Alan C. Monheit

Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

RESEARCH OBJECTIVE To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parents private health plan. Nearly one-in-three young adults lacked coverage before the ACA. STUDY DESIGN, METHODS, AND DATA: Data from the Current Population Survey 2005-2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws. PRINCIPAL FINDINGS This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law. CONCLUSIONS AND IMPLICATIONS ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.

Race/ethnicity and health insurance status: 1987 and 1996.

Health insurance confers important private and social benefits. Disparities in coverage among the population remain an important public policy issue. The authors focus on the health insurance status of white, black, and Hispanic Americans in both 1987 and 1996 and identify gaps in minority health care coverage relative to white Americans. They also investigate the access of workers in these groups to employment-based health insurance. Identified are factors underlying changes in the insurance status of workers during the past decade in terms of changes in population characteristics and structural shifts underlying the demand for and supply of health insurance. The authors find that while coverage has declined for workers in most racial/ethnic groups, the experience of Hispanic males appears to be unique in that changes in their characteristics as well as structural shifts account for their decline in employment-related coverage. Structural shifts dominated the changes in coverage rates for other groups.

Persistence in health expenditures in the short run: prevalence and consequences.

Background. Knowing whether persons in the top percentiles of the health expenditure distribution exhibit persistently high expenditure is fundamental to developing health plan payment policies, containing costs, and understanding the consequences of costly illnesses. Objectives. To determine the extent of high expenditure persistence over a 2‐year period. To identify the correlates and consequences of expenditure persistence. Subjects. A national sample of the population from a longitudinal panel of the Medical Expenditure Panel Survey (MEPS). Methods. Changes in a persons position in the expenditure distribution were examined. &khgr;2 tests were used to identify differences in characteristics between high and low spenders. Logistic regression was used to predict the likelihood of expenditure persistence. Changes in income, employment, out‐of‐pocket expenditure burden, and health insurance were compared for high and low spenders. Results. Of the top 5% of spenders in 1996, 30% retain this position in 1997 and 45% are in the top decile of 1997 spenders. High expenditures begin to regress to the mean over the study period. Cancer, mental disorders, diabetes, and infectious diseases and being in the top decile of 1996 spenders increase the probability of expenditure persistence (P < 0.05 for all). This probability also has a strong random component. An increased proportion of persons in the top expenditure decile for both years had out‐of‐pocket health spending greater than 20% of income in 1997 (P < 0.10). Persons with persistently high expenditures were less likely than low spenders to lose employment‐based coverage (5.4% vs. 8.8%, P < 0.05) but no changes in income or employment status were detected. Conclusions. A sizable minority of persons exhibits persistently high expenditures, creating incentives for favorable risk selection. Few consequences of short‐run expenditures persistence are observed.

Children without Health Insurance.

