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Study tracks potential coverage gaps under Affordable Care Act

Sep. 13, 2012, 9:13 AM

An analysis of Massachusetts’ health care reform program by a Vanderbilt researcher indicates insurance gaps may remain as the Affordable Care Act (ACA) expands insurance coverage beginning in 2014.

John Graves, Ph.D., assistant professor of Preventive Medicine and a policy expert for the Institute of Medicine and Public Health, co-authored the report published in the Sept. 5 New England Journal of Medicine, which examined periods without insurance in Massachusetts before and after the state’s 2006 health reforms.

John Graves, Ph.D.

“Because of the high cost and complexity of the Affordable Care Act, there is a great demand for information about how it might be implemented most effectively as care is expanded to 32 million uninsured Americans,” Graves said. “The ACA is similar to the Massachusetts reforms, providing clues about where gaps remain.”

The Massachusetts health care reforms expanded insurance coverage options for people not covered under Medicaid or employer insurance. Massachusetts residents can shop for private insurance through an insurance exchange — a web portal that closely resembles how many people will shop for insurance in all states in 2014 under the ACA.

Those with incomes up to three times higher than the poverty line will be eligible for state and federally subsidized coverage options through Medicaid and the exchange.

Graves and his co-author reviewed the fluctuations in numbers of insured people in Massachusetts and compared them with nearby states.

They found the median amount of time people remained uninsured dropped from 12 months to eight between 2006 and 2009. But they found specific groups of people who saw little change in their coverage rates, specifically those who were uninsured for the shortest, and the longest, periods of time.

Graves said about 25 percent of uninsured Massachusetts residents fell into a group that remained without insurance for the longest time period — more than two years.

The proportion of uninsured people for this length of time or longer was little changed after 2006 reforms, and it remained nearly identical to other states.

“This may be because these workers were employed, and were eligible for employer sponsored insurance they could not afford. Under the Massachusetts plan, if they cannot afford this insurance they are exempt from the individual mandate but ineligible for subsidies to purchase coverage through the state’s insurance exchange,” Graves said.

Similarly, those who were uninsured for a very short period of time, about three months, remained unchanged as well despite Massachusetts’ reform.

Graves said this may represent people who temporarily go without coverage when they are in-between jobs, or who are waiting to become eligible for employer insurance once after they start a new position.

Graves and his co-author, Katherine Swartz, Ph.D., professor of Health Economics and Policy at the Harvard School of Public Health, say it is important for policymakers to begin now to consider ways to address these gaps.

They also say knowing more about the people affected by these gaps is especially important to hospitals as disproportionate share (DSH) payments are dramatically reduced under the ACA.

Those payment reductions were designed under the assumption that the long-term uninsured would be covered and would no longer need uncompensated care at acute care hospitals.

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