Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts

June 22, 2017

Subsidizing Health Insurance for Low-Income Adults: Evidence from
Massachusetts. Amy Finkelstein, Nathaniel Hendren, Mark Shepard∗
April 2017.

Abstract: How much are low-income individuals willing to pay for health insurance, and what are the implications for insurance markets? Using administrative data from Massachusetts’ subsidized insurance exchange, we exploit discontinuities in the subsidy schedule to estimate willingness to pay and costs of insurance among low-income adults. As subsidies decline, insurance take-up falls rapidly, dropping about 25% for each $40 increase in monthly enrollee premiums. Marginal enrollees tend to be lower-cost, consistent with adverse selection into insurance. But across the entire distribution we can observe – approximately the bottom 70% of the willingness to pay distribution – enrollee willingness to pay is three to four times below own expected medical costs. As a result, we estimate that take-up will be highly incomplete even with generous subsidies: if enrollee premiums were 25% of insurers’ average costs, at most half of potential enrollees would buy insurance, and even premiums subsidized down to 10% of average costs would still leave at least 20% uninsured. We briefly consider explanations for this finding – which suggests an important role for uncompensated care for the uninsured – and explore normative implications for insurance subsidies for low-income individuals.

https://scholar.harvard.edu/files/hendren/files/commcare.pdf


The disappearing ACA insurance market – Axios

June 19, 2017

We’ve all heard about the insurers that are pulling out of Affordable Care Act marketplaces, but sometimes you have to see it to really get it. This map is based on data from the Kaiser Family Foundation for the first four years of the ACA marketplaces. You can really see the difference in 2017, when high-profile insurance exits left 21 percent of all ACA customers with only one insurer in their area.

Source: The disappearing ACA insurance market – Axios


Community Health Centers: Recent Growth and the Role of the ACA – Issue Brief – 8961 | The Henry J. Kaiser Family Foundation

February 6, 2017

In 2013, 65% of health center patients were insured (Figure 3) – 41% by Medicaid, 14% by private insurance, 8% by Medicare, and 2% by other public insurance. By 2015, 76% of health center patients had coverage – an increase of 11 percentage points. About half were covered by Medicaid, 17% by private insurance, 9% by Medicare, and 1% by other public insurance. These increases in coverage coincided with implementation of the ACA insurance expansions, which began January 1, 2014. The increased share of patients with Medicaid reflects the low-income communities served by health centers. The potential for gains in private insurance in these communities is more limited because of the high concentration of poverty and the fact that individuals with income below 100% FPL are not eligible for subsidies to purchase coverage in the ACA marketplaces.

Source: Community Health Centers: Recent Growth and the Role of the ACA – Issue Brief – 8961 | The Henry J. Kaiser Family Foundation


Stopping Surprise Medical Bills: Federal Action Is Needed

February 1, 2017

Two recent nationwide studies, published in Health Affairs and The New England Journal of Medicine, both found that 20 percent of emergency department visits and resulting admissions at in-network facilities involved an out-of-network physician. The Health Affairs study conducted by researchers at the Federal Trade Commission, corroborated by other recent surveys, also highlights the problem of balance billing beyond only emergency physicians. Specifically, the Health Affairs authors found that 9 percent of elective inpatient care at an in-network facility with an in-network lead physician involved an out-of-network ancillary provider, and thus could have led to a surprise medical bill. Additionally, 51 percent of all ambulance rides in their data (primarily from large employer plans) were out of network.

Source: Stopping Surprise Medical Bills: Federal Action Is Needed


The Effect of State Medicaid Expansions on Prescription Drug Use: Evidence from the Affordable Care Act by Ausmita Ghosh, Kosali Ilayperuma Simon, Benjamin Sommers :: SSRN

February 1, 2017

This study provides a national analysis of how the 2014 Affordable Care Act (ACA) Medicaid expansions have affected aggregate prescription drug utilization. Given the prominent role of prescription medications in the management of chronic conditions, as well as the high prevalence of unmet health care needs in the population newly eligible for Medicaid, the use of prescription drugs represents an important measure of the ACA’s policy impact. Prescription drug utilization also provides insights into whether insurance expansions have increased access to physicians, since obtaining these medications requires interaction with a health care provider.

