‘Twas the night before Holiday Vacation, when all through the city
Not a creature was stirring, not even a subcommittee;
Our coats were hung by the door with care,
Little did we know, the researchers were still there;
A study on the relationship between insurance and mortality ahead;
Men are insured at lower rates than women, they said;
Silver-loading seems to be a successful stopgap,
And for the December Research Round Up, that’s a wrap!

Goldin J, McCubbin J, Lurie I. Health Insurance and Mortality: Experimental Evidence from Taxpayer Outreach. National Bureau of Economic Research (NBER), December 6, 2019. Researchers have long considered the question of how access to health insurance impacts mortality rates. Since the famous 2012 Oregon Health Insurance Experiment – a randomized controlled trial assessing the health effects of having health insurance – other studies have had relatively little success in finding a causal relationship. In a groundbreaking new study, researchers from Stanford Law School and the U.S. Department of Treasury analyzed a pilot program from 2017 in which the IRS sent letters to taxpayers who had previously paid the individual mandate penalty. Due to a lack of funds, the IRS was not able to send these letters to all eligible taxpayers, creating a natural randomized experiment to evaluate the impact of tax incentives on enrollment, and the relationship between health insurance coverage and mortality.

What It Finds

• Receiving a letter reduced the uninsured portion of the sample in 2017 by 2.7 percent.
  • For those who were uninsured all of 2016, receiving a letter increased the probability of enrollment in 2017 coverage by 6.7 percent relative to those who did not receive a letter.
  • For those who were uninsured at least one month in 2016, receiving a letter increased the probability of enrolling in 2017 coverage by 2.8 percent relative to those who did not receive a letter.
• The letter had the largest effect on households with incomes between 100 and 138 percent of the federal poverty level.
• In the two years following the pilot study, the mortality rate for middle-aged adults was reduced in the intervention group, with researchers estimating one fewer death per 1,648 individuals who were sent a letter.

Why It Matters

This is the first study to definitively establish a causal connection between having health insurance and reduced mortality. In the United States, people with lower incomes die at a higher rate than those at higher income levels. Lack of access to affordable, quality health care is not the only reason behind this phenomenon, but this study demonstrates that it can be a contributing factor. As policymakers debate how to improve our health care system in the United States, they can now point to clear evidence that comprehensive health insurance saves lives.

Becker T and Babey S. Persistent Gap: Gender Disparities in Health Insurance and Access to Care in California. UCLA Center for Health Policy Research, December 11, 2019. Historically, men have been more likely to be uninsured and less likely to have a regular source of medical care than women. Researchers from UCLA analyzed the coverage effects of full ACA implementation to observe whether the law helped to close the gender gap in California.

What It Finds

• By 2016, men and women saw similar drops in uninsurance rates after full ACA implementation, both dropping by about 10 percentage points since 2012.
• Although both groups saw significant increases in insurance coverage rates, women were still uninsured at a lower rate (8.7 percent) than men (13.6 percent).
• In both groups, Medi-Cal expansion drove much of the increase in insurance rates, but more so for women than men.
• The socioeconomic status (SES) of uninsured men improved, while the SES of uninsured women remained generally unchanged, largely due to Medi-Cal expansion.
• Despite declines, men remained less likely than women to have a regular source of care or doctor visit within the last year, albeit at a more lower rate.

Why It Matters

While coverage expansion greatly lowered the uninsurance rate across the country, there is still work to be done to close existing disparities among genders, races, and socioeconomic groups. This study suggests that more can be done to help men in particular understand the importance of health coverage and a regular source of primary and preventive care.

Anderson D, Abraham J, Drake C. Rural-Urban Differences in Individual-Market Health Plan Affordability After Subsidy Payment Cuts. Health Affairs, December 1, 2019. In October 2017, the Trump Administration announced that federal payments to insurers for cost-sharing reduction subsidies (CSRs) would be terminated, causing major uncertainty in the ACA-compliant individual market. Most states allowed insurers to practice “silver loading,” or embed the lost funding into silver-level plan premiums, which are used as a benchmark for how premium subsidies are calculated. Silver loading resulted in significantly higher silver-level premiums, and subsequently higher premium subsidies for eligible consumers. Health policy researchers from Duke University, the University of Minnesota, and the University of Pittsburgh teamed up to observe these outcomes played out in rural and urban geographic settings.

What It Finds

• Between 2014 and 2017, prior to the Trump administration’s decision to cut off CSR payments to insurers, the lowest average net monthly premiums (or the least expensive premium after accounting for subsidies) were higher for subsidized enrollees in majority-rural geographic rating areas than they were for those in majority-urban geographic rating areas.
• After CSR payments ceased, in 2018 and 2019, the lowest average net monthly premiums were higher for subsidized enrollees in majority-urban geographic rating areas than those in majority-rural geographic rating areas.
• Since 2014, unsubsidized consumers have face higher premiums in majority-rural geographic areas than majority-urban rating areas.
• States that allowed insurers to load the cost of CSR payments onto silver-level plans saw the greatest decrease in average minimum net monthly premiums for subsidized enrollees in both rural and urban geographic areas between 2017 and 2019, and the lowest increase in average minimum net monthly premiums for unsubsidized enrollees in rural geographic rating areas during that time.

Why It Matters

There is evidence that, despite the turbulence injected into the market in 2017 and 2018 by federal policy decisions, the ACA individual market has found ways to maintain stability. Recently, Congress passed a spending bill that included a provision to ensure the continuation of silver loading through plan year 2021. It is important for policymakers at the federal and state levels to study the impact of this innovation on individual market consumers.