Data from two nationally representative household surveys—the 1977 National Medical Care Expenditure Survey (NMCES) and the 1987 National Medical Expenditure Survey (NMES)—are used to examine changes in children’s health insurance status over the past decade. The consequences of disparities in children’s health insurance status for their use of health services in each of these years and over time is explored. The data demonstrate that children were more likely to lack health insurance in 1987 than in 1977, that in both years children without insurance were at a disadvantage in their use of health services relative to their insured counterparts, and that over time, health service use by uninsured children declined relative to that by children with private or public coverage. Because of the vulnerable health status of children and the importance of children’s health care, the authors assess how the number of uninsured children might be affected by two frequently discussed policy alternatives: mandated employment-related coverage and incremental Medicaid expansions. They conclude that combining an employer mandate with a Medicaid expansion for some children whose parents are ineligible for an employer mandate appears to have the greatest potential for reducing the number of uninsured children. I n a 1991 report describing the welfare of children in the United States, members of the National Commission on Children observed that “perhaps no set of issues moved members of the National Commission more than the wrenching consequences of poor health and limited access to care.” As has been well documented, the consequences of limited access to health care manifest themselves through a variety of child health problems at all stages of child development. Limited prenatal care increases the risk of low birth weight, premature births, and other adverse outcomes, all of which are associated with infant mortality or contribute to developmental disabilities. Because of poor access to preventive health services, fewer than 70% of white children and less than half of black children 1 to 4 years of age received immunizations against common childhood diseases (DPT, polio, measles, mumps, and rubella) in 1985. The proportion of 2-year-olds immunized has declined from 1980 levels and falls short of the goal established by the Surgeon General of the United States of immunizing 90% of all 2-year-old children by 1990. Finally, limited access to health care services by school-age and adolescent children may reduce the frequency of periodic health assessments and, therefore, the ability of parents and physicians to monitor the physical growth, weight, and By reducing the out-of-pocket costs of health care, nutrition of children; to screen for private and public health insurance coverage possible child abuse and neglect; to play a critical role in improving children’s access detect learning disabilities and poto health care services. tentially debilitating mental health problems; and to provide children with sex education and with education regarding drug and alcohol abuse. (See the article by Perrin, Guyer, and Lawrence in this journal issue.) By reducing the out-of-pocket costs of health care, private and public health insurance coverage play a critical role in improving children’s access to health care services. Depending on the breadth and generosity of coverage, health insurance may enhance access both to preventive care and to services that address acute and chronic health problems. Consequently, concern over disparities in children’s use of health services must necessarily focus on their health insurance status. In this paper, we use data from two nationally representative household surveys, the 1977 National Medical Care Expenditure Survey (NMCES) and the 1987 National Medical Expenditure Survey (NMES), to examine changes in children’s health insurance status over the past decade. We also explore the consequences of disparities in children’s health insurance status for their use of health services in each of these years and examine how their use of health services has changed over time. NMCES and NMES are particularly well suited for this purpose because each survey contains detailed information about the health care use, expenditures, health insurance coverage, and demographic characteristics of the civilian noninstitutionalized population and because each survey has been designed to produce national estimates of health care use and expenditures. These data demonstrate that over this period children were more likely to lack health insurance in 1987 than in 1977, that in both years children without insurance were at a disadvantage in their use of health services relative to their insured counterparts, and that over time, health service use by uninsured children declined relative to that of children with private or public coverage. 156 THE FUTURE OF CHILDREN – WINTER 1992 Children’s Health Insurance Status: 1977 and 1987 In the decade between 1977 and 1987, the likelihood that a child less than 18 years of age would be covered by private or public health insurance declined sharply. Estimates for the first quarter of 1977 and 1987 indicate that the percent of uninsured children increased by some 40%— from 12.7% to 17.8%—or by 3.1 million children. This increase in the number of uninsured children reflects the decline in the percentage covered by private, largely employment-related coverage, and the fact that fewer children in single-parent households were eligible for public insurance programs such as Medicaid. As we have discussed elsewhere, these changes in children’s health insurance status reflect a number of social, legislative, and economic influences over the past 2 decades. In 1987, 25% of all children lived in single-parent households compared to 17% in 1977. Their parents were far less likely to receive an offer of employment-related health insurance than were the parents of children in two-parent households. Figure 1. Annual Health Insurance Status of Children, 1977 and 1987 Uninsured All Year 8.8% Uninsured Part Year 8.7% Public Insurance 10.9% Public and Private Insurance 0.6% Private Insurance 71%

Health Insurance Availability at the Workplace: How Important are Worker Preferences?

Analysts have frequently interpreted the uneven distribution of health insurance across firms of varying size as evidence of insurance market failure in the small group market. We explore an additional explanation by considering the relationship between employee preferences for health insurance and its availability at the workplace. We apply a simple model of job choice to data from the 1987 National Medical Expenditure Survey to examine whether workers with weak preferences for health insurance sort themselves into jobs without coverage. Our results for a sample of single workers are consistent with such sorting behavior.

Insurance coverage and the demand for dental care: Results for non-aged white adults

The fraction of the U.S. population with private dental insurance coverage increased considerably during the past two decades. Experimental data from the Rand Health Insurance Study have revealed that dental insurance is an important determinant of demand. In this analysis, detailed health insurance data from the National Medical Care Expenditure Survey are used to study the effects of insurance on demand by a standard population of white adults aged 16 to 64. Results from this national probability sample are generally comparable to those from the Rand experimental data. Estimates indicate that the primary effects of dental insurance are to facilitate access to care and to increase dental expenditures. Results are consistent with the notion that first-dollar coverage exerts a greater effect on demand than insurance which requires payment of a deductible. Findings also suggest that insurance affects the mix of dental services received. Loss of dental benefits because of cost containment efforts will result in significant reductions in demand for dental services.

