The Dynamics Of Medicaid Enrollment, Employment, And Beneficiary Health Status.

Some policy makers are proposing Medicaid work or community engagement requirements. Using national data, we found that 13.9 percent of new, nonelderly adult Medicaid beneficiaries in 2015-16 had experienced a decline in health before enrollment, and a similar percentage had had jobs that ended before they enrolled. These findings highlight the need for careful design of work requirement policies.

High-Deductible Health Plan Enrollment Increased From 2006 To 2016, Employer-Funded Accounts Grew In Largest Firms.

Over the past decade, employers have increasingly turned to high-deductible health plans (HDHPs) to limit health insurance premium growth. We used data from private-sector establishments for 2006 and 2016 from the Medical Expenditure Panel Survey-Insurance Component to examine trends in HDHP enrollment and heterogeneity in HDHPs by firm size. We studied insurance plan offerings along the following dimensions: whether employers fund accounts to help defray employees' out-of-pocket health care spending, the availability of non-HDHP plan choices, and single and family deductible levels. We extend the literature by examining these characteristics by detailed firm-size categories and by including all plans with deductibles that met or exceeded Internal Revenue Service thresholds to be qualified for health savings accounts. We found that in 2016, 78.0 percent of HDHP enrollees in the smallest firms (those with fewer than 25 employees) lacked an employer-funded account, compared to 35.2 percent in the largest firms (those with 1,000 or more employees). Overall, HDHP enrollees in the largest firms had significant advantages relative to workers in smaller firms along all of the dimensions examined.

Duration Of Uninsured Spells For Nonelderly Adults Declined After 2014.

Using longitudinal data from the Medical Expenditure Panel Survey-Household Component (MEPS-HC), we found that nonelderly respondents in 2014-15, following implementation of ACA coverage provisions, experienced shorter periods of being uninsured than did respondents in 2012-13 and 2013-14. This was particularly true for people with preexisting (or "high-risk-pool") health conditions.

Substantial Churn In Health Insurance Offerings By Small Employers, 2014-15.

New data for 2014-15 from the Medical Expenditure Panel Survey-Insurance Component longitudinal survey show substantial churn in insurance offers by small employers (those with fifty or fewer workers), with 14.6 percent of employers that offered insurance in 2014 having dropped it in 2015 and 5.5 percent of those that did not offer it adding coverage.

The availability and marginal costs of dependent employer-sponsored health insurance.

In this study, we examine differences by firm size in the availability of dependent coverage and the incremental cost of such coverage. We use data from the Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) to show that among employees eligible for single coverage, dependent coverage was almost always available for employees in large firms (100 or more employees) but not in smaller firms, particularly those with fewer than 10 employees. In addition, when dependent coverage was available, eligible employees in smaller firms were more likely than employees in large firms to face two situations that represented the extremes of the incremental cost distribution: (1) they paid nothing for single or family coverage or (2) they paid nothing for single coverage but faced a high contribution for family coverage. These results suggest that firm size may be an important factor in policy assessments, such as analyses of the financial implications for families excluded from subsidized Marketplace coverage due to affordable offers of single coverage or of potential rollbacks to public coverage for children.

Gaining Coverage In 2014: New Estimates Of Marketplace And Medicaid Transitions.

We used data from the Medical Expenditure Panel Survey-Household Component to examine coverage transitions for nonelderly US adults. We found that 71.5 percent of Marketplace enrollees in 2014 had some period of uninsurance before enrollment. In Medicaid expansion states, 17.4 percent of adults who were uninsured throughout 2013 gained Medicaid coverage in 2014, compared with only 5.6 percent in those states between 2012 and 2013.

Access To Care Improved For People Who Gained Medicaid Or Marketplace Coverage In 2014.

Newly available longitudinal survey data show that people who lacked health insurance in 2013 and gained coverage through Medicaid or the Marketplaces in 2014 were far more likely to obtain a usual source of care and receive preventive care services than their counterparts who remained uninsured in 2014.

Several Factors Responsible For The Recent Slowdown In Premium Growth In Employer-Sponsored Insurance.

