This study exploited the time variation in expansion program implementation and state variation in eligibility levels to assess the impact of childless adult health insurance expansions on insurance status and access to care. Results indicate that childless adult expansion programs resulted in significant gains in insurance coverage regardless of cost-sharing requirements. However, cost-sharing requirements were found to play an important role in providing access to preventive health screenings. The results indicate that the expansions had no impact on the likelihood of having a personal doctor or health care provider regardless of the cost-sharing requirement. Additionally, the cost-sharing level does not impact the likelihood of forgoing needed medical care due to costs, as both types of programs increase the probability that no financial barriers prevent eligible adults from seeking needed medical care.
These results indicate that eligible childless adults experience improved access to care during disease episodes regardless of the cost-sharing levels. While cost-sharing levels do not have an impact on having a personal doctor or removing barriers to care due to cost, cost-sharing plays an important role in providing access to recommended preventive health screenings. The use of preventive health screenings significantly increased among childless adults eligible for programs with traditional cost-sharing levels. In programs with increased cost sharing, there were either gains in screening utilization that were not statistically significant or no change that could be measured with the used methods.
States may implement increased cost-sharing requirements for a variety of reasons. Increased cost-sharing requirements have financial implications for states as they reduce the public outlay of the program by placing more of the financial burden on enrollees, and can help reduce the use of unnecessary medical services. Increased cost sharing in public insurance programs can also be used as a mechanism to reduce private insurance crowd-out by deterring those eligible from dropping their private insurance and joining public programs. Future studies need to address how various levels of cost sharing are impacting overall program costs and the extent of private insurance crowd-out.
If the goal of public health insurance expansions is to increase access to care when needed, then both types of programs are accomplishing that mission. However, if the goal of public health insurance expansions is to also increase the use of preventive services, then it appears that only those with traditional public insurance cost-sharing requirements will help achieve that goal. As shown, insurance expansions with traditional Medicaid cost-sharing requirements appear to lead to an increased use of preventive health screenings, which in turn could positively impact the rate of early detection of disease and lead to more treatment options and better outcomes among those enrolled. Increased cost-sharing requirements may not allow newly expanded insurance coverage to increase the use of clinically indicated preventive services. Failure to receive such services may result in later stage diagnosis and higher treatment costs over time.
The magnitude of the effects on insurance status and access to care found in this study are modest but similar in magnitude to other studies in the literature examining the effect of public health insurance expansions for adults (Kronick and Gilmer 2002
; Aizer and Grogger 2003
; Busch and Duchovny 2005
;). The magnitude of the effects found in this study may be small for several reasons; the availability of charity care has been shown to reduce the demand for health insurance and increase the likelihood of being uninsured, especially among the low-income population (Rask and Rask 2000
; Herring 2005
;). Additionally, information and administrative costs, along with the perceived stigma and reputation of public insurance have been shown to be important barriers to enrollment in public insurance programs (Aizer 2007
; Ketsche et al. 2007
While the results of this analysis demonstrate that adult health insurance expansions have led to increases in insurance coverage and access to care, much work is left to be done. With recent passage of the Patient Protection and Affordable Care Act (PPACA), Medicaid will be expanded to all citizens, including childless adults, up to 133 percent of the federal poverty level. Additionally, those between 133 and 400 percent of the federal poverty level will be eligible for subsidies to purchase coverage through insurance exchanges. The findings here indicate that expanding health insurance to low-income childless adults presents a promising opportunity to not only increase insurance rates but also to improve access to care. The elimination of cost-sharing requirements for recommended preventive services has the potential to significantly increase the utilization of preventive health services among the newly insured population. However, in order to achieve the large reductions in the number of uninsured as anticipated under PPACA, the expansions must be carefully designed and implemented in an effort to limit enrollment barriers. It is clear that more work needs to be done to better understand these barriers and the role they will play under PPACA. Additionally, it will be important to understand whether the individual insurance mandate, and the related financial penalty for remaining uninsured, helps lead to the magnitude of increases anticipated.