Marketplace Coverage Research Articles

4498 The Effect of the Affordable Care Act on the Stage at Diagnosis in Low income Privately Insured Cancer Patients, including those with Marketplace coverage

OBJECTIVES/GOALS: The goal of this study was to examine the change in the odds of being diagnosed with metastatic cancer after the Affordable Care Act (ACA) among low-income, privately insured, nonelderly patients with newly diagnosed cancer. Low-income was defined as having income<250% FPL (federal poverty level). METHODS/STUDY POPULATION: Using Ohio cancer registry data linked with census tract-level income data, individuals aged 18-64 years diagnosed with one of the 15 leading cancers and reported being privately insured or uninsured were identified. Low-income patients were isolated using probability weighting, a process in which each observation was assigned a weight equal to the probability of a patient having an income <250% FPL based on the patient’s census tract of residence. Then, a multivariable logistic model was fitted to examine the independent association between the exposure (Post-ACA, years 2015-2016 versus Pre-ACA, years 2012-2013) and the outcome (metastatic versus non-metastatic disease at diagnosis). RESULTS/ANTICIPATED RESULTS: Between the Pre-ACA and Post-ACA periods, the percent uninsured in the low-income study population decreased from 14.1% to 4.5% (p <0.01). In the Post-ACA period, among those with insurance coverage, an estimated 11.7% of individuals had Marketplace coverage. After adjusting for potential confounders (sex, age, race-ethnicity, marital status, community-level income, rurality, and cancer type), individuals diagnosed Post-ACA had 5% lower odds of having metastatic disease relative to Pre-ACA (Adjusted Odds Ratio: 0.95, 95% Confidence Interval: 0.91 - 0.99, p = 0.04). DISCUSSION/SIGNIFICANCE OF IMPACT: The shift towards non-metastatic disease likely reflects increases to coverage brought on by the marketplaces. However, the shift is smaller than those observed in Medicaid enrollees, suggesting that policy refinements in the marketplaces can further improve outcomes in low-income cancer patients.

The Relationship Between Insurance Coverage and Use of Prescription Contraception by Race and Ethnicity: Lessons From the Affordable Care Act.

We describe contraception use by race and ethnicity before and after the Affordable Care Act (ACA) and assess the relationship between insurance coverage and prescription contraception use in both periods. Using data for women ages 15 to 45 at risk of unintended pregnancy from the 2006-2010 and 2015-2017 National Surveys of Family Growth, we examined changes in patterns of contraception use over time by race and ethnicity. We also examined changes in insurance coverage over the same period and considered how the relationship between insurance coverage and prescription contraception use has changed over time within each racial and ethnic group using both descriptive and multivariate regression methods. Before the ACA, Black and Hispanic women were less likely than White women to use prescription contraception by 13.2 and 9.9 percentage points, respectively. After the ACA Medicaid and Marketplace coverage expansions, all groups experienced a decrease in uninsurance, but only Black women experienced a significant increase in prescription contraception use. As a result, the post-ACA Black-White difference in prescription contraception use narrowed to 3.9 percentage points, and the Hispanic-White gap remained unchanged. Our results suggest that, despite significant declines in uninsurance under the ACA, there was no increase in use of prescription contraception for White or Hispanic women. Moreover, the decrease in uninsurance among Black women did not fully explain the large increase in use of prescription contraception for this population.

As Insurers Exit Affordable Care Act Marketplaces, So Do Consumers.

Insurer participation in the Marketplaces for individual health insurance has been lower than expected, with large declines among states using the HealthCare.gov platform for policy years 2017 and 2018. Using HealthCare.gov enrollment data, we examined how insurer exits from the Marketplaces affected consumers' decisions to reenroll-that is, to continue Marketplace participation-in policy years 2015-18. Insurer exit was associated with increased likelihood of consumer disenrollment from Marketplace coverage. The increase was twice as large for unsubsidized consumers (18.3 percentage points) than for consumers who received subsidies in the form of Advance Premium Tax Credits (8.7 percentage points) and was largely independent of premium increases measured using the lowest-cost silver plan available. However, premiums increased more in areas affected by insurer exits than in unaffected areas, contributing to increased disenrollment among unsubsidized consumers in policy years 2016-18. These findings suggest that maintaining insurer participation could encourage continued enrollment in the Marketplaces, while preserving competition to limit premium increases.

Options for Dialing Down From Single Payer.

