Reports and Research Table of Contents April 17, 2014 Board Meeting Adults in the Income Range for the Affordable Care Act’s Medicaid Expansion Are Healthier than Pre-ACA Enrollees – Health Affairs April, 2014 Changes in Health Insurance Enrollment Since 2013: Evidence from the RAND Health Reform Opinion Study – RAND Corporation April, 2014 Enrollment Momentum: Accelerating the Affordable Care Act’s Enrollment Momentum:10 Recommendations for Future Enrollment Periods – Families USA April, 2014 In Their Own Words: Consumers’ and Enrollment Counselors’ Experiences with Covered California – California HealthCare Foundation April, 2014 Measuring Marketplace Enrollment Relative to Projections – Robert Wood Johnson Foundation and Urban Institute April, 2014 Medicaid and Marketplace Eligibility Changes Will Occur Often In All States; Policy Options can Ease Impact – Health Affairs April, 2014 Network Adequacy Planning Tool for States – State Health Reform Assistance Network, Georgetown University Health Policy Institute, and Robert Wood Johnson Foundation April, 2014 The Ongoing Importance of Enrollment: Churn in Covered California and Medi-Cal – UC Berkeley Labor Center April, 2014 Recommendations to Strengthen Navigator and Assister Programs – Georgetown University Health Policy Institute April 7, 2014 America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions – The Commonwealth Fund March, 2014 California: Round 1: State-Level Field Network Study of the Implementation of the Affordable Care Act – The Nelson A. Rockefeller Institute of Government, The State University of New York, and Fels Institute of Government March, 2014 Consumer Assistance Resource Guide: American Indians and Alaska Natives – State Health Reform Assistance Network, Center for Health Care Strategies, and Robert Wood Johnson Foundation March, 2014 Deciphering the Data: Health Insurance Marketplace Enrollment Rates by Type of Exchange – Penn LDI and Robert Wood Johnson Foundation March, 2014 Health Insurance Marketplaces Offer a Variety of Dental Benefit Options, but Information Availability is an Issue – American Dental Association March, 2014 How Much Financial Assistance Are People Receiving Under the Affordable Care Act – The Henry J. Kaiser Family Foundation March, 2014 Sizing Up Exchange Market Competition – The Henry J. Kaiser Family Foundation March, 2014 The Out-Front Western Region: An Overview – The Nelson A. Rockefeller Institute of Government and Fels Institute of Government March, 2014 Understanding Special Enrollment Periods, Part 1: A Look at Some Who Will be Out of Luck – The Center on Health Insurance Reforms (Georgetown University Health Policy Institute) March 31, 2014 2 Obamacare’s Invisible Victory – National Journal March 28, 2014 Consumers Face More Hurdles to Accessing Drugs in Exchange Plans Compared to Employer Coverage – Avalere March 24, 2014 The Contraception Case is Big, but Another Challenge Could Really Hurt Obamacare – Washington Post Blog March 24, 2014 Mission Advanced But Not Accomplished: Four Years of Health Reform in California – Health Access March 20, 2014 U.S. Uninsured Rate Continues to Fall – Gallup March 10, 2014 3 Web First By Steven C. Hill, Salam Abdus, Julie L. Hudson, and Thomas M. Selden doi: 10.1377/hlthaff.2013.0743 HEALTH AFFAIRS 33, NO. 4 (2014): – Adults In The Income Range ©2014 Project HOPE— The People-to-People Health For The Affordable Care Act’s Foundation, Inc. Medicaid Expansion Are Healthier Than Pre-ACA Enrollees Steven C. Hill (Steven.Hill@ ABSTRACT The Affordable Care Act (ACA) has dramatically increased the ahrq.hhs.gov) is a senior number of low-income nonelderly adults eligible for Medicaid. Starting economist in the Center for Financing, Access, and Cost in 2014, states can elect to cover individuals and families with modified Trends (CFACT) at the Agency for Healthcare Research and adjusted gross incomes below a threshold of 133 percent of federal Quality, in Rockville, Maryland. poverty guidelines, with a 5 percent income disregard. We used simulation methods and data from the Medical Expenditure Panel Survey Salam Abdus is a senior economist at Social and to compare nondisabled adults enrolled in Medicaid prior to the ACA Scientific Systems, in with two other groups: adults who were eligible for Medicaid but not Rockville. enrolled in it, and adults who were in the income range for the ACA’s Julie L. Hudson is a senior Medicaid expansion and thus newly eligible for coverage. Although economist in CFACT. differences in health across the groups were not large, both the newly Thomas M. Selden is director eligible and those eligible before the ACA but not enrolled were healthier of the Division of Modeling and Simulation in CFACT. on