Dataset Information

Coverage Disruptions and Transitions Across the ACA's Medicaid/Marketplace Income Cutoff.

ABSTRACT:

Background

The Affordable Care Act takes a "patchwork" approach to expanding coverage: Medicaid covers individuals with incomes 138% of the federal poverty level (FPL) in expansion states, while subsidized Marketplace insurance is available to those above this income cutoff.

Objective

To characterize the magnitude of churning between Medicaid and Marketplace coverage and to examine the impact of the 138% FPL income cutoff on stability of coverage.

Design

We measured the incidence of transitions between Medicaid and Marketplace coverage. Then, we used a differences-in-differences framework to compare insurance churning in Medicaid expansion and non-expansion states, before and after the ACA, among adults with incomes 100-200% of poverty.

Participants

Non-elderly adult respondents of the Medical Expenditure Panel Survey 2010-2018 MAIN MEASURES: The annual proportion of adults who (1) transitioned between Medicaid and Marketplace coverage; (2) experienced any coverage disruption.

Key results

One million U.S. adults transitioned between Medicaid and Marketplace coverage annually. The 138% FPL cutoff in expansion states was not associated with an increase in insurance churning among individuals with incomes close to the cutoff.

Conclusions

Transitions between Medicaid and Marketplace insurance are uncommon-far lower than pre-ACA analyses predicted. The 138% income cutoff does not to contribute significantly to insurance disruptions.

SUBMITTER: Goldman AL

PROVIDER: S-EPMC9585127 | biostudies-literature | 2022 Nov

REPOSITORIES: biostudies-literature

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Publications

Coverage Disruptions and Transitions Across the ACA's Medicaid/Marketplace Income Cutoff.

Goldman Anna L AL Gordon Sarah H SH

Journal of general internal medicine 20220311 14

<h4>Background</h4>The Affordable Care Act takes a "patchwork" approach to expanding coverage: Medicaid covers individuals with incomes 138% of the federal poverty level (FPL) in expansion states, while subsidized Marketplace insurance is available to those above this income cutoff.<h4>Objective</h4>To characterize the magnitude of churning between Medicaid and Marketplace coverage and to examine the impact of the 138% FPL income cutoff on stability of coverage.<h4>Design</h4>We measured the inc ...[more]

PMID: 35277806

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Project description:ImportanceThe Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.ObjectiveTo assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.Design setting and participantsUsing 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.Main outcome and measuresThe main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.ResultsThe primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.Conclusions and relevanceIn this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Project description:ImportanceBrief disruptions in insurance coverage among eligible participants are associated with poorer health outcomes for children.ObjectiveTo describe factors associated with coverage disruptions among children enrolled in North Carolina Medicaid from 2016 to 2018 and estimate the outcome of preventing such disruptions on medical expenditures.Design setting and participantsThis was a retrospective cohort study using North Carolina Medicaid claims data. All enrolled individuals were aged 1 to 20 years on January 1, 2016, and with 30 days of prior continuous enrollment. Children were observed from January 1, 2016, until December 31, 2018. Analyses were conducted from June 2020 through December 2020.Main outcomes and measuresRisk of Medicaid coverage disruptions of 1 to less than 12 months was assessed. Among children who disenrolled from Medicaid for 30 or more days, the risk of reenrollment within 1 to 6 months and 7 to 11 months was assessed. An inverse probability of censoring weights method was then used to estimate the outcome of an intervention to reduce coverage disruptions through preventing disenrollment on per member per month (PMPM) cost.ResultsThe study population included 831 173 Medicaid beneficiaries aged 1 to 5 years (23%), 6 to 17 years (68%), and 18 to 20 years (9%); 35% were Black, 44% were White, and 14% were Hispanic/Latinx. Among those with a first disenrollment (n = 214 401, 26%), the risk of reenrollment within 6 months and 7 to 11 months was 19% and 7%, respectively. Risk of coverage disruption was higher for Black children (hazard ratio [HR], 1.21; 95% CI, 1.18-1.24), children of other races (Asian, American Indian, Hawaiian or Pacific Islander, multiple races, or unreported; HR, 1.37; 95% CI, 1.33-1.40), and Latinx children (HR, 1.65; 95% CI, 1.60-1.70) compared with White children. Risk of coverage disruption was also higher for children with higher medical complexity (HR, 1.15; 95% CI, 1.12-1.19). The risk of coverage disruption was lower for children living in counties with the highest unemployment rates (HR, 0.89; 95% CI, 0.85-0.94), and comparisons between county-level measures of child poverty and graduation rates showed little or no difference. The estimated PMPM cost for the full population under a scenario in which all medical costs were included was $125.73. Estimated PMPM cost for the full cohort in a counterfactual scenario in which disenrollment was prevented was slightly lower ($122.14). Across all subgroups, estimated PMPM costs were modestly lower ($2-$8) in the scenario in which disenrollment was prevented.Conclusions and relevanceIn this cohort study, the risk of Medicaid coverage disruption was high, with many eligible children in historically marginalized communities continuing to experience unstable enrollment. In addition to improving health outcomes, preventing coverage gaps through policies that decrease disenrollment may also reduce Medicaid costs.