There are formidable institutional obstacles to passing a single-payer health program in the United States. Advocates should consider incremental improvements that may better match legislative realities. There are three potential directions for incremental coverage policy.One possibility is to build on the successes of the Affordable Care Act; this might include rolling back regulatory changes, further incentivizing Medicaid expansion, enhancing coverage in the Affordable Care Act marketplaces, and imposing regulations on private employer-based insurance to ensure that all Americans have access to affordable coverage that provides adequate financial security. A second direction is to offer more publicly sponsored insurance options, which might involve offering a public option to those eligible for marketplace coverage, creating a Medicare or Medicaid buy-in program, lowering the eligibility age for Medicare, or developing a public plan that serves as a default for those who do not choose to buy alternative private coverage. A third direction is to build on federalism, offering states incentives to expand coverage.Federal and state legislators could also consider incremental cost-containment steps, such as rate setting.

Texas Arguments Lead Heavy ACA Action.

Arguments in Texas raise questions about the ACA's fate as enrollment holds steady and new state reinsurance waivers are approved.

Information Gaps and Health Insurance Enrollment: Evidence from Affordable Care Act Assister Programs

I study changes in health insurance coverage associated with a large government initiative to help people understand and compare their health insurance options. Funding for the initiative was not associated with increased rates of marketplace coverage, but was associated with increased uptake of free Medicaid coverage in expansion states. Novel data on the policy’s target population, people with low insurance literacy, show potential mechanisms: 69% had over-estimated the generosity of insurance, and 36% were income eligible for Medicaid but unaware. These findings demonstrate the importance of measuring the beliefs and characteristics of the targeted individuals when designing and evaluating policy.

Insurance-Based Disparities In Access, Utilization, And Financial Strain For Adults With Psychological Distress.

Limited provider participation within Medicaid and narrow provider networks on health insurance Marketplaces pose potential barriers to accessing and using the health care system for people with behavioral health needs. We compared employer-sponsored insurance, Medicaid, and Marketplace coverage for people with psychological distress across three domains of health care: access, utilization, and financial strain. We found evidence that adults with psychological distress reported greater difficulty accessing health care relative to those without such distress, regardless of insurance source. Among adults with psychological distress, Medicaid enrollees were more likely to use care and less likely to experience health-related financial strain than those enrolled in employer-sponsored insurance were. However, people with Marketplace coverage were more likely to experience barriers across all domains, relative to people with the other two coverage sources. Policy makers should be cognizant of the participation of providers within Medicaid and the Marketplaces and work to make network breadth more transparent.

Is the Affordable Care Act Affecting Retirement Yet?

We analyze whether the Affordable Care Act (ACA) has affected labor supply of older Americans using data that span more than four years after the policy’s implementation in 2014. We find no changes in labor supply of older Americans either in response to subsidized marketplace coverage, which became available nationally in 2014, or in response to the expansion of Medicaid eligibility in some states but not others. We analyze multiple dimensions of labor supply — labor force participation; employment; full-time work conditional on employment — as well as several measures of retirement including self-reported retirement and the receipt of retirement income. We fail to find labor supply effects even for subgroups with less than a high school education or those with fair or poor health, who might have been expected to have a greater labor supply response. The lack of a labor supply response stands in contrast to the large gains in coverage observed in 2014. These results suggest that for Americans approaching retirement the Affordable Care Act achieved its primary goal of increasing coverage without the unintended consequence of reducing labor supply.

Court Rules Individual Mandate, Entire ACA Unconstitutional.

The holiday season brought a potentially fatal blow to the Affordable Care Act, but enrollment remained steady, and the law remains in place.

Risk Factors for Early Disenrollment From Colorado's Affordable Care Act Marketplace.

Midyear disenrollment from Marketplace coverage may have detrimental effects on continuity of care and risk pool stability of individual health insurance markets. The main objective of this study was to assess associations between insurance plan characteristics, individual and area-level demographics, and disenrollment from Marketplace coverage. All payer claims data from individual market enrollees, 2014-2016. We estimated Cox proportional hazards models to assess the relationship between plan actuarial value and Marketplace enrollment. The primary outcome was disenrollment from Marketplace coverage before the end of the year. We also calculated the proportion of enrollees who transitioned to other coverage after leaving the Marketplace, and identified demographic and area-level factors associated with early disenrollment. Finally, we compared monthly utilization rates between those who disenrolled early and those who maintained coverage. Nearly 1 in 4 Marketplace beneficiaries disenrolled midyear. The hazard rate of disenrollment was 30% lower for individuals in plans receiving cost-sharing reductions and 21% lower for those enrolled in gold plans, compared with silver plans without cost-sharing subsidies. Young adults had a 70% increased hazard of disenrollment compared with older adults. Those who disenrolled midyear had greater hospital and emergency department utilization before disenrollment compared with those who maintained continuous coverage. Plan generosity is significantly associated with lower disenrollment rates from Marketplace coverage. Reducing churning in Affordable Care Act Marketplaces may improve continuity of care and insurers' ability to accurately forecast the health care costs of their enrollees.

