How much would expanding Medicaid help in states that haven’t accepted the expansion?

Perhaps the single biggest story about the implementation of the Affordable Care Act has been the battle in states deciding whether to accept the Medicaid Expansion. The expansion is perhaps the single most important tool in the ACA’s coverage expansion tool kit. It takes 50 state-based single payer systems and drastically expands eligibility for them, which is the single largest progressive victory in politics since the Great Society. Other important Medicaid reforms drastically streamline the application procedures and eliminated asset tests to draw out formerly eligible people who might have gotten tangled up in the system or not bothered applying because the state made you apply in person on Tuesday between the hours of 2:30 p.m. and 3:04 p.m.

However, the expansion is not some magical talisman that instantly enrolls all eligible individuals. Some people will remain ignorant of the program despite the best outreach efforts, while other will not enroll for any variety of reasons. And more to the point, 24 states hadn’t fully taken advantage of the Medicaid expansion by the beginning of 2015. Pennsylvania, Indiana, Montana and Alaska have all signed on this year, leaving 20 holdouts (half of whom were in the former Confederacy – but I digress).

The cool thing that we have some real data of how ACA has actually performed on the ground over the last two years, we make some interesting dynamic projections of what would have happened had some states accepted the Medicaid, instead of simply discussing the number of people who would be eligible for help under the expansion.

I mean, heck, this Charles Gaba fellow has been counting the people who actually signed up for coverage for two years, I might as well take one shot at figuring out who would have signed up if they could have. 

To accomplish that, follow me below the fold, where I build a simple interactive regression model to project the reduction in the uninsured population in states that haven’t expanded Medicaid. Don’t worry; I’ll label the scary part where I work through the model so you can skip the simple summary where I discuss the results in plain English (but you really should read the model section, it’s rather of important and it makes fun of Bobby Jindal).  

Some follow-up technical notes on State-based exchanges

When I reposted the last post as a DailyKos diary, a commentator engaged me a bit on a few ideas to improve the basic concept. He suggested for controlling for partisan control of the state government as a binary variable (cooperative == full Democratic control=1; non-cooperative==full Republican control=0). I thought a tertiary variable (0=GOP 1=split 2=Dem) might be a bit better.

Having an independent variable for partisan control might soak up some of the variation for cooperation with implementing the ACA, but the problem is that any partisan control variable would be extremely highly correlated with State-based exchanges. There were very few complete Democratic states without at least a shared exchange (West Virginia and Illinois jump to mind), and only one GOP controlled state (Idaho) with an exchange. I'm not sure how useful it would be in practice at sorting out variation not associated with exchanges since the two are so strongly correlated.

In any case, it was a thoughtful piece of feedback and definitely worth the brief conversation we had.

Another idea I thought of was to take quarterly data for each state to increase the number of observations for each state from one to six to track changes from the end of 2013 through the second quarter of 2015. Taking the data from cross sectional data to cross-sectional-time series in this manner would create 300 observations (vs. 50) and increase leverage dramatically, while allowing us to track over-time change in states setting up and taking down exchanges and or expanding Medicaid at different points.  Of course, as my old methods prof John Jackson used to stay "No good deed goes unpunished" and we'd have to control for the serial correlation in the states with either a fixed or random-effects model.  At least we wouldn't have to worry about panel-corrected standard errors, seeing that we're dealing with the universe of states, not a subsample.  And there would also be the problem of increase error within states for each quarter, since the Gallup sample would slip to alarmingly low levels for some states, increasing the margin of error around the uninsured rate for a given quarter.

And that's assuming that I could even get the more specific data out of Gallup.

I don't really have the time to try out either of these ideas right at the moment, but anyone in Internet land can feel free to try and report back. I'm rather interested.

Does having a state-run exchange improve health insurance access under the ACA?

With the ruling in King vs. Burwell behind us, focus on the differences between state sponsored health exchanges vs. the federal exchange has fallen away. But as state-based data has been rolling in from Gallup, the CDC, and the Urban Institute on declines in people without health insurance, I began wondering whether providing a state-based exchange has any advantages over a the federal marketplace. Gallup’s comments and tables in particular seem to push the idea that states with state-based exchanges seem to have had more success with reducing the uninsured rate.

Of course, the real reason that state-based exchanges exist is political. The original House of Representatives bill had a national marketplace, while the Senate Bill incorporated state-based marketplaces. This particular breakdown shouldn’t surprise anyone, since Senators represent entire states, and all states are equally represented. The general state-based structure of the Senate bill won out. The final ACA incorporated a mechanism that defaulted to a federal backstop, but the markets themselves were still based on state boundaries.

However, despite that structural political reason, there might be some practical reasons why state exchanges might have superior performance to a unified federal exchange. First, commentators often refer to states as “laboratories of democracies” that can innovate and try numerous different ideas. Over time, the theory goes, good ideas from some states will diffuse across other states naturally and more quickly than if the federal government had installed and tried to improve a clunky national idea. Second, there’s the idea that differing conditions and preferences across states mean that state-based exchanges will allow individual states to customize their exchanges to best fit the needs of their state.

