Does the Individual Mandate Affect Insurance Coverage? Evidence from Tax Returns

We estimate the effect of the ACA’s individual mandate on insurance coverage using regression discontinuity and regression kink designs with tax return data. We have four key results. First, the actual penalty paid per uninsured month is less than half the statutory amount. Second, nonetheless, we find visually clear and statistically signifi-cant responses to both extensive margin exposure to the mandate and to marginal increases in the mandate penalty. Third, we find substantial heterogeneity in who responds; men are especially responsive. Fourth, our estimates imply fairly small quantitative responses to the individual mandate, especially in the Health Insurance Exchanges. (JEL G22, H24, H51, I13, I18)

Have the ACA's Exchanges Succeeded? It's Complicated

The fight over health insurance exchanges epitomizes the rapid evolution of health reform politics in the decade since the passage of the Affordable Care Act (ACA). The ACA's drafters did not expect the exchanges to be contentious because they would expand private insurance coverage to low- and middle-income individuals who were increasingly unable to obtain employer-sponsored health insurance. Instead, exchanges became one of the primary fronts in the war over Obamacare. Have the exchanges been successful? The answer is not straightforward and requires a historical perspective through a federalism lens. What the ACA has accomplished has depended largely on whether states were invested in or resistant to implementation, as well as individual decisions by state leaders working with federal officials. Our account demonstrates that the states that have engaged with the ACA most consistently appear to have experienced greater exchange-related success. But each aspect of states' engagement with or resistance to the ACA must be counted to fully paint this picture, with significant variation among states. This variation should give pause to those considering next steps in health reform, because state variation can mean innovation and improvement but also lack of coverage, disparities, and diminished access to care.

Screening in Contract Design: Evidence from the ACA Health Insurance Exchanges

We study insurers’ use of prescription drug formularies to screen consumers in the ACA Health Insurance exchanges. We begin by showing that exchange risk adjustment and reinsurance succeed in neutralizing selection incentives for most, but not all, consumer types. A minority of consumers, identifiable by demand for particular classes of prescription drugs, are predictably unprofitable. We then show that contract features relating to these drugs are distorted in a manner consistent with multidimensional screening. The empirical findings support a long theoretical literature examining how insurance contracts offered in equilibrium can fail to optimally trade off risk protection and moral hazard. (JEL D82, G22, H51, I13, I18)

Adverse Selection in ACA Exchange Markets: Evidence from Colorado

This study tests for adverse selection in the Affordable Care Act (ACA) health insurance exchanges established in 2014, and quantifies the welfare consequences. Using a new statewide dataset of medical claims from Colorado, I use plausibly exogenous premium variation generated by geographic discontinuities to test for selection. Specifically, each $1 increase in monthly premiums causes a $0.85–0.95 increase in annual medical expenditures of the insured population in 2014, with attenuated effects in 2015. These estimates are consistent with the prevalence of chronic conditions, and difference-in-differences estimates. The results offer the first quasi-experimental evidence of adverse selection in the ACA markets. (JEL D82, G22, H51, H75, I13, I18)

Federalism and Public Opinion on Healthcare: The Design of the Affordable Care Act’s Insurance Exchanges and User Experience with the Exchanges

Using original survey data and the 2016 American National Election Study (ANES), we examine the effects of healthcare exchange type and user experience on individuals’ support for the Affordable Care Act (ACA). States are divided into three different types of ACA exchange implementation regimes: state-run exchanges, federally operated exchanges, and mixed state-federal exchanges. We hypothesize that individuals in states running their own exchanges will demonstrate greater support for the ACA and individuals with experience using the exchanges will exhibit greater levels of support for the ACA. Results from a survey conducted in 2016 in Alabama (a federal exchange), Kentucky (a state exchange at the time), and Arkansas (a mixed state-federal exchange) support these hypotheses. These findings are also confirmed using national data from the ANES. We therefore provide evidence that local control over healthcare implementation leads to better outcomes in terms of citizen satisfaction and that citizens who have experience with exchanges established by the ACA are more likely to feel positively about the law.