Universal Health Care: Lessons From San Francisco.

The San Francisco Health Care Security Ordinance is the country's only local law designed to promote universal health care. It provides access to health services for the uninsured while requiring employers to contribute financially toward employees' health care costs. Enrollment in Healthy San Francisco, a program for the uninsured that is one component of the ordinance, fell significantly after the Affordable Care Act extended other types of coverage. Healthy San Francisco continues as a major source of care for undocumented people. Many other California counties have programs that provide at least some nonemergency care to undocumented residents, which demonstrates the versatility of this approach for localities. San Francisco employer contributions also fund medical reimbursement accounts that help insured people pay their health costs, including through a program added in 2016 to make Marketplace insurance more affordable. The city's experiences show that programs to help people pay for private coverage should be simple and include strong outreach and education and that the affordability of Marketplace coverage would be most easily addressed at the state level.

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

Descriptive studies have suggested that the Affordable Care Act's (ACA's) health insurance Marketplaces improved access to care. However, no evidence from quasi-experimental studies is available to support these findings. We used longitudinal survey data to compare previously uninsured adults with incomes that made them eligible for subsidized Marketplace coverage (138-400percent of the federal poverty level) to those who had employer-sponsored insurance before the ACA with incomes in the same range. Among the previously uninsured group, the ACA led to a significant decline in the uninsurance rate, decreased barriers to medical care, increased the use of outpatient services and prescription drugs, and increased diagnoses of hypertension, compared to a control group with stable employer-sponsored insurance. Changes were largest among previously uninsured people with incomes of 138-250percent of poverty, who were eligible for the ACA's cost-sharing reductions. Our quasi-experimental approach provides rigorous new evidence that the ACA's Marketplaces led to improvements in several important health care outcomes, particularly among low-income adults.

Simulating Variation in Families' Spending across Marketplace Plans.

To examine variations in premium and cost-sharing across marketplace plans available to eligible families. 2011-2012 Medical Expenditure PanelSurvey (MEPS), 2014 health plan data from healthcare.gov, and the 2011 Medicare Part D public formulary file. We identified a nationally representative cohort of individuals in the MEPS who would have been eligible for marketplace coverage. For each family, we simulated the total out-of-pocket payment (premium plus cost-sharing) under each available plan in their county of residence, assuming their premarketplace use. Confidential state and county of residence identifiers were merged onto MEPS public use files and used to match MEPS families to the plans available in their county as reported in the publicly available data from healthcare.gov. We found substantial variation in total family health care spending, especially premium component, across marketplace plans. This is true even within a plan tier of the same minimum actuarial value, and for families eligible for subsidies. Variation among families with income below 250 percent of the FPL is larger than variation among families with higher income. Our simulations show substantial variations in net premium and out-of-pocket payments across marketplace plans, even within a plan tier.

New Risk-Adjustment Policies Reduce But Do Not Eliminate Special Enrollment Period Underpayment.

Millions of uninsured Americans do not sign up for available coverage despite job loss or other factors that would make them eligible for special enrollment periods (SEPs). Such periods let people enroll in nongroup insurance outside the usual open enrollment period for Marketplace coverage. Concerned that risk adjustment results in underpayment for the health risks associated with SEP enrollees, carriers rarely market their products to consumers eligible for SEPs, and many do not pay agents and brokers to enroll such consumers. To address the apparent underpayments, federal officials added enrollment duration factors that, starting in 2017, increased risk scores for SEP enrollees and other part-year members. Using individual-market claims data for 2015 from two large carriers, we found that risk adjustment did, in fact, undercompensate plans for part-year members. However, underpayment was much larger for SEP enrollees than for part-year members who joined during open enrollment periods. Short-term, urgent health problems appeared to drive enrollment more for SEP enrollees than for part-year members who signed up during open enrollment. We also found that the federal government's enrollment duration factors will remedy underpayment for part-year members whose coverage begins during open enrollment but leave carriers significantly underpaid for SEP enrollees. For carriers to recruit rather than avoid SEP enrollees, further increases to risk adjustment for such enrollees are likely needed.

Medicaid Versus Marketplace Coverage For Near-Poor Adults: Effects On Out-Of-Pocket Spending And Coverage.

