Publications by Fredric Blavin for Health Policy Center

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

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.

This study creates a pre-reform baseline trend for an evaluation of the Affordable Care Act’s (ACA) impact on health insurance coverage in the United States. Using the 2000 to 2010 Current Population Survey (CPS), this brief analyzes coverage trends among children, parents, and childless adults, overall and by ACA-relevant income groups. We find that over the past decade, rates of employer-sponsored insurance (ESI) have steadily deteriorated across these population groups, with more substantial declines occurring among the lower-income categories; all three population groups saw increases in Medicaid/CHIP coverage, with children experiencing the largest increase; and the percent of parents and childless adults without health insurance steadily increased whereas the percent of children without health insurance has slightly decreased.

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.

This paper presents several options designed to help the Commonwealth of Massachusetts move to universal health insurance coverage. The alternatives all build upon a common base that includes an expansion of the Medicaid program, income-related tax credits, a purchasing pool, and government-sponsored reinsurance. These measures in themselves would not yield universal coverage, nor would an employer mandate by itself. We show that an individual mandate, and an employer mandate combined with an individual mandate, both would yield universal coverage with a relatively small increase in government costs relative to state gross domestic product and current health spending.

Two-thirds of children in the United States were income-eligible for Medicaid or the State Children's Health Insurance Program (SCHIP) at some point from 1996 to 2000. One in five children were income-eligible for both programs, and 73 percent of children ever eligible for SCHIP were eligible at other times for Medicaid. As SCHIP is reauthorized, Congress will need to give states the tools and financial commitment to assure that uninsured children are enrolled in and retain the coverage for which they are eligible.

This article examines experiences under Medicaid and the State Children's Health Insurance Program (SCHIP), drawing on surveys of over 3,000 enrollees in California and North Carolina in 2002. In both States, Medicaid enrollees were less likely than SCHIP enrollees to have parents who were covered by employer-sponsored insurance (ESI). With the exception of dental care and provider perceptions, access experiences were fairly comparable across the two programs, despite differences in the characteristics of the children served by the two programs. Relative to being uninsured, Medicaid enrollment was found to improve access to care along a number of different dimensions, controlling for other factors. Furthermore, this study emphasizes the need for continued evaluation of access to care for both programs.

Congress mandated in the Balanced Budget Refinement Act of 1999 (BBRA) that the Secretary of the U.S. Department of Health and Human Services conduct an independent comprehensive study of the State Children's Health Insurance Program (SCHIP). This report presents the findings from the mandated surveys of SCHIP enrollees and disenrollees in 10 states (conducted during 2002). SCHIP programs were found to provide health coverage to the population SCHIP was intended to serve, primarily children who would otherwise have been uninsured. The programs availed enrollees of needed primary and other health care services, and were found to have a positive impact on enrollees' access to health care services, leaving enrollees with fewer unmet needs than they would have had in the absence of SCHIP. Families were satisfied with the ease of enrolling children, many of whom remained enrolled for 12 months, depending on the state.

This study uses 2000 to 2004 Current Population Survey data to examine the effects of public premiums on the insurance coverage of children whose family incomes are between 100% and 300% of the federal poverty level. The analysis employs multinomial logistic models that control for factors other than premium costs. While the magnitude of the estimated effects varies across models, the results consistently indicate that raising public premiums reduces enrollment in public programs, with some children who forgo public coverage having private coverage instead and others being uninsured. The results indicate that public premiums have larger effects when applied to lower-income families.
Inquiry, Volume 43, Number 4 (Winter 2006/2007): 345-361.

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