Provider Access and Health Insurance Take-Up After the Affordable Care Act

Monday, June 13, 2016: 9:10 AM
F50 (Huntsman Hall)

Author(s): Victoria Udalova

Discussant: David Auerbach

Recent work on the Affordable Care Act (ACA) highlights the role of “narrow” provider networks in the consumer’s choice of which health insurance plan to purchase (Gruber and McKnight, 2014; AcademyHealth Research Insights, 2015). The ability to see an effective provider within a reasonable timeframe is an important characteristic of a health insurance plan and may affect demand for the product. Consumers may choose a private health plan or enroll in public health insurance or go uninsured based on provider availability. However, current work does not directly address the effect of provider availability on the demand for health insurance because the price of health insurance and the level of access to health care are jointly determined. This paper estimates the impact of changes in access to health care services on demand for health insurance coverage in the U.S. post-ACA.
     I use data from the American Community Survey (ACS) over 2008-2014 on health insurance coverage. I supplement this with data from state statutes and regulations on scope-of-practice laws governing nurse practitioners’ ability to serve as autonomous primary care providers. Prior work (Traczynski and Udalova, 2015) shows that broadening the types of services that nurse practitioners may provide independently increases care utilization through better access to care. The decision of states to adopt broad scope-of-practice laws for nurse practitioners has been shown to be motivated more by political issues than health care concerns, so I take these laws as exogenous. I then determine whether the implementation of the ACA had a differential impact on health insurance rates in states with broad scope-of-practice laws using a difference-in-difference design.

     I use ACS data, so the population studied is a nationally representative sample. The time period allows me to estimate take-up rates both before and after the implementation of the ACA making use of the most recently available ACS data.

     Preliminary results indicate that the ACA led to a larger increase in the insured rate in 2014 in states with broad scope-of-practice laws where nurse practitioners can practice independently of physician oversight. Further analysis of heterogeneity of treatment effects will examine whether the ACA affected health insurance take-up rates differently in states that require nurse practitioners to collaborate with or be supervised by physicians.
Results indicate that consumers evaluate access to care when deciding whether to obtain health insurance. Greater access to primary care services leads to an increase in the number of insured individuals by raising the value of health insurance. The chief implication of this work is that access to care for the insured may affect take-up rates of health insurance. If so, then the effectiveness of future expansions of Medicaid programs or changes to the ACA intended to increase the number of insured will be determined in part by state scope-of-practice laws. Policymakers should be aware of individuals’ interest in access to care when designing social health insurance programs to obtain maximum effect.