Who Entered and Exited the Individual Health Insurance Market Before and After the Affordable Care Act? Evidence from the Medical Expenditure Panel Survey.

Issue: The Affordable Care Act (ACA) made it easier for older adults and those with medical conditions to enroll in individual-market coverage by eliminating risk rating and limiting age rating. While the ACA also encourages young and healthy people to enroll through subsidies and the individual mandate, it's not clear whether these incentives have been sufficient to prevent the risk pool from becoming disproportionately old and sick. Goal: To assess whether patterns in individual-market participation changed following ACA implementation. Methods: Comparison of Medical Expenditure Panel Survey (MEPS) data for the periods 2003­09 and 2014­15. Findings and Conclusion: The analysis found few differences in individual-insurance market participation before and after the ACA. Adverse selection occurred during both: people switching into individual insurance coverage after being uninsured were higher utilizers prior to the switch than were those who remained uninsured. Those who disenrolled from individual plans tended to be lower utilizers of care before switching compared with those who kept their coverage. The main difference was that more people--especially young adults--switched from Medicaid to individual insurance, and vice versa, after the ACA. Adverse enrollment or disenrollment in the individual market did not increase following ACA implementation. The combination of easing rating rules and encouraging participation appears to have maintained market stability.

How Would Americans' Out-of-Pocket Costs Change If Insurance Plans Were Allowed to Exclude Coverage for Preexisting Conditions?

Issue: A current Republican legislative proposal would permit insurers to offer plans that exclude coverage of treatment for preexisting health conditions, even while the bill would maintain the Affordable Care Act's rule prohibiting denial of coverage to people with a preexisting condition. Goal: Estimate patients' out-of-pocket costs for five common preexisting conditions if the bill were to become law and assess any additional impact on out-of-pocket expenditures if spending on care for preexisting conditions no longer counted against plan deductibles. Methods: Analysis of 2014­2016 Medical Expenditure Panel Survey data for the privately insured adult population under age 65; and the proposed Ensuring Coverage for Patients with Pre-Existing Conditions Act (S. 3388). Findings and Conclusion: If preexisting conditions were excluded from coverage, nearly all people with these conditions would see increased out-of-pocket costs. Average out-of-pocket costs for those with cancer or diabetes would triple, while costs for arthritis, asthma, and hypertension care would rise by 27 percent to 39 percent. Some individuals would see much larger increases: for example, 10 percent of diabetes patients could expect to incur over $9,200 annually in out-of-pocket costs. Many with preexisting conditions also would spend more on conditions that are not excluded, since out-of-pocket spending on their preexisting conditions would no longer count toward the deductible and out-of-pocket maximum.

The Potential Implications of Work Requirements for the Insurance Coverage of Medicaid Beneficiaries: The Case of Kentucky.

Issue: With encouragement from the Trump administration, 14 states have received approval for or are pursuing work requirements for nondisabled Medicaid beneficiaries. The requirements have sparked controversy, including two legal challenges. Goal: To predict the effect of work requirements on the insurance coverage of Medicaid enrollees over time. Methods: Analysis of the coverage patterns of a national cohort of nondisabled adults in the federal Medical Expenditure Panel Survey. Their experience is applied to a similar cohort of adults in Kentucky (which has received approval for work requirements, subject to a legal challenge) to project the potential effects of work requirements on their insurance coverage. Findings and Conclusions: Adding a new administrative hurdle in the form of work requirements in Kentucky would double the number of enrollees who disenroll from the program over a two-year period. We estimate that as many as 118,000 adults enrolled in Medicaid would either become uninsured for an extended period of time or experience a gap in insurance over a two-year period. These findings should be of concern to policymakers: research has found that adults who experience coverage gaps report problems getting health care or paying medical bills at rates nearly as high as those who are uninsured continuously.

Access to Coverage and Care for People with Preexisting Conditions: How Has it Changed Under the ACA?

ISSUE: Prior to the Affordable Care Act (ACA), people with preexisting health conditions could be denied insurance coverage or charged higher rates. If the law is repealed, these protections could be diluted or lost altogether. GOALS: Assess the ACA's impact on coverage and access for people with preexisting conditions and compare their coverage gains with state high-risk-pool enrollment pre-ACA. METHODS: Analysis of Behavioral Risk Factor Surveillance System data for the period 2011­13 to 2015. KEY FINDINGS AND CONCLUSIONS: Between 2013 and 2015, 16.5 million nonelderly adults gained coverage following full ACA implementation. Of those, 2.6 million had preexisting conditions that could have otherwise precluded them from coverage because of discriminatory denials and pricing; 9.4 million had conditions that could have otherwise affected insurance cost. We found strong correlations between these coverage gains and access to care. Coverage and access gains for people with preexisting conditions were unrelated to the size or existence of the state high-risk pools that 35 states funded for such individuals pre-ACA. Our findings suggest that proposals to replace current protections for people with preexisting conditions with high-risk pools are unlikely to be sufficient to maintain the ACA's gains.

The Future of the Affordable Care Act and Insurance Coverage.

We describe the patterns of coverage gains associated with the Affordable Care Act (ACA) expansions and use these patterns to assess the potential impact of alternative repeal or repeal and replace strategies because Congress and the president are weighing options to repeal or replace the ACA. We find that specific provisions of the ACA, including the Medicaid expansion and the structure of premium subsidies, have been associated with large and robust gains in insurance coverage. We evaluate the impact of retaining dependent coverage and high-risk pool provisions and show, on the basis of the ACA experience, that these provisions would have little effect on coverage. We find that many replacement proposal components, including flat tax credits and maintaining cost savings provisions, could jeopardize the ability of many of the ACA's primary beneficiaries, as well as other Americans, to access coverage and care. By leading to a deterioration of the safety net, these strategies could also imperil population health activities.