Did Medicare Advantage Payment Cuts Affect Beneficiary Access to Care?

Research Objective: Under the Affordable Care Act (ACA), Medicare Advantage (MA) plan payments were cut between 2009-2015, reducing the amount of funds available to provide extra benefits or lower cost-sharing to their enrollees. CBO expected these changes to reduce enrollment, but MA grew significantly - from 23 percent of beneficiaries in 2009 to 31 percent in 2015. This study examines whether MA payment reductions between 2009-2015 were associated with any changes in access to care, affordability of care, or satisfaction with care.

Study Design: This study uses the 2009-2015 Medicare Current Beneficiary Survey (MCBS) to assess changes in access, affordability, and satisfaction for MA and traditional Medicare (TM) enrollees. Our sample is limited to adults aged 65+ with MA or Part A and B TM benefits, excluding dual-eligibles. We use a difference-in-differences approach to explore whether changes in access, affordability, and satisfaction between 2009-2015 in MA differed from those in TM. To asses whether changes in rebates were associated with changes in access, affordability, and satisfaction among MA enrollees, we use a difference-in-difference-in-differences approach to compare changes in MA and TM by county-level rebate changes. All models control for enrollee demographic, socioeconomic, and health characteristics.

Findings: Preliminary results show that between 2009-2015, the share of MA enrollees without a usual source of care increased by 4.4 percentage points and the share trouble getting care increased by 1.5 percentage points after controlling for changes in demographic, socioeconomic, and health characteristics. However, none of these changes were statistically different from changes in TM (3.5 and 1.0 percentage points, respectively). MA and TM enrollees did not report statistically significant changes in delays in care due to cost, satisfaction with the quality of medical care, or satisfaction with out-of-pocket costs between 2009-2015.

Among only MA enrollees, county-level average rebate changes were not statistically associated with changes in access, affordability, or satisfaction between 2009-2015. When compared to TM enrollees in similarly-situated counties using a difference-in-difference-in-differences model, there were not any statistically significant differences in changes in these outcomes between MA and TM enrollees.

Conclusions: While access to care worsened between 2009-2015 in MA, those trends were not statistically different from TM, even after incorporating county-level average rebate changes into our model. Our results suggest that rebate reductions did not play a significant role in changes in access, affordability, and satisfaction among MA enrollees between 2009-2015.

Research indicates that MA plans were overpaid prior to the ACA and significantly reduced costs in response to ACA payment pressure. These preliminary findings show that plans preserved sufficient rebates to maintain enrollees’ access to and affordability of care relative to TM. While our study does not directly address the effect of rebate amounts on enrollment choices, these findings, combined with the growth in MA enrollment between 2009-2015, may indicate rebate amounts have less effect on enrollee’s choice of and experience with MA than previously thought.