In states that expanded Medicaid eligibility under the Affordable Care Act, nonelderly near-poor adults-those with family incomes of 100-138percent of the federal poverty level-are generally eligible for Medicaid, with no premiums and minimal cost sharing. In states that did not expand eligibility, these adults may qualify for premium tax credits to purchase Marketplace plans that have out-of-pocket premiums and cost-sharing requirements. We used data for 2010-15 to estimate the effects of Medicaid expansion on coverage and out-of-pocket expenses, compared to the effects of Marketplace coverage. For adults with family incomes of 100-138percent of poverty, living in a Medicaid expansion state was associated with a 4.5-percentage-point reduction in the probability of being uninsured, a $344 decline in average total out-of-pocket spending, a 4.1-percentage-point decline in high out-of-pocket spending burden (that is, spending more than 10percent of income), and a 7.7-percentage-point decline in the probability of having any out-of-pocket spending relative to living in a nonexpansion state. These findings suggest that policies that substitute Marketplace for Medicaid eligibility could lower coverage rates and increase out-of-pocket expenses for enrollees.

Marketplace Coverage and Limited Access to Care Among Employed Beneficiaries? Evidence From Ohio.

This article examines the initial effect of Affordable Care Act (ACA) Health Insurance Marketplace (Exchange) insurance on access to care among employed beneficiaries in a highly populated US state. Does Exchange insurance lead to better/worse health care access for employed beneficiaries, compared with similar individuals covered through standard employer-sponsored insurance (ESI) coverage? This retrospective study uses data from the 2015 Ohio Medicaid Assessment Survey, a dual-frame and computer-assisted telephone survey administered by the Ohio Colleges of Medicine Graduate Resource Center, the Ohio Department of Medicaid, the Ohio Department of Health, and Ohio State University, in conjunction with RTI International. This study examines a sub-sample of employed adults (age 18-64) covered by either an Exchange plan or ESI, extracted from the full sample of n = 42 876. We use linear propensity score matching using Euclidean distance to balance treatment groups and logistic regression models to estimate the treatment effect of Exchange coverage on all outcome variables. McNemar tests, Rosenbaum sensitivity analysis, and Benjamini-Hochberg procedure adjustments are also conducted. Compared with ESI insurance, Exchange insurance has no significant effect on outcomes measuring either perceived access to care or, more specifically, perceived financial barriers to accessing care. Exchange plan viability remains a hot topic of debate across the United States, given the potential repeal of the individual mandate. We use risk-adjustment methods to demonstrate that Exchange plan beneficiaries do not experience worse access to care than ESI beneficiaries. That said, several key limitations are discussed.

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

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 100-138percent 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.

Do individuals respond to cost-sharing subsidies in their selections of marketplace health insurance plans?

The Affordable Care Act (ACA) provides assistance to low-income consumers through both premium subsidies and cost-sharing reductions (CSRs). Low-income consumers’ lack of health insurance literacy or information regarding CSRs may lead them to not take-up CSR benefits for which they are eligible. We use administrative data from 2014 to 2016 on roughly 22 million health insurance plan choices of low-income individuals enrolled in ACA Marketplace coverage to assess whether they behave in a manner consistent with being aware of the availability of CSRs. We take advantage of discontinuous changes in the schedule of CSR benefits to show that consumers are highly sensitive to the value of CSRs when selecting insurance plans and that a very low percentage select dominated plans. These findings suggest that CSR subsidies are salient to consumers and that the program is well designed to account for any lack of health insurance literacy among the low-income population it serves.

The availability and marginal costs of dependent employer-sponsored health insurance.

In this study, we examine differences by firm size in the availability of dependent coverage and the incremental cost of such coverage. We use data from the Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) to show that among employees eligible for single coverage, dependent coverage was almost always available for employees in large firms (100 or more employees) but not in smaller firms, particularly those with fewer than 10 employees. In addition, when dependent coverage was available, eligible employees in smaller firms were more likely than employees in large firms to face two situations that represented the extremes of the incremental cost distribution: (1) they paid nothing for single or family coverage or (2) they paid nothing for single coverage but faced a high contribution for family coverage. These results suggest that firm size may be an important factor in policy assessments, such as analyses of the financial implications for families excluded from subsidized Marketplace coverage due to affordable offers of single coverage or of potential rollbacks to public coverage for children.

Most Newly Insured People In 2014 Were Long-Term Uninsured.

In 2014-after the implementation of most of the Affordable Care Act provisions, including Medicaid expansions in some states and subsidies to purchase Marketplace coverage in all states-adults who had been uninsured for more than three years represented a larger share of the newly insured, compared to adults who had been insured for shorter periods of time.