The impact of the repeal of the federal individual insurance mandate on uninsurance.

The federal individual mandate of the Affordable Care Act, which required people to pay a tax penalty if they did not have health insurance, was repealed in 2019. However, some states implemented state-level insurance mandates which essentially replaced the federal mandate. I use nationally representative survey data from the 2015-19 Annual Social and Economic Supplement to the Current Population Survey to compare the probability of becoming newly uninsured among people living in states without state-level insurance mandates versus states with a mandate, before and after the 2019 repeal. In a sample of 214,821 lower-income, nonelderly adults, the repeal of the federal mandate was associated with a 0.5% point, or 24%, increase in the year-over-year probability of becoming newly uninsured. These results suggest that people respond to financial incentives when making insurance enrollment decisions. In the absence of a federal mandate, state-level mandates may reduce transitions to uninsurance.

State versus federal health insurance marketplaces: A bigger deal for Medicaid and a smaller deal for the individual mandate.

States retain significant power over key components of Affordable Care Act implementation. Using data from the US Census from 2010 to 2018, we examine how states' decisions to either establish state-run marketplaces or to default to the federal marketplace influenced the distribution of health insurance types within states. We find, somewhat counterintuitively, that state-based marketplaces are associated with greater change in enrollment for Medicaid compared to the federal marketplace. These findings confirm that, at least until 2018, the most significant increases in insurance coverage resulting from the ACA were in public insurance, rather than private insurance. We explore a number of possible explanations to help explain these findings, raising important questions about the efficacy of the individual mandate (a key mechanism in legislative efforts to reduce the numbers of uninsured), the related administrative burdens associated with state and federal marketplaces, and, equally as important, differential access to Medicaid entitlements among citizens living in different states-access that hinges not only or always on Medicaid expansion, but also and perhaps more importantly, on policy decisions about insurance marketplaces.

Contraceptive Mandate, ACA Final Rules, And COVID-19.

The Supreme Court upheld broad exemptions to the Affordable Care Act contraceptive mandate; new ACA rules were finalized.

The ACA Turns 10: Reflections Of Four Industry Leaders.

These leaders celebrate the ACA's successes, reflect on its shortcomings, and explain the politics that led to passage of the landmark act.

The ACA's Individual Mandate In Retrospect: What Did It Do, And Where Do We Go From Here?

The Affordable Care Act required most people to obtain health insurance or pay a tax penalty. Legislation enacted in December 2017 effectively repealed that requirement, starting in 2019. This article reviews recent research on the mandate's effects, concluding that the mandate meaningfully increased insurance coverage, but likely by less than was projected before implementation. These coverage gains are likely to erode as mandate repeal takes hold. Looking ahead, policy makers have many options for expanding insurance coverage without restoring an individual mandate. However, achieving universal coverage without some form of mandatory individual contribution to health insurance would have a very large fiscal cost.

Putting The Pieces Together Again: American States and the End of the ACA's Shared Responsibility Payment.

The Tax Cuts and Jobs Act (TCJA) eliminated the ACA's "shared responsibility payment," which penalized those who failed to comply with the requirement to purchase health insurance. In this article the authors explain efforts in several states to respond to this change by adopting individual health insurance mandates at the state level. Although there are good reasons to think that states may be reluctant to consider establishing their own mandates, New Jersey, the District of Columbia, and Vermont quickly joined Massachusetts in establishing such measures in 2018. In 2019 California and Rhode Island enacted state-level mandates. Four other states-Maryland, Connecticut, Hawaii, and Washington-formally considered mandates but have not enacted them. The authors compare the policy debates among these states and one other state, New York, which has not seen a legislative proposal for a mandate despite its strong support for the ACA. Their analysis explores the dynamics within the US federal system when a key component of a complex and politically salient national initiative is eliminated and states are left with many policy, political, and administrative questions of what to do next.

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.

Demand for health insurance: Evidence from the California and Washington ACA exchanges.