Containing growth in health care spending is important to the long-term fiscal health of the United States. Researchers have been seeking to identify which factors behind the recent spending slowdown might continue to have an impact after the economy has fully recovered from the Great Recession (2007-09). We extended this inquiry by decomposing trends in the growth of private-sector employer-sponsored insurance premiums. Using data for 2001-13 from the Medical Expenditure Panel Survey-Insurance Component and a combination of cell- and regression-based decomposition methods, we found that the slowdown in premium growth that preceded the recession reflected declining growth rates in per policyholder premiums. For 2009-11, however, the dominant contributors to the slowdown were factors underlying declining employee enrollment: a sharp downturn in employment in 2009, followed by eroding offer and eligibility rates. Growth in per policyholder premiums slowed in 2012 and 2013 compared to the preceding few years. Like other researchers, we found that a substantial portion of premium growth remained unexplained. However, it is likely driven, in part, by growth in the underlying cost of medical care.

Many families may face sharply higher costs if public health insurance for their children is rolled back.

Millions of US children could lose access to public health care coverage if Congress does not renew federal funding for the Children's Health Insurance Program (CHIP), which is set to expire September 30, 2015­the end of the federal fiscal year. Additional cuts in public coverage for children in families with incomes above 133 percent of the federal poverty level are possible if the Affordable Care Act's "maintenance of effort" provisions regarding Medicaid and CHIP are allowed to expire as scheduled in 2019. The potential for a significant rollback of public coverage for children raises important policy questions regarding alternative pathways to affordable and high-quality coverage for low-income children. For many children at risk of losing eligibility for public coverage, the primary alternative pathway to coverage would be through their parents' employer-sponsored insurance, yet relatively little is known about the cost and quality of that coverage. Our estimates, based on data from the Insurance Component of the 2012 and 2013 Medical Expenditure Panel Surveys, show that many families would face sharply higher costs of covering their children. In many cases, the only employer-sponsored coverage available would be a high-deductible plan.

Declines in employer-sponsored insurance between 2000 and 2008: examining the components of coverage by firm size.

OBJECTIVE: To examine trends in employer-sponsored health insurance coverage rates and its associated components between 2000 and 2008, to provide a baseline for later evaluations of the Affordable Care Act, and to provide information to policy makers as they design the implementation details of the law. DATA SOURCES: Private sector employer data from the 2000, 2001, and 2008 Medical Expenditure Panel Survey-Insurance Component (MEPS-IC). STUDY DESIGN: We examine time trends in employer offer, eligibility, and take-up rates. We add a new dimension to the literature by examining dependent coverage and decomposing its trends. We investigate heterogeneity in trends by firm size. DATA COLLECTION: The MEPS-IC is an annual survey, sponsored by the Agency for Healthcare Research and Quality and conducted by the U.S. Census Bureau. The MEPS-IC obtains information on establishment characteristics, whether an establishment offers health insurance, and details on up to four plans. PRINCIPAL FINDINGS: We find that coverage rates for workers declined in both small and large firms. In small firms, coverage declined due to a drop in both offer and take-up rates. In the largest firms, offer rates were stable and the decline was due to falling take-up rates. In addition, enrollment shifted toward single coverage and away from dependent coverage in both small and large firms. For small firms, this shift was due to declining offer and take-up rates for dependent coverage. In large firms, offers of dependent coverage were stable but take-up rates dropped. Within the category of dependent coverage, the availability of employee-plus-one plans increased in all firm size categories, but take-up rates for these plans declined in small firms.

The health insurance status of low-wage workers: the role of workplace composition and marital status.

Many of the provisions in the Affordable Care Act (ACA), such as tax credits and penalties for employers, vary by employer size and average wage level. Therefore, knowing the wage and firm size distribution of low-wage workers and how employer-sponsored insurance (ESI) characteristics vary by these dimensions is particularly important for understanding the extent to which low-wage workers and their employers may be affected by different provisions in the ACA. To inform this issue, the authors use data from the 2006 Medical Expenditure Panel Survey-Insurance Component to examine offers of coverage and cost-sharing requirements by the wage distribution and firm size dimensions of employers. They also draw on Medical Expenditure Panel Survey household-level data to describe the household circumstances of low-wage workers. The authors find that where low-wage workers are employed, who their colleagues are, and their spouses' wage levels are important factors in determining low-wage workers' access to coverage and the cost and generosity of such coverage.

