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Early Experience with the ACA: Coverage Gains, Pooling of Risk, and Medicaid Expansion

Published online by Cambridge University Press:  01 January 2021

Linda J. Blumberg  and
John Holahan
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Abstract

We provide an overview of the characteristics of those who have gained insurance coverage due to the ACA as well as the characteristics of the remaining uninsured. We also describe the implications for the broader sharing of health care risks required under the law, and how they vary by individuals' health status. Finally, we assess the implications of state decisions to expand or not expand Medicaid eligibility under the law, how those decisions affect state finances, health care providers, residents, and how the effects may vary for those states using waivers to expand eligibility using strategies designed to be more broadly politically acceptable.

Type
Symposium Articles
Information
Journal of Law, Medicine & Ethics , Volume 44 , Issue 4: Health Reform: Assessing the Affordable Care Act and Moving Forward , Winter 2016 , pp. 538 - 545
Copyright
Copyright © American Society of Law, Medicine and Ethics 2016

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References

Blumberg, L. J., Garrett, B., and Holahan, J., “Estimating the Counterfactual: How Many Uninsured Adults Would There Be Today without the ACA?” Inquiry 53 (2016) : 1–13, available at <http://inq.sagepub.com/content/53/0046958016634991.full.pdf+html> (last visited September 28, 2016); S. Marken, “U.S. Uninsured Rate 11.9% in Fourth Quarter of 2015,” Gallup, January 7, 2016, available at <www.gallup.com/poll/188045/uninsured-rate-fourth-quarter-2015.aspx> (last visited September 28, 2016); M. Karpman and S. K. Long, “QuickTake: Taking Stock: Gains in Health Insurance Coverage under the ACA Continue as of September 2015, but Many Remain Uninsured,” The Urban Institute, November 2015, available at <http://hrms.urban.org/quicktakes/Gains-in-Health-Insurance-Coverage-under-the-ACA-Continue-as-of-September-2015-but-Many-Remain-Uninsured.html> (last visited September 28, 2016); “National Health Interview Survey Early Release Program,” National Center for Health Statistics, 2016, available at <www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf> (last visited October 11, 2016).Google Scholar
Holahan, J., Blumberg, L. J., and Wengle, E., Increases in 2016 Marketplace Nongroup Premiums: There Is No Meaningful National Average, THE URBAN INSTITUTE, November 2015, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000526-2016-Premium-Increases-In-The-ACA-Marketplaces.pdf> (last visited September 28, 2016); J. Holahan, L. J. Blumberg, and E. Wengle, Marketplace Premium Changes throughout the United States, 2014–2015, The Urban Institute, March 2015, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000149-Marketplace-Premium-Changes-Throughout-the-United-States-2014-2015.pdf> (last visited September 28, 2016).+(last+visited+September+28,+2016);+J.+Holahan,+L.+J.+Blumberg,+and+E.+Wengle,+Marketplace+Premium+Changes+throughout+the+United+States,+2014–2015,+The+Urban+Institute,+March+2015,+available+at++(last+visited+September+28,+2016).>Google Scholar
Karpman, M. and Long, S. K., 9.4 Million Fewer Families Are Having Problems Paying Medical Bills, Health Reform Monitoring Survey Policy Brief, The Urban Institute, available at <http://hrms.urban.org/briefs/9-4-Million-Fewer-Families-Are-Having-Problems-Paying-Medical-Bills.html> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
Blumberg, L. J. and Holahan, J., “Don't Let The Talking Points Fool You: It's All About The Risk Pool,” Health Affairs Blog, 2016, available at <http://healthaffairs.org/blog/2016/03/15/dont-let-the-talking-points-fool-you-its-all-about-the-risk-pool/> (last visited September 28, 2016).Google Scholar
The 18 million estimate reflects the effect as of March 2015 (Blumberg, Garrett, Holahan 2016 Inquiry); the 20 million estimate reflects the effect as of March 2016, estimated using different methods by M. Buettgens, L.J. Blumberg, J. Holahan, and S. Ndwandwe, The Cost of ACA Repeal, The Urban Institute, June 2016, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000806-The-Cost-ofthe-ACA-Repeal.pdf> (last visited October 11, 2016) and by N. Uberoi, K Finelgold, and E. Gee, Health Insurance Coverage and the Affordable Care Act, 2010-2016, Washington: US Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, available at <https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-2010-2016> (last visited October 11, 2016).+(last+visited+October+11,+2016)+and+by+N.+Uberoi,+K+Finelgold,+and+E.+Gee,+Health+Insurance+Coverage+and+the+Affordable+Care+Act,+2010-2016,+Washington:+US+Department+of+Health+and+Human+Services,+Assistant+Secretary+for+Planning+and+Evaluation,+available+at++(last+visited+October+11,+2016).>Google Scholar
Buettgens, M., Health Insurance Policy Simulation Model (HIPSM) Methodology Documentation, The Urban Institute, December 2011, available at <http://www.urban.org/research/publication/health-insurance-policy-simulation-model-hipsm-methodology-documentation> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
Findings on the characteristics of the remaining uninsured here differ somewhat from those in our other recent work due to differences in data (Current Population Survey versus American Community Survey); differences in year of analysis (2015 versus 20106); the fact that the current work benchmarks to administrative data on enrollment in marketplaces and Medicaid, thereby adjusting for underreporting of public insurance, whereas the prior research did not; and the use of a simulation model in the current work rather than relying strictly on self-reported data. L. J. Blumberg, M. Karpman, M. Buettgens, and P. Solleveld, Who Are the Remaining Uninsured, and What Do Their Characteristics Tell Us About How to Reach Them? Robert Wood Johnson Foundation, March 2016, available at <http://www.rwjf.org/en/library/research/2016/03/who-arethe-remaining-uninsured--and-what-do-their-characteristi.html> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
