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

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.

Updated results from our Health Insurance Policy Simulation model show that, contrary to critics' claims, the law has a negligible impact on total employer-sponsored coverage and costs, leaves large business costs-per-person-insured largely untouched and makes small businesses-for whom coverage expands the most-financially better off, through tax credits and market efficiencies that lower premiums. Only among mid-size businesses does the ACA noticeably increase costs, largely due to increased enrollment. Our simulation does not reflect ACA cost containment provisions that may contain private as well as public cost growth-potentially slowing the decline of employer-sponsored health insurance that has been occurring for more than a decade.

While upholding the Affordable Care Act, the Supreme Court ruled that states could opt out of the Medicaid expansion without losing existing federal funding. In this report, we analyze Medicaid enrollment and costs for Washington under a full expansion to 138% FPL, expansion to 100% FPL, and no Medicaid expansion. By 2020, a full expansion would lead to 256,000 more adults and 16,000 more children enrolled than with no expansion. This would lead to $2.1 billion more in total spending on Medicaid. However, the difference in the state share would only be $115 million. Savings in uncompensated care could offset this increase.

Using the Health Insurance Policy Simulation Model, this report analyzes four policy options for assessing employers who do not provide affordable health insurance to their workers as Massachusetts brings its health reform law into compliance with the Affordable Care Act (ACA). Overall coverage and costs are similar across all options, but replacing the state's Fair Share Contribution (FSC) requirement with the ACA assessment would eliminate a source of state revenue. Similarly, maintaining the FSC for small employers only would raise one-fifth as much revenue as leaving the current assessment in place.

Many officials implementing the ACA are concerned about "churning," the involuntary movement of consumers from one health plan or coverage system to another. Churning makes programs more costly to administer and interrupts continuity of coverage and care. Unless measures are taken to reduce churning, 27 million nonelderly people will be forced to change coverage systems from year to year, two-thirds of whom will move between Medicaid and ineligibility for all subsidies. We estimate the impact of several steps states can take to reduce churning and mitigate its adverse effects. This is the first churning study to consider employer coverage offers.

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 Affordable Care Act provides states with the opportunity to develop health benefit exchanges – structured marketplaces for the purchase of health insurance coverage by small employers and individual purchasers. The law provides an array of design choices to the states in an effort to allow the exchanges to reflect varying preferences across the country. This analysis uses the Health Insurance Policy Simulation Model (HIPSM) to delineate the cost and coverage implications of a standard implementation of the ACA in New York compared to the no reform case, along with the differential effects of a number of alternative design options.

The "individual mandate"-the requirement that individuals either have health insurance coverage or pay a fine-is both the best known and the least popular component of the Affordable Care Act (ACA). That people know about the mandate-and may even worry about it-is not surprising, given both the heated political controversy and the constitutional challenge surrounding this provision of the law. What may be surprising, however, is that if the ACA were in effect today, 94 percent of the total population would not have to newly purchase insurance or pay a fine. While a small number of people would be affected by the individual responsibility requirement, the overall benefit to the population would be large, in terms of reducing premiums and increasing stability of insurance markets.

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