In the spirit of Valentine’s Day, this February CHIR’s Nia Gooding reviewed some lovely studies on trends in the uninsured population, the impact of Medicaid expansion on coverage rates and healthcare access among young adults, and the effect that cost-sharing has on patient behavior and health outcomes. 

Chandra, A. The Health Costs of Cost Sharing. National Bureau of Economic Research, February 2021

In this working paper, researchers from the National Bureau of Economic Research examine data taken from Medicare’s prescription drug benefit program to assess the impact cost-sharing has on patient behavior and mortality. 

What it Finds

• An increase of 33.6 percent in patient out-of-pocket costs (valued at $10.40 per drug) causes a 22.6 percent drop in total drug consumption (valued at $61.20), and a 32.7 percent increase in monthly mortality.
• For each percentage point increase in coinsurance, patients make about 6-19 percent fewer fills for drugs that lower cholesterol, blood pressure or blood sugar, and drugs that treat acute exacerbations of asthma. 
• A 15 percent mean increase in price causes 18 percent more patients to fill no prescriptions, regardless of how many drugs they had taken previously, or of their individual health risks.
  • Among patients taking four or more different types of drugs, 72.6 percent more fill no prescriptions under these conditions.
• With increased cost sharing, patients tend to cut back on essential life-saving medicines such as statins and antihypertensives, not only on “low value” drugs. 
  • Patients with the highest risk of having a heart attack, stroke, or acute diabetic or pulmonary complications, who would benefit the most from taking these drugs, are 280.6 percent more likely to cut back than lower risk patients. 

Why it Matters

As health care costs rise, health insurance payers and purchasers are increasingly shifting those costs to enrollees through higher cost-sharing. However, this study demonstrates that doing so can have serious adverse effects on enrollees’ health outcomes, as patients forego not just low-value care but also necessary – and in some cases life-saving – care. At the same time, the evidence is clear that the true driver of health system cost growth is not utilization but rather the prices for goods and services. This study can help policymakers, purchasers, and payers better assess the risks of pursuing cost containment strategies that do not address the actual drivers of health system costs.

Gangopadhyaya, A. & Johnston, E. Impacts of the ACA’s Medicaid Expansion on Health Insurance Coverage and Health Care Access. Urban Institute, February 18, 2021

In this report, Urban Institute researchers examine trends in coverage rates and access to care among young adults aged 19 to 25 between 2011 and 2018, and consider how Medicaid expansion has contributed to changes in these rates.

What it Finds

• Changes in uninsurance and Medicaid coverage rates were concentrated between 2013 and 2016, when most major ACA coverage provisions were implemented.
• Between 2011 and 2018, uninsurance rates among young adults fell from 30.2 percent to 16 percent, with the greatest effects in Medicaid expansion states. Uninsurance rates decreased by 16.4 percent in Medicaid expansion states, and by 11.9 percent in non-expansion states.
• Medicaid expansion was associated with a 14 percent decrease in uninsurance among all young adults, with larger effects for those from low-income households. 
• Medicaid expansion reduced differences in coverage by race or ethnicity, educational attainment, and household income. 
  • Medicaid expansion is associated with a large decrease in the likelihood of delaying necessary medical care due to cost among non-Hispanic Black young adults. 
  • Among low-income young adults and those with lower education attainment (having no college degree), Medicaid expansion was associated with an increased likelihood of having a personal doctor.
• The likelihood of receiving a routine checkup increased by 5.3 percent in expansion states and by 3.5 percent in non-expansion states. The likelihood of delaying necessary care due to cost decreased by 5.6 percent in expansion states and 4.7 percent in non-expansion states. The likelihood of having a personal doctor increased by 2.1 percent in expansion states and did not change in non-expansion states.

Why it Matters

These findings indicate that the ACA, and particularly Medicaid expansion, have done much to improve young adults’ rates of healthcare access and use, particularly for those who are from minority groups or are socioeconomically disadvantaged. This data should be helpful in advancing the case to expand Medicaid in those states that have not yet done so, as well as encouraging increased investment in outreach and marketing for Medicaid and Marketplace coverage. 

Finegold, K. et al. Trends in the U.S. Uninsured Population, 2010-2020. U.S. Department of Health & Human Services’ Office of the Assistant Secretary for Planning & Evaluation (ASPE), February 11, 2021

In this report, ASPE researchers assess findings from the Centers for Disease Control and Prevention National Health Interview Study (NHIS) on trends in health coverage from 2010 through 2020.

What it Finds

• The ACA has had a significant impact on coverage since its enactment in 2010. The number of uninsured nonelderly adults fell from 48.2 million in 2010 to 28.2 million – its lowest point during the entire 10-year period – in 2016.
  • The gains in coverage during this time were largely due to the dependent coverage provisions of the ACA, the expansion of Medicaid, and the availability of Marketplace premium tax credits and cost-sharing reductions for those who qualified.
• However, the uninsured rate began to increase after 2016; the uninsured rate rose by 1.7 percentage points during each year between 2017 and 2019, going from 10.4 percent (28.2 million) in 2016 to 12.1 percent (32.8 million) in 2019.
  • These outcomes are associated with policy changes made to coverage options available under the ACA and Medicaid, reduced funding for outreach and enrollment in the ACA marketplaces, and enforcement of the public charge rule.
• From 2010 through early 2016, the ACA produced particularly large coverage gains for Black, Latino, Asian, and Native American people, and for low-income families. During this period, 3 million Black and 4 million Hispanic nonelderly adults gained coverage.
• The uninsured rate among nonelderly adults in Medicaid expansion states decreased from 18.4percent in 2013 to 9.1 percent in 2019. Comparatively, there were more modest reductions in the uninsured rate in non-expansion states during the same period, going from 22.7 percent in 2013 to 17.1 percent in 2019. 
• The number of uninsured individuals increased from 30.5 million in 2019 to about 32 million in 2020. This shift in coverage was smaller than originally expected, despite the COVID-19 pandemic. 

Why it Matters

The number of nonelderly uninsured adults is higher now than it was in 2016, and the COVID-19 pandemic has created new threats to coverage. In an effort to reduce the number of uninsured people in the country, President Biden has mandated a COVID Special Enrollment Period (SEP) from February 15 to May 15, 2021, for both new and current enrollees. He is also working with Congress to expand financial assistance to both low- and moderate-income individuals. However, this study highlights that more needs to be done to reverse the increase in uninsured rates, including significant new investments in outreach and consumer assistance, permanent enhancements to premium and cost-sharing subsidies, encouraging states who have not yet done so to expand Medicaid, and ending the so-called “Family Glitch.”