How has small group market reform affected employee health insurance coverage

Abstract In the early 1990s, over 40 states passed legislation designed to limit a number of exclusionary practices by insurers in the small group market in order to improve the availability and affordability of health insurance to employees in small firms. In this paper, we address the effects of reform on the likelihood that workers are offered insurance, have employment-based coverage, or are policyholders of an employment-based plan. We use differences-in-differences (DD) and differences-in-differences-in-differences (DDD) estimators to evaluate the differential effects of alternative reform measures on high and low risk workers. We generally find little effect of reform on offer rates and find that, in states with the most stringent reform, employment-based coverage and policyholder rates increased for high risk workers relative to low risk workers. Our results also indicate that the effects of reform varied significantly by the extent to which states adopted guaranteed issue.

Expenditures on Health Care for Children and Pregnant Women

The chronic health care crisis in the United States is primarily the result of rapidly rising health care costs which leave millions of children and pregnant women without health insurance, with restricted access to health care, and at risk for poor health. A better understanding of the current system is key to any reform effort. The authors analyze estimates of annual expenditures on medical care services for children covering the period from conception through age 18 years, including expenditures on pregnancy and delivery. They focus their attention on the distribution of health care expenditures by type of service and source of payment, on how expenditures differ for children of different ages and for adults, and on the rate of growth in expenditures on health care for children. The authors suggest that, because there has been a decline in the relative share of expenditures accounted for by children, efforts to expand third-party financing of their health care will be less likely to overwhelm the system than would efforts to expand coverage to other groups. Families who are especially in need of extended health care coverage are those of children with major illnesses who are exposed to catastrophic costs. Efforts at cost containment may be most effective if focused on pregnancy and newborn care, areas in which expenditures have grown extremely rapidly in recent years. Finally, the authors conclude that, if expansion of health insurance coverage for children in the near term were to be incremental, expanded coverage for children 3 to 12 years old would probably have the smallest budgetary impact of any expansion in access to care.

Children's health insurance coverage and family structure, 1977-1996.

Using data from a series of nationally representative medical expenditure surveys, the authors document changes in children’s health insurance coverage in a period of two decades. Overall, it is found that the proportion of children with private coverage declined, while the proportions publicly insured and uninsured increased. However, when the authors account for differences in family structure, they find striking disparities in children’s insurance experiences. Contrary to overall trends, children in single-parent households made significant gains in private health insurance coverage after 1977 and experienced reductions in public insurance. Coincident with Medicaid expansions in the late 1980s, children in two-parent households experienced significant increases in public health insurance. It is found that the rise in the proportion of children who were uninsured in this period was largely a single-parent family phenomenon, and that parents’ marital status, employment status, and family income are crucial factors associated with children’s insurance status.

State health insurance market reform : toward inclusive and sustainable health insurance markets

1. Introduction Alan C. Moheit and Joel C. Cantor Part One: Critical Evaluation of Research Findings 2. What Have We Learned from Research on Small-Group Market Reform? Kosali Ilayperuma Simon 3. What Have We Learned from Research on Individual Market Reform? Deborah Chollet Part Two: Responses to Findings on Insurance Market Reform 4. What Can We Learn from the Research on Insurance Market Reform? Thomas M. Buchmueller 5. A Critical Assessment of Research on Insurance Market Reform Barbara Steinberg Schone Part Three: Perpectives from the Field: How Can Access to Affordable Coverage be Sustained? 6. An Insurance Executive Reflects on Health Insurance Market Reform Sanford B. Herman 7. An Insurance Commissioner Reflects on Insurance Market Reform Steven B. Larsen 8. Can Access to Affordable Health Insurance be Sustained? Karen Pollitz Part Four: Reforming Insurance Market Reforms: What are the Possibilities? What are the Alternatives? 9. How Can Reform Work Better? M. Susan Marquis 10. Improving State Insurance Market Reform: Whats Left to Try? Len M. Nichols 11. Insurance Market Reform: When, How, Why? Katherine Swartz 12. Conclusions Alan C. Monheit and Joel C. Cantor