Lessons from Analyses of Health Insurance Expansions from the 1980s through 2012

By | February 16, 2017

In a recent Medical Care article, Guy and colleagues analyzed health insurance expansions among parents from 1999 through 2012 to assess the impacts of four different types of public and private expansions. They primarily examined changes in parents’ health insurance coverage, but they also analyzed whether expanding coverage for parents could “spill over” and raise coverage rates for children of affected parents.

During the analysis time period, 10 states expanded public health insurance for parents and did not require a premium payment. Arizona’s no-premium public health insurance expansion in 2001 extended eligibility from 36% of the federal poverty line to 100%. Eight states expanded public health insurance, but required that enrollees pay a premium. Other expansions involved providing premium assistance for private plans (5 states) or offering special subsidized plans. The special subsidized plans typically offered subsidies to purchase a state-offered plan or a state-selected managed care plan. Five states’ expansions involved special subsidized plans: Arkansas (2006), Maine (2005), Massachusetts (2006), New Mexico (2005), and Vermont (2007). Twenty-two states that did not expand health insurance coverage for parents between 1999 and 2012 were used as controls.

Guy and colleagues observed that, on average, parents’ insurance coverage declined in both expansion and control states, but the decline in control states was much larger. Expansion states had parental health insurance coverage of 73.9% in 1999, which declined slightly to 71.5% in 2012. Control states, however, had average coverage of 72.7% in 1999, which declined to 61.5% in 2012. At the same time, Guy’s sample showed a decline in uninsurance for a parent and matching child in both expansion and control states. In expansion states, 15.8% of the parents and a matched child were uninsured in 1999, declining to 11.5% by 2012. In the control states, 16% of the parents and a matched child were uninsured in 1999, falling to 13.8% by 2012.

After controlling for other covariates and including state and year fixed effects, the authors found that no-premium public insurance expansions and special subsidized plans resulted in a 4 percentage point increase in parents’ insurance coverage, about 5% of the 1999 coverage of 73.9% in expansion states. The other two types of expansions resulted in small or no effects. The analysis also showed an apparent spillover to children’s coverage for the no-premium public expansions. They found a 1.8  percentage point reduction in the uninsured fraction for parents and their matched child, or about a 12% decline (relative to the average of 15.8% uninsured in 1999 in expansion states).

Results from this paper are consistent with findings from other analyses that have examined the impact of health insurance expansions at the state level from the 1980s up through the recent Affordable Care Act expansions. McMorrow et al. found that Medicaid expansions from the late 1990s through 2009 resulted in higher coverage and improved mental health outcomes among low-income parents. Sommers, Baicker, and Epstein examined the impact of Medicaid expansions for childless adults (19 to 64 years) for 3 states relative to controls. Consistent with the Guy et al. analysis, Sommers and colleagues found a 3.2 percentage point decrease in uninsurance rates. They also found a remarkable 6% relative reduction in mortality.

How can findings from the Guy article and other analyses of health insurance expansions inform ongoing health policy debates? First, findings consistently suggest that the structure of health insurance expansions matters a great deal. In general, upfront costs, such as premiums or high deductibles are a barrier to health insurance coverage and health care access, even if subsidies are available to offset costs. Second, although expanding health insurance coverage may improve health and mortality outcomes, expansions may also result in socioeconomic benefits  beyond health-related improvements. Lincoln Groves found evidence that expanding children’s access to health insurance led to higher graduation rates. And Kathleen McQueeney is exploring the impact of health insurance on family wealth and crime. As policy makers consider changes to health insurance policy, they should carefully weigh the evidence on the non-health, as well the health, impacts of expanded health insurance. Additional analyses of the impacts of health insurance continuity over the lifetime could also support evidence-based policy decisions.

Amanda Honeycutt

Amanda Honeycutt

Senior Economist at RTI International
Amanda A. Honeycutt, PhD, is a senior economist at RTI International, a not-for-profit research institute. She directs the Public Health Economics Program and conducts research on the burden of disease and the value of public health and health care interventions to prevent or treat disease and promote health.
Amanda Honeycutt