Premium growth and its effect on employer-sponsored insurance.

We use variation in premium inflation and general inflation across geographic areas to identify the effects of downward nominal wage rigidity on employers' health insurance decisions. Using employer level data from the 2000 to 2005 Medical Expenditure Panel Survey-Insurance Component, we examine the effect of premium growth on the likelihood that an employer offers insurance, eligibility rates among employees, continuous measures of employee premium contributions for both single and family coverage, and deductibles. We find that small, low-wage employers are less likely to offer health insurance in response to increased premium inflation, and if they do offer coverage they increase employee contributions and deductible levels. In contrast, larger, low-wage employers maintain their offers of coverage, but reduce eligibility for such coverage. They also increase employee contributions for single and family coverage, but not deductibles. Among high-wage employers, all but the largest increase deductibles in response to cost pressures.

Overweight in adolescents: implications for health expenditures.

We consider a compelling research question raised by the growing prevalence of overweight among adolescents: do overweight adolescents incur greater health care expenditures than adolescents of normal weight? To address this question, we use data from the Medical Expenditure Panel Survey (MEPS) and estimate a two-part, generalized linear model (GLM) of health spending. Considering separate models by gender, we find that overweight females incur $790 more in annual expenditures than those of normal weight but we find no expenditure differences by bodyweight for males. We find that mental health spending is associated with part of the disparity in expenditures for adolescent females but establishing causality between mental health problems and weight-related health expenditure differences is challenging.

Health insurance enrollment decisions: preferences for coverage, worker sorting, and insurance take-up.

The weak response by the uninsured to initiatives encouraging voluntary enrollment in health insurance has raised concerns regarding the extent to which the uninsured value insurance. This concern is also relevant for proposals to mandate health insurance coverage since workers will suffer welfare losses if compelled to purchase coverage they perceive to be of little value. To address this issue, we use the 2001 Medical Expenditure Panel Survey to examine decisions by single workers to seek out and enroll in employer-sponsored insurance. We find that single workers with weak or uncertain preferences for health insurance are less likely to have jobs that offer coverage or to enroll in coverage when offered. Our results suggest a dual approach to expanding coverage that includes both subsidies and educational efforts regarding the value of health insurance.

Pathways to coverage: the changing roles of public and private sources.

Using data from the Medical Expenditure Panel Surveys for 1997 and 2005, spanning the eight-year period after enactment of the State Children's Health Insurance Program (SCHIP), we examine whether the composition of insurance coverage has changed for working families. Public coverage has played an increasingly important role for working families with children. For families without access to job-based insurance, roughly two-thirds of single-parent and over half of two-parent families with children had at least one family member covered by public insurance in 2005. Among families with access to job-based insurance, nearly half of minority single-parent families had at least one family member with public coverage.

A closer look at the managed care backlash.

BACKGROUND: Much anecdotal evidence exists regarding the managed care backlash of the late 1990s, but limited empirical evidence is available. OBJECTIVES: Using a unique series of employer surveys, we examined trends in enrollment rates in health maintenance organizations (HMOs) and other plan types between 1997 and 2003. RESEARCH DESIGN: We present enrollment rates in employer-sponsored health plans by plan type. These plan-level enrollment rates are disaggregated by whether or not enrollees had a choice of plan types and by firm size and year. SUBJECTS: Employees who were enrolled in employer-sponsored health insurance in private sector establishments. RESULTS AND CONCLUSIONS: Although we found evidence of a decline in the popularity of HMOs, it occurred later than indicated in earlier studies. In our data, HMO enrollment rates fell from roughly 32% to 26% between 1997 and 2003, with most of the decline occurring after 2001. Earlier studies reported that the decline in HMO enrollment rates occurred between 1996 and 1998, and between 2000 and 2001. In addition, an interesting story emerged when we examined trends by firm size. We found evidence of a decline in the HMO enrollment rate for large employers starting in 1998. However, this was offset by an increase in the HMO enrollment rate in small employers, which explains the stability in our figures before 2002. Our data also indicated that when workers were given a choice between an HMO and other plan types, workers increasingly opted for the non-HMO plan during this time period.