We use 2013-2015 data from a large, nationally representative, all-payer pharmacy transactions database to examine effects on overall prescription medication utilization as well as effects within specific drug classes.

Using a differences-in-differences (DD) regression framework, we find that within the first 15 months of expansion, Medicaid-paid prescription utilization increased by 19 percent in expansion states relative to states that did not expand; this works out to approximately seven additional prescriptions per year per newly enrolled beneficiary. The greatest increases in Medicaid prescriptions occurred among diabetes medications, which increased by 24 percent. Other classes of medication that experienced relatively large increases include contraceptives (22 percent) and cardiovascular drugs (21 percent), while several classes more consistent with acute conditions such as allergies and infections experienced significantly smaller increases. As a placebo test, we examine Medicare-paid prescriptions and find no evidence of a post-ACA effect. Both expansion and non-expansion states followed statistically similar trends in Medicaid prescription utilization in the pre-policy era, offering support for our DD approach.

We did not observe reductions in uninsured or privately insured prescriptions, suggesting that increased utilization under Medicaid did not substitute for other forms of payment. Within expansion states, increases in prescription drug utilization were larger in geographical areas with higher uninsured rates prior to the ACA. Finally, we find some suggestive evidence that increases in prescription drug utilization were greater in areas with larger Hispanic and black populations.

Source: The Effect of State Medicaid Expansions on Prescription Drug Use: Evidence from the Affordable Care Act by Ausmita Ghosh, Kosali Ilayperuma Simon, Benjamin Sommers :: SSRN


How Molina Healthcare views Obamacare now – Axios

January 25, 2017

Molina Healthcare CEO J. Mario Molina isn’t fazed by President Trump’s Obamacare executive order. But he’s also not entirely confident about what will happen with the law and its insurance marketplaces — and he won’t commit to staying in the marketplaces in 2018.In an interview, Molina said the executive order is “symbolic” and doesn’t change the plans for his company, an insurer that mostly covers Medicaid members but also has more than a half million Obamacare customers. Yet when asked if Molina Healthcare would keep offering Obamacare plans in 2018, he said: “There are just too many unknowns at this point to give a definitive answer.”

Source: How Molina Healthcare views Obamacare now – Axios


Narrow Provider Networks for Employer Plans by Mark A. Hall, Paul Fronstin :: SSRN

January 5, 2017

The authors conducted in-depth qualitative research to examine questions around provider networks in employer health plans, particularly the development of so-called “narrow networks,” which have grown in the individual market exchanges under the Patient Protection and Affordable Care Act of 2010 (ACA). These narrow networks are characterized by offering considerably fewer health providers than is typical in the group market, and they are formed primarily based on price discounting. The research includes the review of peer-reviewed journals, news sources, and public policy reports; structured interviews with a convenience sample of human resource benefit directors at 11 large employers; and field research by health-policy experts in a dozen states. This paper describes the research in more detail and analyzes the reported facts and viewpoints.

Major findings include the following: Narrow provider networks are receiving renewed attention, following their increasing prominence in the ACA’s individual (nongroup) marketplace exchanges, which are highly price-competitive. So far, this renewed interest in narrow networks has not translated strongly to employers. For example, in 2016, only 7 percent of employers with health plans offered a narrow network. Also, in 2014, employers ranked narrow networks the least effective among several strategies to manage health insurance costs. Reasons employers give for their subdued interest include absence of a track record showing sustained (year-over-year) savings; concern about antagonizing workers; spotty availability of narrow networks, especially in rural areas; greater interest currently in other cost-savings strategies; and reluctance to adopt substantial changes in benefit structures until the future of the ACA’s so-called “Cadillac tax” is resolved. There are signs that employers’ interest in narrow networks may grow in the near future. More than one-third of employers with health plans that have 5,000 or more workers now offer some type of alternative network, including tiered or “high-performance” networks. Field reports indicate increasing adoption of narrow networks by both large and small employers, particularly in urban markets around the country. Where narrow networks are offered, their adoption could be increased by giving workers stronger financial incentives to consider them. Offering workers a fixed (“defined”) contribution that does not vary by choice of plan is one way to confer such incentives, and private exchanges are a way to offer workers a broader range of choice. Currently, however, neither defined contributions nor private exchanges are widely used by employers.

Source: Narrow Provider Networks for Employer Plans by Mark A. Hall, Paul Fronstin :: SSRN