Association for Public Policy Analysis & Management

The objective of this study is to identify how enrollment in off- and on-exchange plans impacts differences in health care access, utilization, and financial strain among individuals who are eligible for subsidies under the Affordable Care Act (ACA). To accomplish this, we use individual-level survey data from the National Health Interview Survey (2014-2017) and examine the experiences of non-elderly adults (18-64 years old) who are eligible for subsidies on the ACA’s exchanges. We use propensity score matching to control for differences between exchange and off-exchange enrollees and selection out of subsidies made available by the ACA. Compared to off-exchange enrollees, exchange enrollees were more likely not to be accepted as a new patient and were more likely to forgo or delay health care due to cost. Exchange enrollees experienced worse measures of health care access and financial strain, with differences in plan types likely driving these disparities. The insurance expansions of the ACA greatly reduced the uninsurance rate in the United States, but problems remain. Given that any future health insurance reforms are likely to affect the exchanges, policymakers should be cognizant of the differences that exist between exchange and off-exchange plans and take actionable steps to mitigate these differences.