3371 The Devil is in the Details: Unbalanced Gains in Healthcare Access and Affordability in the Health Insurance Exchanges

OBJECTIVES/SPECIFIC AIMS: Evaluate how access and affordability has changed before and after the implementation HIEs in three subpopulations. The subpopulations are individuals who are currently insured through the HIE but were previously: 1. Insured through Employment-based insurance (PEBI subpopulation) 2. Insured through Private Insurance (PPI subpopulation) and 3. Uninsured (PU subpopulation). The three access and affordability measures are: Outcome measure 1. Did not fill a prescription in the past year due to cost Outcome measure 2. Could not get needed medical exam in the past year due to cost and Outcome measure 3. Had problems paying medical bills in the past year. METHODS/STUDY POPULATION: We analyzed the de-identified public use data from the 2012 and 2015 Ohio Medicaid Assessment Survey (OMAS). Sponsored by the Ohio Department of Medicaid, Ohio Department of Health, and the Ohio State University, the OMAS is a representative cross-sectional survey of non-institutionalized Ohio residents, regardless of their Medicaid status. In order to “longitudinalize” the 2012 and 2015 cross-sectional data of the OMAS, we employed a propensity score-based approach. We started with the 2015 OMAS, and carefully characterized each of the PEBI, PPI, and PU subpopulations along 17 demographic, health utilization, health behavior, and health status covariates using a propensity score model. Then, we identified controls for the three subpopulations within the 2012 OMAS data using the propensity scores. Finally, we estimated the odds ratios for the three outcome measures between 2012 and 2015. RESULTS/ANTICIPATED RESULTS: In 2015 there were approximately 201,381 adults (unweighted count = 996) who were insured through the HIE in Ohio. Of those individuals, 17.7% fell into the PEBI subpopulation, 17.6% fell into the PPI subpopulation, and 53.3% fell into the PU subpopulation; the balance of the respondents (11.4%) reported previously having Medicaid, or “Other” insurance. There are several key differences in the covariates at baseline between the three subpopulations. In general, the PU subpopulation tended to younger, more minority, more socioeconomically disadvantaged, and more likely to not have a primary care provider compared to both the PEBI and PPI subpopulations. In the 2012 data, we were able to identify 170 controls for the PEBI subpopulation, 167 controls for the PPI subpopulation, and 516 controls for the PU subpopulation. Compared to 2012, in 2016 (after the implementation of the HIEs):. Outcome measure 1: The PEBI subpopulation was more likely to report not filling a prescription in the past year due to cost (there were no significant changes in the PPI or PU subpopulations). Outcome measure 2: The PEBI subpopulation was more likely to report not getting a needed medical exam or medical supplies in the past year due to cost. The PPI subpopulation was less likely to report not getting a needed medical exam or medical supplies in the past year due to cost. There were no significant changes for the PU subpopulation for this outcome measure. Outcome measure 3: There were no changes in the “had problems paying medical bill in the past year” outcome across the three subpopulations. DISCUSSION/SIGNIFICANCE OF IMPACT: This is among the most detailed studies of health insurance exchanges known to the investigators. Analyzing outcomes at the subpopulation level illustrates that there have been unbalanced gains in access and affordability as a result of the HIEs. In general, those who were previously insured through employer-based insurance saw their access and affordability decrease; those previously insured through private insurance saw modest increases to access and affordability; and perhaps most surprising, those that were previously uninsured saw no changes to their access and affordability. Future studies will incorporate 2017 OMAS data (when it becomes available) to see if these trends persist over time. During this time of rapid health systems and health policy change, our study adds an important contribution to the discussion surrounding how to best deliver highly effective and efficient health care.

Introduction

The Affordable Care Act (ACA) is the most significant health reform legislation enacted in generations. However, politics does not end after a bill is signed into law. This chapter outlines why states were given such a prominent role in the implementation of core elements of the ACA, including the health insurance exchanges. This sets the stage for the question of this book: given that state leaders say they want flexibility and that Republicans say they prefer market-oriented reforms, why did so many states reject state control over exchanges? I outline the four main insights from the case study chapters: (1) the importance of governors, (2) the power of the Tea Party, (3) the ways in which differences in institutional design and procedures shaped policy outcomes, and (4) the importance of leadership. I ask whether this episode supports or undermines the federalism notion of states as laboratories of learning.