Medicaid Versus Marketplace Coverage For Near-Poor Adults: Effects On Out-Of-Pocket Spending And Coverage

Abstract

In states that expanded Medicaid eligibility under the Affordable Care Act, nonelderly near-poor adults-those with family incomes of 100-138 percent of the federal poverty level-are generally eligible for Medicaid, with no premiums and minimal cost sharing. In states that did not expand eligibility, these adults may qualify for premium tax credits to purchase Marketplace plans that have out-of-pocket premiums and cost-sharing requirements. We used data for 2010-15 to estimate the effects of Medicaid expansion on coverage and out-of-pocket expenses, compared to the effects of Marketplace coverage. For adults with family incomes of 100-138 percent of poverty, living in a Medicaid expansion state was associated with a 4.5-percentage-point reduction in the probability of being uninsured, a $344 decline in average total out-of-pocket spending, a 4.1-percentage-point decline in high out-of-pocket spending burden (that is, spending more than 10 percent of income), and a 7.7-percentage-point decline in the probability of having any out-of-pocket spending relative to living in a nonexpansion state. These findings suggest that policies that substitute Marketplace for Medicaid eligibility could lower coverage rates and increase out-of-pocket expenses for enrollees.

Effect of Medicaid Expansion on Health Insurance Coverage and Access to Care Among Adults With Depression

“…We also found that Medicaid expansion in Kentucky and Arkansas was associated with an increased probability of having a personal doctor and a decreased probability of delaying care or medications because of cost. These changes are consistent with prior findings for the general low-income population (6–8) but extend these results to a high-risk population with active symptoms of depression. Given the high prevalence and substantial morbidity associated with depression, these results have important public health implications.…”

“…Second, as with any quasi-experimental study, unobserved variables may have changed differentially in expansion versus nonexpansion states. Although our estimates were similar to those in a number of other quasi-experimental comparisons of health outcomes between expansion and nonexpansion states, we still cannot rule out the possibility of residual confounding (6–8).…”

“…This research has found that Medicaid expansion is associated with lower rates of uninsured individuals and increased health care utilization, as well as modest improvements in health outcomes (2,3,6,7). In addition, expanded Medicaid coverage has been associated with a reduced likelihood of medical bankruptcy, fewer delays in care because of cost, and less trouble with other bills (3,8). These studies have analyzed the general adult population; however, there has been less research focused explicitly on the Medicaid expansion’s effects on those with mental illness, including depression.…”

Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study

“…This larger reduction might indicate that the benefit of Medicaid coverage on financial risk protection is larger for lower income families. Possibly, also, the effect size was smaller among individuals with income in the range 100-138% of the federal poverty level because those individuals in this range living in the non-expansion states had access to subsidized health insurance marketplace plans developed by the Affordable Care Act 44…”

Persisting Gaps in Coverage and Services of Illinois Women Who Acquired Insurance After Implementation of the Affordable Care Act

“…11 In addition, plans obtained through health exchanges compared with Medicaid have been associated with an increase in out-of-pocket spending, a decrease in affordability, and less continuity of coverage. 12,13 A lack of available and geographically accessible in-network providers and an increase in out-of-pocket costs for women gaining some types of insurance through the Illinois Health Exchange may also be driving the negative health care experiences reported in our study.…”