View Research by Author - Matthew Buettgens

Matthew Buettgens, PhD, is a mathematician leading the development of the Urban Institute's Health Insurance Policy Simulation (HIPSM) model. The model is currently being used to provide technical assistance for health reform implementation in Massachusetts, Missouri, New York, Virginia, and Washington as well as to the federal government. His recent work includes a number of papers analyzing various aspects of national health insurance reform, both nationally and state-by-state. Topics have included the costs and savings of health reform for both federal and state governments, state-by-state analysis of changes in health insurance coverage and the remaining uninsured, the effect of reform on employers, the role of the individual mandate, the affordability of coverage under health insurance exchanges, and the implications of age rating for the affordability of coverage. Dr. Buettgens was previously a major developer of the HIRSM model—the predecessor to HIPSM—used in the design of the 2006 roadmap to universal health insurance coverage in the state of Massachusetts.

Publications

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.

Insurers are calling attention to a potential "rate shock" that will push young adults out of the nongroup insurance market under the ACA due to limitations on premium differences by age. We compare the impact of the ACA's 3:1 rate band to a "looser" 5:1 alternative. Loosening the bands would have very little impact on out-of-pocket rates paid by the youngest purchasers once subsidies are taken into account. Also, the majority of young adults currently purchasing nongroup coverage will also be financially protected by the exchange subsidies, the ACA's Medicaid expansion, and the expansion of dependent coverage to young adults.

The Urban Institute developed a New York state-specific version of its Health Insurance Reform Simulation Model (HIPSM) to support to the state in its effort to assess the implications of the implementation of the Affordable Care Act (ACA). Initial findings from this work were made available in March of 2012.The tables presented here provide sub-state analyses, focusing on those without insurance coverage of any kind prior to reform. We show the share of uninsured expected to gain coverage under the ACA, and include the distribution of characteristics for those anticipated to gain insurance of each type whenever sample sizes allow.

The Affordable Care Act required states to expand their Medicaid programs to cover more low-income people, including mid-life adults. However, a recent U.S. Supreme Court decision, while upholding the rest of the health reform law, effectively turned the mandate into a state option. This brief examines the Court's decision and how uninsured midlife adults in states that take up this option could benefit.

The authors simulate the effect of the Affordable Care Act (ACA) in Alaska, both with and without the Medicaid expansion. The ACA would reduce the uninsured rate in Alaska from 21% without the ACA to 10% under the ACA with the expansion, or 15% without the expansion. The Medicaid expansion would increase enrollment 30% by 2020, while state Medicaid spending on the nonelderly would only increase 3.7%. The report includes a sensitivity analysis of Medicaid take-up rates and detailed characteristics of new enrollees by sub-state region.

Consumers offered employer-sponsored insurance (ESI) can be ineligible for subsidies in health insurance exchanges (HIX). Until better ESI data become available, HHS proposes using post-enrollment audits, rather than pre-enrollment verification for this eligibility requirement. Using the Health Insurance Policy Simulation Model (HIPSM), we find that more than 70 percent of eligible consumers work for firms that do not sponsor ESI. HIXes could thus avoid the need to audit them by developing databases that show which employers sponsor ESI. Alternatively, HIXes could target non-ESI recipients for audits based on HIPSM results that show their relative likelihood of being offered ESI.

The Affordable Care Act changes the small group insurance market substantially, but most of these changes do not apply to self-insured group plans. This exemption provides an opening for small employers with healthier workers to avoid broader sharing of health care risk, isolating higher-cost groups in the fully insured market. We simulate employer decisions under the ACA for a range of stop loss insurance plans, which mediate financial risk, and find that if low-risk stop loss policies are allowed, fully insured small group premiums could be higher by up to 25%. Regulation of stop loss could prevent such adverse selection.

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.

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