Publications by Matthew Buettgens for Health Policy Center

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More about Matthew Buettgens's areas of expertise can be found on this Urban Institute expert's page.

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.

The Affordable Care Act calls for the creation of health insurance exchanges in each state, where individuals and small employers can purchase health insurance. States have considerable flexibility in how they design and implement their health insurance exchanges. This study analyzes several exchange design options using the Urban Institute's Health Insurance Policy Simulation Model (HIPSM), looking specifically at the cost and coverage implications of creating separate versus merged small group and non-group markets; eliminating age rating in these markets; removing the small employer credit; and defining the size threshold for the small group market at 50 versus 100 workers.

We use the Health Insurance Policy Simulation Model to explore the correlations between a state's progress toward implementing the Affordable Care Act and the anticipated benefits of the reform for state residents, as measured by the expected state gains in insurance coverage and federal subsidies. We group states in three categories based on the status of legislative action and the receipt of level 1 federal establishment grants. We find that states that have made the least progress in establishing health insurance exchanges are in general those that have the largest potential gains in coverage and federal subsidy dollars per capita.

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.

When the Affordable Care Act is fully implemented, it will extend health insurance coverage to many uninsured adult Americans. New analysis projects that the ACA will also cut the number of uninsured children by about 40 percent and the number of uninsured parents by almost 50 percent, provided states continue their Medicaid and CHIP coverage for children. However, if the maintenance of effort requirement is rescinded and if Congress does not continue funding CHIP, the uninsurance rate for children could be higher than it is today.

The Congressional Budget Office, the Rand Corporation, and the Urban Institute have estimated that the Affordable Care Act (ACA) will leave employer-sponsored coverage largely intact; in contrast, some economists and benefit consultants argue that the ACA encourages employers to drop coverage thereby making both their workers and their firms better off (a “win–win" situation). This brief's analysis shows that no such "win–win" situation exists and that employer-sponsored insurance will remain most workers' primary source of coverage. Analysis of three issues-the terms of the ACA, worker characteristics, and the fundamental economics of competitive markets-supports this conclusion.

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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