to Marketplace expansions, as Medicaid has retroactive and presumptive eligibility practices. These practices allow hospitals and other providers to be paid even if the patient was not already enrolled in coverage at the time of service. Combining several sources of publicly available data, the study compares hospital level finances (operating margin, bad debt and uncompensated care) across geographical locations with different rates of Marketplace and Medicaid take-up. Surprisingly, the study finds insignificant differences in hospital finances between hospitals operating in referral regions with high Medicaid gain and those in regions with similar level of Marketplace enrollment growth. 

The third paper looks specifically at Medicaid take-up and the poverty-reducing effects of Medicaid among low-income adults with health challenges. Using public sources of data and a difference-in-difference framework, the study evaluates medical-out-of-pocket spending (MOOP), poverty as measured by the Supplemental Poverty Measure (SPM), and deep SPM poverty for adults experiencing a recent health challenge.  The paper demonstrates that Medicaid expansion markedly reduced disparities among this group of disadvantaged low-income adults, with health insurance coverage increasing among non-labor force participants with health and work-limiting health challenges. Similarly, this group experienced a reduction in MOOP larger than 15 percent, as did labor force participants with work-limiting disabilities. Both groups saw reductions in deep SPM poverty rates, suggesting that the MOOP reductions had a significant effect on overall household budgets.

There has been considerable recent state policy activity around both Medicaid and Marketplace coverage. Several states appear poised to expand Medicaid under the ACA while other states are considering partial Medicaid expansions and/or imposing work requirements for enrollees. Some states are revisiting Medicaid reactive coverage policies. Our panel contributes to an empirical basis for anticipating the potential consequences of such approaches and can be used to inform future Medicaid and Marketplace policy.

Comparing Medicaid and Marketplace Coverage: Effects on Health Care Utilization, out-of-Pocket Spending and Costs
Heidi Allen1, Sarah Gordon2, Dennis Lee3 and Benjamin Sommers3, (1)Columbia University, (2)Brown University, (3)Harvard University

The Impact of Medicaid and Marketplace Enrollment on Hospital Finances
Cong Gian, Indiana University, Bloomington, Coleman Drake, University of Pittsburgh, Aparna Soni, American University and Kosali Simon, Indiana University

Effects of Medicaid Expansion on Health Insurance Coverage and Poverty Among Adults with Health Challenges
Jessica Pac, Jane Waldfogel and Christopher Wimer, Columbia University

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