ABSTRACT:Significant policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal level. We assessed changes in health care use and self-reported health after three years of the ACA's coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group, and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016, the uninsured rate in the two expansion states had dropped by more than 20 percentage points relative to the non-expansion state. For uninsured individuals gaining coverage, this change was associated with a 41 percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23 percentage-point increase in "excellent" self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health.3

Changes in insurance over time -"churning" -may lead to adverse consequences, but there has been little evidence to date on churning since the implementation of the Affordable Care Act (ACA). We explored the frequency and implications of churning with a survey of over 3000 low-income adults in three states with different ACA policies: Arkansas, Kentucky, and Texas. We also compared 2015 churning rates in these states to pre-ACA survey data from 2013. Overall, 20-25% of respondents experienced a change in coverage in the previous 12 months. While frequent, this rate was lower than some pre-ACA predictions. Churning rates were similar after Kentucky's Medicaid expansion and Arkansas' private option, compared to Texas, which did not expand. Common causes were job-related changes and loss of Medicaid/Marketplace eligibility. Churning was associated with disruptions in physician care and medications, trouble obtaining primary and specialty care appointments, and more ED use. Overall, 35-40% of churners felt that it had adversely impacted their quality of care and health. Outcomes were worst among those experiencing gaps in coverage, but even those who churned without becoming uninsured reported adverse effects. Our results indicate policies are needed to reduce churning frequency and to mitigate negative impacts when it occurs.3

ABSTRACT:States are taking variable approaches to the Affordable Care Act (ACA) Medicaid expansion, Marketplace design, enrollment outreach, and navigator programs. We surveyed nearly 3000 low-income adults in late 2014 to compare experiences in three states with markedly different ACA policies: Kentucky, which expanded Medicaid, created a successful state Marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership Marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed onerous restrictions on navigators. We found that application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst on most outcomes. Awareness of the ACA was low -less than half of adults had heard some or a lot about the law. Navigator assistance was the strongest predictor of successful enrollment, while Latinos were much less likely to complete the process. Twice as many respondents felt the ACA had helped them as hurt them, though advertising was strongly associated with perceptions of the law's impact. While the ACA is a national law, state policy choices have had major impacts on enrollment experiences among low-income adults and their overall perceptions of the ACA.

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