Drawbacks and Aftermath of the Affordable Care Act: Ex-Ante Moral Hazard and Inequalities in Health Care Access

Abstract

Background: Following the introduction of the Affordable Care Act, various studies have tried to identify the effects of the reform, without reaching a clear consensus. The aim of this study was to investigate whether expansion of the Medicaid program has led to less inequality in access to health care and to a higher level of ex-ante moral hazard.Design and Methods: The analysis was conducted on two-year longitudinal data (2014-2015) regarding a cohort of 15,898 individuals from a Medical Expenditure Panel Survey (MEPS). After a data cleaning procedure, a sample of 9,255 individuals was selected for the inequality part of the study and 2,307 for the exante moral hazard analysis. Propensity score matching with nearest- neighbour and kernel matching algorithms, difference-in-difference models and concentration index, corrected according to Erreygers methodology, were adopted.Results: The analysis showed that disparities were reduced between social classes although the ex-ante moral hazard is a real problem with the Affordable Care Act since individuals covered by public insurance tended to abuse the public service. Among those who benefited from the Act, a reduction in preventive behaviours was observed: there was an increase in smoking and a decrease in level of physical activity. As far as concerns access to health care, there was a decrease in inequality in emergency visits, inability to get care and getting care when needed among beneficiaries of the reform.Conclusions: This study demonstrates that the extension of Medicaid has had a dual effect of reducing disparities in access to health care but, at the same time, it seems to have induced people to take less care of themselves. Significance for public health In the last years, the debate about the Affordable Care Act has been vigorous. For the first time, the US health system experienced a strong and revolutionary change with the introduction of a public programme into a previously totally private system. The debate about the consequences of this policy is open since the effects are unclear. The recent US presidential election proved the relevance of the debate. The analysis reported here is an attempt to add another piece to the puzzle, highlighting some critical aspects from a different point of view in a field that is still controversial.