Project description:ImportancePolicy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown.ObjectiveTo compare maternal coverage and care by Medicaid vs marketplace eligibility.Design, setting, and participantsA retrospective cohort study using a difference-in-difference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey.ExposuresEligibility for Medicaid or marketplace coverage under the Affordable Care Act.Main outcomes and measuresOutcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use.ResultsThe study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age ≥30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (-10.8 percentage points; 95% CI, -13.3 to -7.5 percentage points), and decreased uninsurance (-8.7 percentage points; 95% CI, -20.1 to -0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-in-difference models. No evidence of significant differences in early prenatal care, postpartum check-ups, or postpartum contraception was identified.Conclusions and relevanceIn this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.

Project description:ImportanceIndividual health insurance marketplaces established through the Affordable Care Act of 2010 (ACA) fill a critical gap for those who lack other coverage options. The high degree of coverage turnover, or churn, has raised concerns about affordability and strategic behavior on the part of individuals to sign up only when they need care.ObjectiveTo assess the role of California's ACA marketplaces in the broader health care landscape by understanding enrollment tenure and churn.Design, setting, and participantsThis cross-sectional study analyzed survey data from a representative, probability-based sample of enrollees in California's ACA marketplace, Covered California, collected immediately after the open enrollment periods in 2018, 2019, and 2021. Administrative data from Covered California from January 1, 2014, to December 31, 2021, were used to analyze marketplace tenure. Survey data included 9571 heads of households aged 18 to 64 years who were newly enrolled or had recently terminated their plan, directly drawn from Covered California's administrative records. Administrative data included individuals up to age 65 years who enrolled in the marketplace during 2014 to 2021.ExposuresNew enrollment in or termination from health care coverage through California's ACA marketplace.Main outcomes and measuresEnrollment tenure in California's ACA marketplace, sources of coverage prior to enrolling and after terminating coverage, and demographic or plan characteristics associated with the decision to go uninsured.ResultsMedian (IQR) length of coverage among 5.4 million enrollees (mean [SD] age, 38 [16] years; 17% Asian American/Native Hawaiian or other Pacific Islander, 2.5% Black or African American, 23% Latino [response options were Hispanic, Spanish, or Latino origin], 29% White, 7.5% categorized as other [including American Indian/Alaskan Native, multiple races, and other], and 21% of unknown race or ethnicity) was 14 (6-35) months, and 41% to 46% of enrollees disenrolled within 1 year, with substantial variation by subgroups. Despite this churn, only 14% (95% CI, 12%-15%) of 6474 terminating members surveyed across 3 years (2018, 2019, and 2021) reported being uninsured after leaving the marketplace, with the rest moving to job-based coverage or Medicaid. Most of those surveyed (mean [SE] percentage, 56% [0.016] individuals) reported having had employer-sponsored insurance or Medicaid prior to enrolling in the marketplace. Among subsidized renewal candidates, Latino candidates were 1.5 percentage points (95% CI, 0.8-2.3 percentage points) more likely to go uninsured compared with White candidates, and those with no expected physician visits in the coming year were 4.8 percentage points (95% CI, 2.4-7.2 percentage points) more likely to go uninsured vs those who expected physician visits.Conclusions and relevanceThe results of this cross-sectional study of coverage churn found that ACA marketplaces served 2 distinct types of individuals, long-term enrollees but, more often, individuals with short-term-coverage needs due to a change in eligibility for other insurance. These results suggest that marketplaces are smoothing coverage disruptions and that policies to reduce gaps in coverage should be designed with this in mind.

Dataset Information

Coverage Disruptions and Transitions Across the ACA's Medicaid/Marketplace Income Cutoff.

Background

Objective

Design

Participants

Key results

Conclusions

Publications

Coverage Disruptions and Transitions Across the ACA's Medicaid/Marketplace Income Cutoff.

Similar Datasets

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