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Under the Affordable Care Act, thirty states and the District of Columbia have expanded eligibility for Medicaid, with several states using Medicaid funds to purchase private insurance (the "private option"). Despite vigorous debate over the use of private insurance versus traditional Medicaid to provide coverage to low-income adults, there is little evidence on the relative merits of the two approaches. We compared the first-year impacts of traditional Medicaid expansion in Kentucky, the private option in Arkansas, and nonexpansion in Texas by conducting a telephone survey of two distinct waves of low-income adults (5,665 altogether) in those three states in November-December 2013 and twelve months later. Using a difference-in-differences analysis, we found that the uninsurance rate declined by 14 percentage points in the two expansion states, compared to the nonexpansion state. In the expansion states, again compared to the nonexpansion state, skipping medications because of cost and trouble paying medical bills declined significantly, and the share of individuals with chronic conditions who obtained regular care increased. Other than coverage type and trouble paying medical bills (which decreased more in Kentucky than in Arkansas), there were no significant differences between Kentucky's traditional Medicaid expansion and Arkansas's private option, which suggests that both approaches improved access among low-income adults. [ABSTRACT FROM AUTHOR]

In June 2018 Arkansas became the first US state to implement work requirements in Medicaid, requiring adults ages 30-49 to work twenty hours a week, participate in "community engagement" activities, or qualify for an exemption to maintain coverage. By April 2019, when a federal judge put the policy on hold, 18,000 adults had already lost coverage. We analyze the policy's effects before and after these events, using a telephone survey performed in late 2019 of 2,706 low-income adults in Arkansas and three control states compared with data from 2016 and 2018. We have four main findings. First, most of the Medicaid coverage losses in 2018 were reversed in 2019 after the court order. Second, work requirements did not increase employment over eighteen months of follow-up. Third, people in Arkansas ages 30-49 who had lost Medicaid in the prior year experienced adverse consequences: 50 percent reported serious problems paying off medical debt, 56 percent delayed care because of cost, and 64 percent delayed taking medications because of cost. These rates were significantly higher than among Arkansans who remained in Medicaid all year. Finally, awareness of the work requirements remained poor, with more than 70 percent of Arkansans unsure whether the policy was in effect. [ABSTRACT FROM AUTHOR]

Major policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of the ACA's coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in "excellent" self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health. [ABSTRACT FROM AUTHOR]

Changes in insurance coverage over time, or "churning," may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a "private option" expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months--a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts. [ABSTRACT FROM AUTHOR]

States are taking variable approaches to the Affordable Care Act (ACA) Medicaid expansion, Marketplace design, enrollment outreach, and application assistance. We surveyed nearly 3,000 low-income adults in late 2014 to compare experiences in three states with markedly different policies: Kentucky, which expanded Medicaid, created a successful state Marketplace, and supported outreach efforts; Arkansas, which enacted the private option and a federal-state partnership Marketplace, but with legislative limitations on outreach; and Texas, which did not expand Medicaid and passed restrictions on navigators. We found that application rates, successful enrollment, and positive experiences with the ACA were highest in Kentucky, followed by Arkansas, with Texas performing worst. Limited awareness remains a critical barrier: Fewer than half of adults had heard some or a lot about the coverage expansions. Application assistance from navigators and others was the strongest predictor of enrollment, while Latino applicants were less likely than others to successfully enroll. Twice as many respondents felt that the ACA had helped them as hurt them (although the majority reported no direct impact), and advertising was strongly associated with perceptions of the law. State policy choices appeared to have had major impacts on enrollment experiences among low-income adults and their perceptions of the ACA. [ABSTRACT FROM AUTHOR]

Expansion of Medicaid under the Affordable Care Act to millions of low-income adults has been controversial, yet little is known about what these Americans themselves think about Medicaid. We conducted a telephone survey in late 2013 of nearly 3,000 low-income adults in three Southern states-Arkansas, Kentucky, and Texas-that have adopted different approaches to the options for expansion. Nearly 80 percent of our sample in all three states favored Medicaid expansion, and approximately two-thirds of uninsured respondents said that they planned to apply for either Medicaid or subsidized private coverage in 2014. Yet awareness of their state's actual expansion plans was low. Most viewed having Medicaid as better than being uninsured and at least as good as private insurance in overall quality and affordability. While the debate over Medicaid expansion continues, support for expansion is strong among low-income adults, and the perceived quality of Medicaid coverage is high. [ABSTRACT FROM AUTHOR]