Advocates for Evidence-Based Health Policy Speakers
The ACA Marketplaces are Working
The roll out of Healthcare.gov stands out as an early stumble for the Affordable Care Act. Meant to be the access point for the ACA’s health insurance Marketplaces, the website was beset with technical glitches when it first went live in October 2013. Many users found themselves unable to sign-up for insurance or even to log on. Despite that dismal beginning, Healthcare.gov eventually got fixed and the Marketplaces began to thrive.
These Marketplaces, along with Medicaid expansion, represent the key prongs of the ACA’s efforts to expand insurance coverage. But while the effects of Medicaid expansion have been explored through rigorous research, the attention paid to the Marketplaces has been largely limited to observational reports. This study helps to address that deficiency through a quasi-experimental approach comparing two groups within the income range eligible for subsidized Marketplace coverage: the previously uninsured and those with employer-sponsored insurance.
So have the Marketplaces achieved more than their inauspicious beginning would suggest? The answer would appear to be a solid yes. The difference in rates of uninsurance between the two groups dropped by 10.8%, the difference in having a hospital admission narrowed by 2.5%, and the difference in receiving a hypertension diagnoses decreased by 7% percent. Several other indicators also improved, albeit without achieving statistical significance. These included self-reported access to necessary medical care, the number of outpatient visits, and the average number of prescription drugs used. When the analysis was limited to a low-income subgroup (138-250% of federal poverty line) eligible for cost-sharing subsidies, the difference in average number of prescription drugs (3.91) and the number of outpatient visits (1.80) became significant to p< 0.01.
This study is limited by its inclusion of only the first year of the Marketplaces with more than half of the study group remaining uninsured in that time frame. Still, it appears that Marketplace coverage was effective in improving an assortment of indicators with particularly large effects for lower-income groups receiving cost-sharing subsides. Possible policy lessons include the value of insurance and especially cost sharing subsidies for low-income groups. Perhaps policy makers might want to reconsider the elimination of the Marketplace subsidies that occurred in October 2017.
Abstract
Descriptive studies have suggested that the Affordable Care Act’s (ACA’s) health insurance Marketplaces improved access to care. However, no evidence from quasi-experimental studies is available to support these findings. We used longitudinal survey data to compare previously uninsured adults with incomes that made them eligible for subsidized Marketplace coverage (138-400 percent of the federal poverty level) to those who had employer-sponsored insurance before the ACA with incomes in the same range. Among the previously uninsured group, the ACA led to a significant decline in the uninsurance rate, decreased barriers to medical care, increased the use of outpatient services and prescription drugs, and increased diagnoses of hypertension, compared to a control group with stable employer-sponsored insurance. Changes were largest among previously uninsured people with incomes of 138-250 percent of poverty, who were eligible for the ACA’s cost-sharing reductions. Our quasi-experimental approach provides rigorous new evidence that the ACA’s Marketplaces led to improvements in several important health care outcomes, particularly among low-income adults.
PMID: 29608372
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