Worker take-up of employer-sponsored insurance increased due to the ACA's individual mandate to obtain insurance coverage or pay a fine.Google Scholar
Blumberg, L. J., Holahan, J., and Buettgens, M., How Much Do Marketplace and Other Nongroup Enrollees Spend on Health-care Relative to Their Incomes, The Urban Institute, December 2015, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000559-How-Much-Do-Marketplace-and-Other-Nongroup-Enrollees-Spend-on-Health-Care-Relative-to-Their-Incomes.pdf> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
This last group includes those caught in the so-called “family glitch.” The ACA has been interpreted through regulation as prohibiting all family members from qualifying for marketplace premium tax credits if at least one member has an employer based insurance offer for single coverage with a direct worker contribution of less than 9.66 percent of income, regardless of the direct cost of family coverage.Google Scholar
See , Blumberg et al., supra note 7.Google Scholar
These include: prohibitions on lifetime and annual benefit limits, prohibitions on rescissions, first dollar coverage of in-network preventive care, utilization of uniform explanation of coverage documents and standardized definitions, requirements for appeals processes for claims denials, and extension of dependent coverage to adults under age 26.Google Scholar
See , Blumberg et al., supra note 4.Google Scholar
Many of these examples will apply to enrollees in the fully insured small group insurance market as well; however, extensions of ACA non-compliant plans through 2017 suggest that many of these individuals are still not enrolled in ACA compliant coverage.Google Scholar
See , Blumberg et al., supra note 7.Google Scholar
See , Buettgens, supra note 5.Google Scholar
Buettgens, M. and Kenney, G., What if More States Expanded Medicaid in 2017?Changes in Eligibility, Enrollment, and the Uninsured, The Urban Institute, July 2016, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000866-What-if-More-States-Expanded-Medicaid-in-2017-Changes-in-Eligibility-Enrollment-and-the-Uninsured.pdf> (last visited October 11, 2016).+(last+visited+October+11,+2016).>Google Scholar
Calculations based on The Cost of Not Expanding Medicaid using data for the following states that have yet to decide to expand Medicaid eligibility: Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming. See J. Holahan, M. Buettgens, and S. Dorn, The Cost of Not Expanding Medicaid, The Henry J. Kaiser Family Foundation, July 17, 2013, available at <http://kff.org/medicaid/report/the-cost-ofnot-expanding-medicaid/> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
Dreher, A., “Poll: Majority in State Support Medicaid Expansion, But the Legislature Doesn't,” Jackson Free Press, April 11, 2016, available at <http://www.jacksonfreepress.com/news/2016/apr/11/poll-majority-state-support-medicaid-expansion-leg/> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
Dentzer, B., “Bloc of Idaho Lawmakers Often Vote ‘No’ on Appropriations,” Idaho Statesman, April 25, 2016, available at <http://magicvalley.com/news/local/govt-and-politics/bloc-of-idaho-lawmakers-often-vote-no-on-appropriations/article_093938b5-f4b1-535b-8f8a-837c40f0db74.html> (last visited October 11, 2016); “Senator ‘Firm’ in Opposition to Medicaid Expansion,” Boonville Democrat, April 19, 2016, available at <http://boonevilledemocrat.com/news/senator-%E2%80%98firm%E2%80%99-opposition-medicaid-expansion.html> (last visited September 28, 2016).+(last+visited+October+11,+2016);+“Senator+‘Firm’+in+Opposition+to+Medicaid+Expansion,”+Boonville+Democrat,+April+19,+2016,+available+at++(last+visited+September+28,+2016).>Google Scholar
See , Holahan et al., supra note 18 and S. Dorn, J. Holahan, C. Carroll, and M. McGrath, Medicaid Expansion Under the ACA: How States Analyze the Fiscal and Economic Trade-Offs, The Urban Institute, June 13, 2013, available at, <http://www.urban.org/research/publication/medicaid-expansion-under-aca-how-states-analyze-fiscal-and-economic-trade-offs> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
According to a 2015 state survey conducted by the Kaiser Family Foundation, California, Colorado, Kentucky and Nevada reported they plan to increase provider taxes in order to fund some of the state share of expansion costs when the federal matching rate declines to 95% in 2017.Google Scholar
See , Holahan et al., supra note 18; Dorn et al., supra note 21.Google Scholar
Donovan, S. and Munoz, C., More than Halfway There: New Opportunities to Expand Medicaid and Level the Playing Field, White House blog, January 14, 2016, available at <https://www.whitehouse.gov/blog/2016/01/14/more-halfway-there-new-opportunities-expand-medicaid-and-level-playing-field> (last visited October 11, 2016).+(last+visited+October+11,+2016).>Google Scholar
Blumberg, L. and Holahan, J., After King v. Burwell: Next Steps for the Affordable Care Act, The Urban Institute, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000328-After-King-v.-Burwell-Next-Steps-for-the-Affordable-Care-Act.pdf> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar
Wishner, J. B., Holahan, J., Upadhyay, D., and McGrath, M., Medicaid Expansion, the Private Option, and Personal Responsibility Requirements: The Use of Section 115 Waivers to Implement Medicaid Expansion Under the ACA, The Urban Institute, May 2015, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000235-Medicaid-Expansion-The-Private-Option-and-Personal-Responsibility-Requirements.pdf> (last visited September 28, 2016).+(last+visited+September+28,+2016).>Google Scholar