Terrizzi Sabrina, Mathews-Schultz A Lanethea, Deegan Michele Moser
Moravian University, Economics and Business Department, 1200 Main Street, Bethlehem, PA 18018, United States.
Muhlenberg College, Department of Political Science, 2400 Chew St, Allentown, PA 18104, United States.
Health Policy Open. 2021 Dec 2;3:100059. doi: 10.1016/j.hpopen.2021.100059. eCollection 2022 Dec.
States retain significant power over key components of Affordable Care Act implementation. Using data from the US Census from 2010 to 2018, we examine how states' decisions to either establish state-run marketplaces or to default to the federal marketplace influenced the distribution of health insurance types within states. We find, somewhat counterintuitively, that state-based marketplaces are associated with greater change in enrollment for Medicaid compared to the federal marketplace. These findings confirm that, at least until 2018, the most significant increases in insurance coverage resulting from the ACA were in public insurance, rather than private insurance. We explore a number of possible explanations to help explain these findings, raising important questions about the efficacy of the individual mandate (a key mechanism in legislative efforts to reduce the numbers of uninsured), the related administrative burdens associated with state and federal marketplaces, and, equally as important, differential access to Medicaid entitlements among citizens living in different states-access that hinges not only or always on Medicaid expansion, but also and perhaps more importantly, on policy decisions about insurance marketplaces.
各州在《平价医疗法案》实施的关键组成部分上仍保留着重大权力。利用2010年至2018年美国人口普查的数据，我们研究了各州决定建立州立医保市场还是默认采用联邦医保市场如何影响州内医疗保险类型的分布。我们发现，有点违反直觉的是，与联邦医保市场相比，基于州的医保市场与医疗补助参保人数的更大变化相关。这些发现证实，至少在2018年之前，《平价医疗法案》带来的保险覆盖范围最显著的增加是在公共保险方面，而非私人保险。我们探讨了一些可能的解释来帮助说明这些发现，这引发了关于个人强制参保（立法努力减少未参保人数的关键机制）的效力、与州和联邦医保市场相关的行政负担，以及同样重要的是，居住在不同州的公民获得医疗补助资格的差异——这种获得不仅或总是取决于医疗补助的扩大，而且也许更重要的是，取决于关于保险市场的政策决定等重要问题。