We would have to hold these potential advantages against some very real drawbacks. First, there’s administrative complexity and cost of constructing and running an exchange for a state-level. With federal grants to construct exchanges running out, several smaller states are already transitioning back to the federal marketplace, while others are having trouble paying the upkeep costs. Also note that there’s a question of whether several states even have enough potential subscribers to form a healthy individual insurance market to begin with.

With these ideas in mind, I used Gallup’s state-based data to build an extremely simple statistical model to predict the effects of a state-based exchange on improvements in health insurance coverage.  Follow me below the fold for more details.

Medicaid Expansion gets entrenched in Arkansas -- even with a conservative GOP government

The latest news out of Arkansas offers more evidence that the Medicaid expansion will durable even in the most conservative states once it gets entrenched.  

I argued this point tentatively in March when new Republican Governor Asa Hutchinson and large GOP majorities in the state legislature reauthorized the expansion, which had been put in place under Democrat Mike Beebe’s administration, for the current fiscal year while putting together a task force to examine long-term tweaks in the system.

Arkansas has an unusual expansion: instead of simply enrolling everyone eligible in traditional Medicaid, the expansion provides subsidies to fully pay for private health insurance sold on the exchanges. As Richard Mayhew notes, commercial policies have higher costs than Medicaid, so the plan is a more expensive piece of “performance art,” albeit one that still accomplishes the primary goal of getting people covered.

The Arkansas Times picks up the story from there. As the federal match starts dropping in 2017 (and Arkansas enters new negotiations for a waiver with the Feds), the state found its was going to be on the hook for an extra $50-60 million, and Hutchinson implored the task force to cut costs.

Last week he met with the Task Force and made a speech with three major parts.

First, he engaged in the usual right-wing Kabuki ritual of complaining about how horrible Obamacare was and that it was taking away health insurance and….

(insert Charlie Brown trombone sounds here).

Oh, sorry, nodded off there. 

Second, he offered several of the usual conservative pet rocks to cut costs: notably requiring  more premium cost sharing for people above the poverty line (Iowa does this and the Feds would likely approve it in a waiver), requiring some sort of job search requirement for people on Medicaid that wouldn’t require a new waiver (this Feds won’t tolerate much here, and most of the people on expanded Medicaid work anyway) and making sure that working people with access to health insurance take that rather than enrolling in Medicaid (this will affect almost no one).

Finally, after emphasizing his anti-Obama bona-fides, he got to the real point: The Medicaid expansion had covered more than 220,000 of “our friends, our neighbors and our families,” and that rejecting it would cut them off of health care and drain more than $1.4 billion from the state economy. He also made the biggest policy proposal, which would be to shift everyone below the poverty line from private plans to the cheaper (and just as comprehensive) traditional Medicaid.

So the big conservative plan to tweak the “private option” Medicaid expansion in Arkansas and be fiscally responsible is to …. move more people into traditional Medicaid, just like Obamacare originally envisioned. I swear HHS Secretary Sylvia Burwell and President Obama just exchanged knowing glances and an extremely restrained fist bump in the Oval Office.

---

ACA reduces uninsured in Texas, but would do more if state expanded Medicaid

Shockingly (not really), failure to expand Medicaid continues to cost poor Texans access to health insurance.

The Baker Institute at Rice University the Episcopal Health Foundation have released their latest issue brief on the latest results of the Health Reform Monitoring Survey, a quarterly survey which tracks the effects of the Affordable Care Act on individuals.  The Institute and  the Foundation implement the survey for Texas.

This report contains absolutely no surprises for anyone with more than three functioning brain cells and who hasn’t been living under a rock for the last five years.

First, the good news: The percentage of uninsured working-age adults (ages 18-64) estimated by the survey declined by nearly one third, from nearly 25 percent to 17 percent between September 2013 and March 2015. Most encouragingly, Hispanics – though still the higher proportion of uninsured in Texas – had the largest decline, with a drop of 38 percent.

This indicates that the health exchange model, supported by federal subsidies, is helping a large number of uninsured individuals get coverage.

The bad news of course, is that poor people who fall into “Medicaid gap” – those who earn income less than 100 percent of the poverty line necessary to obtain subsidies on the exchange, but higher than current Texas cutoffs for Medicaid -- are still left out in the cold.  The memo notes that respondents under 138 percent of the poverty line have increased from roughly 63 percent to 67 percent of those uninsured in Texas. This change in the two surveys isn’t statistically distinct from zero, but almost surely understates the impact of the state’s failure to expand Medicaid, because individuals between 100-138 percent of the poverty line qualify for subsidies.

Two other nuggets in the report are of interest.  First, the potential tax penalty for health insurance, also known as the individual mandate -- appears to have some effect on driving the uninsured to seek insurance. More than half (53 percent) of uninsured respondents say that the prospect of a fine for not purchasing insurance is “somewhat” or “very” important to them. (Note that the IRS is waiving the fine for households that fall into the “Medicaid gap.”

Finally, uninsured respondents overwhelming say that they can’t purchase insurance because they can’t afford it (57 percent) instead of because they don’t want it (17 percent). That’s useful because it undermines (again) the talking point that uninsured people are satisfied in their current state and that the government should just butt out.

To sum up then: Texans generally want health insurance, the ACA is effective in helping them get insurance, and the ACA would help a lot more Texans get insurance if the state were to expand Medicaid. Absolutely all these things were predicted by proponents of Obamacare.