Dataset Information

The Role of Marketplace Policy on Welcome Mat Effects for Children Eligible for Medicaid or the Children's Health Insurance Program.

ABSTRACT: The Affordable Care Act (ACA) required coordination between Marketplaces, Medicaid, and the Children's Health Insurance Program (CHIP) in an effort to streamline application processes and improve enrollment. We use 2013-2018 data from the American Community Survey and difference-in-difference models to estimate the relationship between Marketplace policy and increases in Medicaid/CHIP coverage observed among pre-ACA eligible children after the implementation of the ACA ("welcome mat effects"). Our sample includes non-disabled, citizen children (0-18) at 139-250% FPL who were Medicaid-/CHIP-eligible before (and after) the implementation of the ACA. Marketplace policies studied include state-based versus federally-facilitated, and whether the Marketplace had authority to directly enroll Medicaid-/CHIP-eligible applicants into public coverage. Models also control for ACA adult Medicaid expansion policy and provide the first estimates in this literature for non-expansion states. Welcome mat effects were present among all Marketplace and expansion policy categories. However, public coverage increased more in states that empowered their Marketplace to enroll publicly-eligible applicants directly into Medicaid/CHIP and these results were driven by enrollment policy, not by choice of state-based versus federal based Marketplaces. Welcome mat effects were largest in expansion states (for most years) and among children whose parents did not hold employer-sponsored insurance coverage. Ranging from 9 to 13 percentage points, these estimates are larger than those found among other subgroups of children in the welcome mat literature. Although there is evidence of lagged effects for both welcome mat effects and the role of Marketplace policy in non-expansion states, by 2018 we find no differences in these measures by expansion policy.

SUBMITTER: Hudson JL

PROVIDER: S-EPMC7656880 | biostudies-literature | 2020 Jan-Dec

REPOSITORIES: biostudies-literature

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The Role of Marketplace Policy on Welcome Mat Effects for Children Eligible for Medicaid or the Children's Health Insurance Program.

Hudson Julie L JL Moriya Asako S AS

Inquiry : a journal of medical care organization, provision and financing 20200101

The Affordable Care Act (ACA) required coordination between Marketplaces, Medicaid, and the Children's Health Insurance Program (CHIP) in an effort to streamline application processes and improve enrollment. We use 2013-2018 data from the American Community Survey and difference-in-difference models to estimate the relationship between Marketplace policy and increases in Medicaid/CHIP coverage observed among pre-ACA eligible children after the implementation of the ACA ("welcome mat effects"). O ...[more]

PMID: 33161820

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Project description:ImportanceThe Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.ObjectiveTo assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.Design setting and participantsUsing 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.Main outcome and measuresThe main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.ResultsThe primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.Conclusions and relevanceIn this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.

Project description:In the United States, health insurance is not universal. Observational studies show an association between uninsured parents and children. This association persisted even after expansions in child-only public health insurance. Oregon's randomized Medicaid expansion for adults, known as the Oregon Experiment, created a rare opportunity to assess causality between parent and child coverage.To estimate the effect on a child's health insurance coverage status when (1) a parent randomly gains access to health insurance and (2) a parent obtains coverage.Oregon Experiment randomized natural experiment assessing the results of Oregon's 2008 Medicaid expansion. We used generalized estimating equation models to examine the longitudinal effect of a parent randomly selected to apply for Medicaid on their child's Medicaid or Children's Health Insurance Program (CHIP) coverage (intent-to-treat analyses). We used per-protocol analyses to understand the impact on children's coverage when a parent was randomly selected to apply for and obtained Medicaid. Participants included 14409 children aged 2 to 18 years whose parents participated in the Oregon Experiment.For intent-to-treat analyses, the date a parent was selected to apply for Medicaid was considered the date the child was exposed to the intervention. In per-protocol analyses, exposure was defined as whether a selected parent obtained Medicaid.Children's Medicaid or CHIP coverage, assessed monthly and in 6-month intervals relative to their parent's selection date.In the immediate period after selection, children whose parents were selected to apply significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a nonsignificant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent's selection compared with children whose parents were not selected (adjusted odds ratio [AOR]=1.18; 95% CI, 1.10-1.27). The effect remained significant during months 7 to 12 (AOR=1.11; 95% CI, 1.03-1.19); months 13 to 18 showed a positive but not significant effect (AOR=1.07; 95% CI, 0.99-1.14). Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage (AOR=2.37; 95% CI, 2.14-2.64).Children's odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents' access to Medicaid coverage and their children's coverage.

Dataset Information

The Role of Marketplace Policy on Welcome Mat Effects for Children Eligible for Medicaid or the Children's Health Insurance Program.

Publications

The Role of Marketplace Policy on Welcome Mat Effects for Children Eligible for Medicaid or the Children's Health Insurance Program.

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