I estimate demand for health insurance using consumer-level data from the California and Washington ACA exchanges. I use the demand estimates to simulate the impact of policies targeting adverse selection, including subsidies and the individual mandate. I find (1) own-premium elasticities of -7.2 to -10.6 and insurance coverage elasticities of -1.1 to -1.2; (2) limited response to the mandate penalty amount, but significant response to the penalty's existence, suggesting consumers have a "taste for compliance"; (3) mandate repeal slightly increases consumer surplus because the ACA's price-linked subsidies shield most consumers from premium increases resulting from repeal and some consumers are not compelled to purchase insurance against their will; and (4) mandate repeal decreases consumer surplus if ACA subsidies are replaced with vouchers that expose consumers to premium increases. The economic rationale for the mandate depends on the extent of adverse selection and the presence of other policies targeting selection.

The Affordable Care Act's insurance market regulations' effect on coverage.

Much of the debate surrounding reform of the Patient Protection and Affordable Care Act (ACA) revolves around its insurance market regulation. This paper studies the impact on health insurance coverage of those provisions. Using data from the American Community Survey, years 2008-2015, I focus on individuals, ages 26 to 64, who are ineligible for the subsidies or Medicaid expansions included in the ACA to isolate the effect of its market regulation. To account for time trends, I utilize a differences-in-differences approach with a control group of residents of Massachusetts who were already subject to a similarly regulated health insurance market. I find that the ACA's regulations caused an increase of 0.95 percentage points in health insurance coverage for my sample in 2014. This increase was concentrated among younger individuals, suggesting that the law's regulations ameliorated adverse selection in the individual health insurance market.

Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act.

Using premium subsidies for private coverage, an individual mandate, and Medicaid expansion, the Affordable Care Act (ACA) has increased insurance coverage. We provide the first comprehensive assessment of these provisions' effects, using the 2012-2015 American Community Survey and a triple-difference estimation strategy that exploits variation by income, geography, and time. Overall, our model explains 60% of the coverage gains in 2014-2015. We find that coverage was moderately responsive to price subsidies, with larger gains in state-based insurance exchanges than the federal exchange. The individual mandate's exemptions and penalties had little impact on coverage rates. The law increased Medicaid among individuals gaining eligibility under the ACA and among previously-eligible populations ("woodwork effect") even in non-expansion states, with no resulting reductions in private insurance. Overall, exchange premium subsidies produced 40% of the coverage gains explained by our ACA policy measures, and Medicaid the other 60%, of which 1/2 occurred among previously-eligible individuals.

Risk selection and heterogeneous preferences in health insurance markets with a public option.

Conventional wisdom suggests that if private health insurance plans compete alongside a public option, they may endanger the latter's financial stability by cream-skimming good risks. This paper argues that two factors may contribute to the extent of cream-skimming: (i) degree of horizontal differentiation between public and private options when preferences are heterogeneous; (ii) whether contract design encourages choice of private insurance before information about risk is revealed. I explore the role of these factors empirically within the unique institutional setting of the German health insurance system. Using a fuzzy regression discontinuity design to disentangle adverse selection and moral hazard, I find no compelling support for extensive cream-skimming of public option by private insurers despite their ability to fully underwrite risk. A model of demand for private insurance supports the idea that heterogeneity in non-pecuniary preferences and long-term structure of private insurance contracts may be muting cream-skimming in this setting.

Mandate-based health reform and the labor market: Evidence from the Massachusetts reform.

We model the labor market impact of the key provisions of the national and Massachusetts "mandate-based" health reforms: individual mandates, employer mandates, and subsidies. We characterize the compensating differential for employer-sponsored health insurance (ESHI) and the welfare impact of reform in terms of "sufficient statistics." We compare welfare under mandate-based reform to welfare in a counterfactual world where individuals do not value ESHI. Relying on the Massachusetts reform, we find that jobs with ESHI pay $2812 less annually, somewhat less than the cost of ESHI to employers. Accordingly, the deadweight loss of mandate-based health reform was approximately 8 percent of its potential size.