It is well documented that lack of health insurance negatively affects access to care and health outcomes. Uninsured people are less likely, compared to those with health insurance, to have usual source of care and receive necessary care primarily due to the cost, leading to detrimental health consequences. The Medicaid expansions under the Patient Protection and Affordable Care Act (ACA) were intended to provide access to health insurance coverage for many of the more than 45 million uninsured Americans. This major policy change originally required all states to expand the eligibility of their Medicaid programs to those younger than 65 years with incomes up to 138% of the federal poverty level (FPL), based solely on income without regard to categorical eligibility status. To date, there is ample evidence that the percentage of the uninsured has been significantly reduced nationally despite the fact that 14 states have not adopted the ACA Medicaid expansions as of August 2019 due to the 2012 Supreme Court ruling making those expansions voluntary rather than mandatory.

This dissertation assessed the further effects of the ACA Medicaid expansions on out-of-pocket spending, healthcare utilization, and health outcomes for chronic conditions using a nationally representative sample of the low-income non-elderly population from the 2010-2016 Medical Expenditure Panel Survey and 2005-2016 National Health and Nutrition Examination Survey. It took advantage of the natural experiment that allowed a comparison of changes in outcomes between the expansion and non-expansion states. The three studies found that the ACA Medicaid expansions were associated with reduced out-of-pocket spending and improved financial risk protection, a modest increase in primary care physician visits without any meaningful change in emergency department visits, and improved clinical measures for hypertension and diabetes (but no improvement in outcomes for hyperlipidemia and depression), during the three years after the policy implementation.

The findings suggest that the ACA has been successful in achieving its goals of removing financial barriers, promoting access to primary care, and improving population health among low-income uninsured Americans. It has important implications for state decisions on adopting the ACA Medicaid expansions and for the ongoing national debate over the repeal of the ACA, including the Medicaid expansions.

About 1.71 million nonelderly Californians were uninsured for all or part of 2009 and are estimated to be eligible to participate and receive subsidies in the new California Health Benefit Exchange marketplace under the Patient Protection and Affordable Care Act (ACA) of 2010. Another 737,000 are currently insured with individual policies and will also be eligible for participation in the Exchange based on their employment, income and citizenship status. This policy brief examines the characteristics of these Exchange-eligible with subsidies groups, based on 2009 California Health Interview Survey data. Among the findings, these Exchange-eligible populations alifornia has established the California Health Benefit Exchange in compliance with the Patient Protection and Affordable Care Act (ACA) of 2010. Premium and cost-sharing subsidies are offered to eligible individuals under 65 who earn between 133% and 400% of the federal poverty level (FPL) and those with lower incomes who do not qualify for Medi- Cal.1,2 The ACA also restricts the ability to purchase insurance through the Exchange to citizens and legal permanent residents who are not incarcerated. An estimated 1.71 million Californians were uninsured for all or part of 2009 and are estimated to be eligible to participate in the Exchange with subsidies. Another 737,000 legal California residents insured through privately-purchased individual policies in the past year will also be eligible to participate in the Exchange with subsidies. Subsidies are tax credits, vary by income level, and can be used towards premiums or cost-sharing. It is not possible to accurately predict how many Californians will participate in the Exchange as implementation details are currently in development and market dynamics are anticipated to change by 2014.3,4 This brief does not predict who will participate in the Exchange, but uses the latest available estimates from the 2009 California Health Interview Survey (CHIS 2009) to estimate the size and characteristics of the uninsured and individually-insured populations who are eligible and can participate in the Exchange. are often single, young working-age adults, and are employed in small firms. Most are healthy and the prevalence rates of most chronic conditions are similar to those with employmentbased insurance. However, several indicators show poorer access to care for those who are uninsured. The characteristics of the Exchangeeligible with subsidies are likely to change by 2014 when the major provisions of the ACA are implemented. Nevertheless, these data indicate that the California Health Benefit Exchange is likely to improve access to care for the uninsured, and has the potential to improve coverage and access to care of those with individual policies.

California’s health maintenance organizations (HMOs) face serious challenges in meeting the needs of their members who have diverse language proficiency and educational attainment. This policy brief summarizes findings from a report that is the most comprehensive profile of the state’s entire HMO membership available to date, including commercial, Medicare, Medi- Cal, and Healthy Families members. Also included are an assessment of the readability of HMO member materials and the availability of linguistic services for limited Englishproficiency members, who represent almost 5% of HMO members statewide

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In this brief we consider a middle ground alternative that would base eligibility for the individual worker on the cost of self-only coverage, but would use the additional cost to the employee for family coverage as the basis for determining affordability and eligibility for subsidies for the remaining family members.

This brief summarizes the evidence on the health benefits of expanded access, with particular attention to the newest studies from recent coverage expansions in Massachusetts, Oregon, and parts of California.