Medicaid Expansion And Marketplace Eligibility Both Increased Coverage, With Trade-Offs In Access, Affordability

Abstract

Affordable Care Act (ACA) provisions implemented in 2014 provide a valuable case study regarding the merits of using public versus subsidized private insurance to help low-income people obtain and finance health care. In particular, nonelderly adults with incomes of 100-138 percent of the federal poverty level gained Medicaid eligibility if they lived in states that implemented the ACA's Medicaid expansion, whereas those in nonexpansion states became eligible for subsidized Marketplace coverage. Using data for 2008-15 from the National Health Interview Survey, we found that as of 2015, adults with family incomes in this range had experienced large declines in uninsurance rates in both expansion and nonexpansion states (the adjusted declines were 22 percentage points and 18 percentage points, respectively). Adults in expansion and nonexpansion states also experienced similar increases in having a usual source of care and primary care visits, and similar reductions in delayed receipt of medical care due to cost. There were, however, important differences: Adults in expansion states experienced larger reductions in out-of-pocket spending but also faced greater difficulty accessing physician care relative to adults in nonexpansion states.

Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults

“…This finding is consistent with prior research that found that Marketplace enrollees are exposed to higher out-of-pocket costs and are at greater risk of extremely high spending even with significant federal subsidies. 10,32,34,35 In terms of clinical quality, we found no difference for the primary outcome of ambulatory caresensitive hospitalizations. Among secondary outcomes, 5 measures favored Marketplace coverage (though 1 was of minimal clinical relevance, a 1 percentage-point difference in flu vaccination), 1 measure favored Medicaid, and the rest (6 of 12) showed no significant differences.…”

“…One possibility is that limited access to outpatient care in Medicaid led some individuals to pursue ED care instead. One recent study reported Medicaid enrollees experienced longer wait times for appointments than those in Marketplace coverage, 32 and lower physician participation rates in Medicaid is a long-standing concern. 33 Another potential explanation is that some individuals signed up for Medicaid while in the ED, because Medicaid's policy of retroactive eligibility creates an additional pathway for people to gain coverage; this option is not available for Marketplace coverage.…”

Disparities in Medical Debt Among U.S. Adults with Serious Psychological Distress

“…1,2 Findings post-ACA indicate that health insurance coverage was expanded [3][4][5] ; however, high out-of-pocket costs continue to create barriers to accessing needed health care. [6][7][8][9][10] Furthermore, the literature on personal bankruptcy filings suggests that medical conditions continue to be a driver of personal bankruptcy filings. [11][12][13] Although the relationship between medical bills and bankruptcy has been studied, fewer studies have been conducted on medical debt.…”

Effects Of The ACA’s Health Insurance Marketplaces On The Previously Uninsured: A Quasi-Experimental Analysis

“…(36) While our study shows this coverage has been beneficial, our post-ACA estimates show that many adults still experience barriers to care, and cost-related challenges may be more common in Marketplace plans with high cost-sharing than in Medicaid, which traditionally has only minimal out-of-pocket payments. (37) Our subgroup analysis revealed that improvements in access to care was generally larger in the lower-income (138-250% of poverty) subgroup. This has important implications for the ACA's cost-sharing reductions, which are available to Marketplace enrollees with incomes below 250% of FPL.…”