several measures than pre-ACA enrollees. Twenty-five states have opted not to use the ACA to expand Medicaid eligibility. If these states reverse their decisions, their Medicaid programs might not enroll a population that is sicker than their pre-ACA enrollees. By expanding Medicaid eligibility, states could provide coverage to millions of healthier adults as well as to millions who have chronic conditions and who need care. he Affordable Care Act (ACA) seeks Medicaid coverage to adults whose incomes do to dramatically increase the num- not exceed an effective threshold of 138 percent ber of low-income nonelderly of the federal poverty level (133 percent of pov- adults who are eligible for Medic- erty with a 5 percent income disregard). Adults aid. Eligibility for this federal-state whose incomes are at or below 138 percent of Tprogram has traditionally been restricted to low- poverty and who were not eligible for full Med- income pregnant women; poor children; elderly icaid benefits under their state’s eligibility rules people; people with disabilities; and, to varying in December 2009 are termed newly eligible.3 degrees, the parents of poor children. Little cov- Even if a state decides not to expand coverage erage has been available to childless adults. In under the ACA, it may still experience increased 2009 only six states provided full Medicaid ben- enrollment. This is because Medicaid, like all efits to some childless adults, and twelve states public programs, has populations that are eligi- provided more-limited Medicaid benefits.1 How- ble but not enrolled. The outreach efforts related ever, many of these programs were closed to new to the ACA and the rollout of private insurance applicants. In 2009 an additional nineteen states through state and federal exchanges, also known extended coverage to some people ages nineteen as Marketplaces, may prompt adults who had and twenty.2 been eligible before the ACA to enroll now.4 Beginning in 2014, states can elect to offer The newly eligible and adults who were eligible April 2014 33:4 Health Affairs 1 Downloaded from content.healthaffairs.org by Health Affairs on April 16, 2014 by KATHERINE MARCELLUS Web First before the passage of the ACA but not enrolled Study Advantages Our study has four advan- have different fiscal implications for states. tages. First, it used a large number of health States and the federal government share the status measures. Second, we built on previous costs of the Medicaid program. States pay for studies5,6 by better identifying newly eligible none of the care for the newly eligible from adults, especially by distinguishing between 2014 through 2016, with states’ shares gradually the newly Medicaid-eligible and those eligible rising to 10 percent between 2017 and 2020. For before the ACA but not enrolled. the pre-ACA eligible, including those not yet en- Third, we excluded adults enrolled in Medicaid rolled, each state generally must pay its usual because of disability. The adults in this group share of expenditures for care—which ranged differ from other adults in numerous ways. For from 26 percent to 50 percent across the states example, compared to other adults in Medicaid, in fiscal year 2013—with the federal government their health status is poorer, and their per capita paying the remainder. The exception is the seven Medicaid expenditures are five times higher, on or so states that expanded eligibility for both average.12 As we show below, both adults eligible parents and childless adults with incomes up before ACA but not enrolled and adults who are to or exceeding 100 percent of poverty prior to newly eligible have health profiles that are simi- March 2010: These states receive a higher match lar to—indeed, even better than—those of non- rate from the federal government for some disabled pre-ACA Medicaid enrollees. Thus, in- adults, but the federal government has not yet cluding the adults enrolled because of disability determined which of those states will qualify. would lead to incorrect conclusions about the States, the federal government, and providers extent to which sicker adults enroll in Medicaid. can use information about the characteristics of Fourth, our results are for both the United adults who are newly eligible for Medicaid and of States as a whole—assuming that all states were those eligible before the ACA but not enrolled to to expand Medicaid eligibility—and for states help implement the ACA. Pre-ACA insurance sta- that are expanding Medicaid eligibility to adults tus among these two groups of adults is a key targeted by the ACA and states that are not. characteristic, because it will likely influence Medical Expenditure Panel Survey MEPS their decisions about enrolling