Effects of state reinsurance programs on health insurance exchange premiums and insurer participation.

OBJECTIVE: The aim of the study was to estimate the effect of the state-based reinsurance programs through the section 1332 State Innovation Waivers on health insurance marketplace premiums and insurer participation. DATA SOURCE: 2015 to 2022 Robert Wood Johnson Foundation Health Insurance Exchange Compare Datasets. STUDY DESIGN: An event study difference-in-differences (DD) model separately for each year of implementation and a synthetic control method (SCM) are used to estimate year-by-year effects following program implementation. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Reinsurance programs were associated with a decline in premiums in the first year of implementation by 10%-13%, 5%-19%, and 11%-17% for bronze, silver, and gold plans (p < 0.05). There is a trend of sustained declines especially for states that implemented their programs in 2019 and 2020. The SCM analyses suggest some effect heterogeneity across states but also premium declines across most states. There is no evidence that reinsurance programs affected insurer participation. CONCLUSION: State-based reinsurance programs have the potential to improve the affordability of health insurance coverage. However, reinsurance programs do not appear to have had an effect on insurer participation, highlighting the need for policy makers to consider complementary strategies to encourage insurer participation.

Effects of the Affordable Care Act Medicaid Expansions on Mental Health During the COVID-19 Pandemic in 2020-2021.

To examine whether previous Affordable Care Act (ACA) Medicaid expansions had an added effect on the mental health of low-income adults during the COVID-19 pandemic in 2020 and 2021. We use the 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data. We use an event study difference-in-differences model to compare the number of days in poor mental health in the past 30 days and the likelihood of frequent mental distress among 18 to 64 year old individuals with household incomes below 100% of the federal poverty level who participated in BRFSS in one of the surveys from 2017 to 2021 and who resided in states that expanded Medicaid by 2016 or states that had not expanded by 2021. We also examine the heterogeneity of the expansion effects across subpopulation groups. We find some evidence that the Medicaid expansion was associated with better mental health during the pandemic for adults younger than 45, females, and non-Hispanic Black and other non-Hispanic non-White individuals. There is some evidence of an added benefit to mental health from Medicaid expansion status during the pandemic for some subgroups among low-income adults, suggesting potential health benefits from Medicaid eligibility during public health and economic crises.

The Affordable Care Act's "community first choice" option: Effect on long-term care expenditures.

OBJECTIVE: To empirically assess the effect of adopting Affordable Care Act's Community First Choice (CFC) option on overall state home and community-based services (HCBS) expenditures as well as distribution of HCBS expenditures across different HCBS mechanisms. We also explore the heterogeneous effect of CFC across adopting states. DATA SOURCE: We used data from the Medicaid Long Term Services and Support (LTSS) expenditure reports prepared by Truven Analytics and Mathematica for the Centers for Medicare & Medicaid Services from 2008-2018 for all 48 states and the District of Columbia. STUDY DESIGN: An event-study difference-in-differences model was used to estimate the effect of CFC on HCBS expenditures using Medicaid LTSS expenditure reports from 2008-2018. We also employ the synthetic control method to unmask heterogeneity across CFC adopting states using data from 2008-2018. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Overall, CFC was not associated with a change in HCBS expenditures per capita or HCBS expenditures as a proportion of LTSS expenditures. However, there appears to be an increase in HCBS expenditures among states that were institutionally-oriented prior to CFC adoption. Additionally, CFC adoption was associated with an overall decrease in expenditures in alternative HCBS mechanisms (Personal Care Services State Plan Option and 1915(c) waivers), suggesting potential substitution across overlapping programs. CONCLUSION: Results indicate heterogeneity across states adopting CFC. More institutionally-oriented states appear to use CFC to expand HCBS. In contrast, more HCBS-oriented states appear to employ CFC to strategically restructure their overall portfolio and processes.

Effects of Repealing the ACA Individual Mandate Penalty on Insurance Coverage and Marketplace Enrollment: Evidence From State Mandates in Massachusetts and New Jersey.

BACKGROUND: Congress eliminated the individual mandate penalty of the Affordable Care Act (ACA) effective January 1, 2019. OBJECTIVE: To examine the effects of repealing the ACA mandate penalty on private health insurance coverage and marketplace enrollment by leveraging state-based mandates in Massachusetts and New Jersey. RESEARCH DESIGN: We employ synthetic control and difference-in-differences methods to compare insurance and enrollment changes separately in Massachusetts and New Jersey, which had insurance mandates effective in 2019, to other states without such mandates. SUBJECTS: Adults aged 18-64 years with income of 150-300% and above 300% of the Federal Poverty Level who participated in the 2016-2019 American Community Survey (ACS) and adults aged 18-64 enrolled in insurance marketplaces based on state-level data from the 2016-2021 Marketplace Open Enrollment Period Public Use Files (MOEP-PUF). MEASURES: Any insurance, individually purchased coverage, and employer-sponsored coverage from the ACS and marketplace enrollment from the MOEP-PUF. RESULTS: Changes in any coverage, individually purchased coverage, and employer-sponsored coverage rates are relatively small (generally in the range of 1-2 percentage points) and statistically nonsignificant in both Massachusetts and New Jersey compared with states without mandates. Furthermore, there is no discernable difference by eligibility for marketplace subsidies based on income level in the ACS data. Similarly, estimates for changes in marketplace enrollment are also small overall and statistically nonsignificant. CONCLUSION: Private insurance coverage rates and marketplace enrollment for adults 18-64 do not appear to have changed thus far owing to the 2019 repeal of the ACA individual mandate penalty.

Trends in Hospital System Affiliation, 2007-2016.

Purpose: This policy brief updates a RUPRI Center brief published in 20141 and documents the continued growth in system affiliation by both metropolitan and non-metropolitan hospitals. Key Findings: (1) From 2007 to 2016, hospital system affiliation continued to increase across all categories of hospital size, metropolitan/non-metropolitan location, and Critical Access Hospital (CAH)status. (2) From 2007 to 2016, hospital system affiliation increased in all census regions except in the West census region among non-metropolitan hospitals.