View Research by Author - Caitlin Carroll

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Adding Medicaid expansion to the remainder of the Patient Protection and Affordable Care Act (ACA) would increase Ohio’s Medicaid costs between $2.4 and $2.5 billion during FY 2014 to 2022. The state could reduce $1.5 billion in spending on medically needy adults, inpatient prison costs, and other services to the poor uninsured. Expansion would yield $2.7 and $2.8 billion in new revenue, including premium taxes, general revenue from economic activity generated by increased federal Medicaid dollars, and prescription drug rebates. Altogether, expansion would generate between $1.8 and $1.9 billion in net state budget gains while covering more than 400,000 uninsured.

State decisions to expand Medicaid have important implications for hospitals. There are a number of provisions in the Affordable Care Act that will reduce hospital payments - lower rates of Medicare reimbursement and cut backs in Medicare and Medicaid disproportionate share hospital payments. On the other hand, hospitals stand to gain considerably from the added insurance coverage because of the Medicaid expansion. Fewer uninsured will mean higher revenues to hospitals. However, some newly covered Medicaid patients will have formally been privately insured. For these patients, Medicaid will typically pay less than private insurance. On balance, we show that for each $1.0 in private revenue that the Medicaid expansion eliminates, hospitals Medicaid revenue increases by $2.59.

This paper examines the effect, by state, of the state's decision to adopt the Medicaid expansion. It also estimates the impact of the state’s decision on Medicaid enrollment and the number of uninsured. The paper shows that if all states implement the Affordable Care Act (ACA) Medicaid expansion, the federal government will fund the vast majority of the increase in Medicaid states. Due to several provisions of the ACA, states will face increased enrollment even if they do not implement the Medicaid expansion. The additional cost of implementing the expansion is small relative to total state spending without the expansion and relative to large increases in federal funding and current state budget expenditures.

Using the American Community Survey augmented with results from the Urban Institute's Health Insurance Policy Simulation Model, we estimated eligibility, enrollment, and costs for a Basic Health Program (BHP) for Utah under the Affordable Care Act. We find that 55,000 Utahns would qualify for BHP; between 31,000 and 41,000 would likely enroll. Federal BHP payments would likely exceed state costs, with the amount depending on BHP plan cost sharing. BHP would reduce the size of the nongroup exchange by about a quarter, leaving about 120,000 covered lives.

The House Budget Plan that would repeal the Affordable Care Act (ACA) and convert Medicaid to a block grant would trigger significant decreases in federal Medicaid spending and could result in substantial reductions in enrollment and payments to providers compared to current projections. The analysis finds that projected federal spending on Medicaid for the period 2013 to 2022 would fall by $1.7 trillion compared to current estimates, a 38 percent decline. Of that total, $932 billion in spending reductions would come from the repeal of the federal support for the ACA Medicaid expansion and another $810 billion would be due to federal Medicaid spending reductions that accompany the block grant. State-specific estimates are provided.

Full implementation of the Affordable Care Act (ACA) will add some 330,000 people to the Medicaid rolls in Washington state and a much smaller number for the Children's Health Insurance Program (CHIP). The state’s cost per new enrollee will be low, however, when compared with current enrollees. The new enrollees are projected to be younger and healthier, and the ACA's new eligible will require a much lower state contribution -- down from 50 percent of medical spending to zero percent initially, rising to 10 percent over time. These are the key findings among numerous projections, which combined the results of prior Urban Institute microsimulation of coverage choices and health care costs with the large population sample of the Washington State Population Survey.

Using the Washington State Population Survey (WSPS) augmented with results from the Urban Institute's Health Insurance Policy Simulation Model (HIPSM), we estimated eligibility, enrollment, and costs for a Basic Health Program (BHP) for Washington State under the rules defined in the Affordable Care Act (ACA). We find that more than 160,000 Washington residents would be eligible for BHP. Enrollment would be between 75,000 and 111,000. Even with BHP, the exchange in Washington would still cover about 250,000 lives, and BHP would not notably affect premiums in the individual market.

Racial and ethnic differentials in uninsurance rates could be greatly reduced under the Affordable Care Act, potentially cutting the black-white differential by more than half and the Hispanic-white differential by just under one-quarter. Improving coverage for these populations will depend on states adopting policies that promote high enrollment in Medicaid/CHIP and new insurance exchanges. Coverage gains among Hispanics will depend on policies in California and Texas (where almost half of Hispanics live). If the projected coverage gains are realized, long-standing racial and ethnic differentials in access to care and health status could shrink considerably. This research was funded in part by the Annie E. Casey Foundation.

The federal requirement for most Americans to have health insurance-the individual mandate-is an important part of how the ACA would reduce the number of uninsured. We use the Health Insurance Policy Simulation Model to estimate the effects of health reform with and without the mandate. With the mandate, the number of uninsured would decrease from 50 million to 26 million. Without a mandate, about 40 million would remain uninsured. Depending on the effectiveness of the health benefit exchanges in enrolling those eligible for subsidized coverage, exchange premiums would be 10 to 25 percent higher without a mandate.

We estimate national and state effects of implementing the Basic Health Program option in national health reform to provide near-poor adults with coverage like Medicaid and the Children's Health Insurance Program. Implemented nationally, such a policy would reduce these adults' annual premium and out-of-pocket costs from $1,652 to $196; lower the number of uninsured by 600,000; provide federal dollars that exceed baseline Medicaid/CHIP costs by 23 percent; reduce exchange enrollment from 9.8 to 8.2 percent of non-elderly residents; save states $1.3 billion annually in Medicaid costs; and raise risk levels in individual markets. State policy choices could change these results.

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