Employer choices of family premium sharing.

In 1997, nearly two-thirds of married couples with children under age 18 were dual-earner couples. Such families may have a variety of insurance options available to them. If so, declining a high employee premium contribution may be a mechanism for one spouse to take money wages in lieu of coverage while the other spouse takes coverage rather than high wages. Employers may use these preferences and the size of premium contributions to encourage workers to obtain family coverage through their spouse. The purpose of this paper is to explore the effects of labor force composition, particularly the proportion of dual-earner couples in the labor market, on the marginal employee premium contribution (marginal EPC) for family coverage. We analyze data from the 1997-2001 Medical Expenditure Panel Survey--Insurance Component (MEPS-IC) List Sample of private establishments. We find strong evidence that the marginal EPC for family coverage is higher when there is a larger concentration of women in the workforce, but only in markets with a higher proportion of dual-earner households.

The effect of SCHIP expansions on health insurance decisions by employers.

This study uses repeated cross-sectional data from the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC), a large nationally representative survey of establishments, to investigate the effect of the State Children's Health Insurance Program (SCHIP) on health insurance decisions by employers. The data span the years 1997 to 2001, the period when states were implementing SCHIP. We exploit cross-state variation in the timing of SCHIP implementation and the extent to which the program increased eligibility for public insurance. We find evidence suggesting that employers whose workers were likely to have been affected by these expansions reacted by raising employee contributions for family coverage options, and that take-up of any coverage, generally, and family coverage, specifically, dropped in these establishments. We find no evidence that employers stopped offering single or family coverage outright.

The demand for dependent health insurance: how important is the cost of family coverage?

From the mid-1980s to the mid-1990s, the proportion of non-elderly Americans with employment-based health insurance declined. Roughly 80% of this decline was due to the loss of coverage by dependent family members. During this period, workers became increasingly responsible for the costs of family coverage, while expanded Medicaid coverage provided low-income working families with an alternative to employment-based insurance. We examine the role of out-of-pocket premiums and expanded Medicaid eligibility in households' demand for employment-based family coverage. Cross-sectional results reveal that demand is affected by both factors. We find that between 1987 and 1996, the increase in out-of-pocket premium costs accounted for nearly half of the decline in dependent coverage while expanded Medicaid eligibility represented 14% of the decline.

Workers' decisions to take-up offered health insurance coverage: assessing the importance of out-of-pocket premium costs.

BACKGROUND: Many proposed policy initiatives involve subsidies directed toward encouraging employers to offer coverage and toward workers to encourage enrollment in offered plans. Given that insurance coverage reflects employers' decisions to offer coverage, eligibility requirements for such coverage, and employees' take-up decisions, all three elements are important when considering mechanisms to decrease the number of uninsured individuals. RESEARCH DESIGN: In this study, we examine the relationship between workers' decisions to take-up offers of health insurance and annual out-of-pocket contributions, total premiums, and employer and workforce characteristics. We model the take-up decision using cross-sectional data from approximately 18,000 establishments per year from the 1997 to 1999 Medical Expenditure Panel Survey - Insurance Component. RESULTS: We find that workers are less likely to enroll in coverage as single employee contributions increase. Our results for family contributions are much smaller than for single contributions and are not statistically significant in all years. Our simulation results suggest that reducing employee contribution levels for single coverage from existing levels in 1999 to zero would yield an increase in take-up rates of roughly 6% points in establishments that had required a positive level of contributions. Our results also indicate that of the 13.8 million private sector workers who decline coverage from their employers, 2.5 million would potentially enroll in employer-sponsored coverage if the cost of single coverage were to fall to zero. CONCLUSION: Reducing employee contributions will increase take-up rates; however, even when employees pay nothing for their coverage, some employees elect not to enroll.