Option 1, which extends coverage to people below the poverty level, results in an increase in federal spending of $15.1 billion in 2022 ($181 billion over 10 years). Federal spending on Medicaid and marketplace subsidies rises by $16.9 billion.
Federal spending on uncompensated care declines by $1.8 billion. Following assumptions made in similar analyses by the Congressional Budget Office (CBO), we assume that 50 percent (or $0.9 billion) of uncompensated care savings will be realized as Medicare Disproportionate Share Hospital (DSH) savings; how the remainder of the reduction in the uncompensated care is realized is uncertain.
If the federal matching rate in expansion states were increased to 100 percent of FPL, federal spending would increase by another $12.1 billion; overall federal sending would increase by $27.2 billion, or $327 billion over 10 years.
Household spending increases slightly ($1.4 billion) as households spend less on premiums, because of the coverage expansions, but spend more out of pocket. State governments also see reduced demand for uncompensated care of $1.1 billion overall. Employers reduce spending on premiums by $2.7 billion because of the small reduction in employer-sponsored insurance. Total health spending in these states increases by $11.1 billion.
Option 2 increases spending by the federal government in nonexpansion states by $22.5 billion in 2022 (the corresponding 10-year estimate is $270 billion). The greater marketplace premium and cost-sharing subsidies, plus a small increase in Medicaid spending, amount to $26.1 billion. There is a reduction in federal spending on uncompensated care of $3.7 billion, because fewer people are uninsured. Of this, Medicare DSH payments fall by $1.8 billion; the distribution of the rest is unknown.
If the federal matching rate in expansion states were increased to 100 percent of FPL, federal spending would increase by $12.1 billion. Under that scenario, federal spending increases by $34.6 billion, or $415 over 10 years.
Households also spend slightly less than under current tax credit eligibility with pre-ARPA tax credits: $3.7 billion less on premiums and $0.1 billion less in total out-of-pocket spending, because more people are purchasing coverage. States would see lower demand for uncompensated care, with costs falling by $2.3 billion. Employers reduce spending on premiums by $2.9 billion, owing to the small decrease in employer coverage. Total health spending increases by $10.4 billion as a result of the coverage expansion and expanded subsidies.
Option 3 increases federal spending in nonexpansion states by $27.9 billion, or $335 billion over 10 years. Increased marketplace subsidies amount to $28.5 billion. Expanded reinsurance adds $3.3 billion. There is a reduction in uncompensated care of $3.9 billion; Medicare DSH payments fall by $2.0 billion, half of the overall reduction in federal uncompensated care spending. If federal matching rates are increased in expansion states, federal spending increases by $12.1 billion, for a increase of $40 billion, or $480 billion over 10 years. Households spend $6.0 billion less as more people buy health insurance. Employers reduce spending on premiums by $4.0 billion. Total health spending in nonexpansion states increases by $12.2 billion.
With Medicaid expansion, the federal government increases spending by $30.5 billion in 2022, or $366 billion over 10 years. Medicaid spending increases by $43.1 billion but there is a reduction in marketplace subsidies ($9.7 billion) and uncompensated care ($2.8 billion) that offsets some of this. While states see $5.2 billion in new Medicaid spending because of required matching payments — offset somewhat by lower spending on uncompensated care — this does not take into account important savings to state governments. Most states have found that Medicaid expansion has a negligible impact on state budgets or even results in net savings.11
There are savings to households of $4.0 billion, primarily reduced out-of-pocket costs. Employers reduce spending on premiums by $3.9 billion because low-wage employees enter Medicaid rather than keeping their employer coverage. Overall health care spending increases by $23.6 billion.
The biggest increase in health coverage for low-income people comes through Medicaid expansion. This offers a broad benefit package and has no or nominal cost sharing. As a result, it costs the federal government more to cover low-income people than under the other two options, which have greater cost sharing and premiums. Options 2 and 3 cover more people at higher incomes by generously subsidizing premiums and cost sharing. Those subsidies are, however, generally much lower than the cost of offering those people full Medicaid coverage.
The Marginal Cost of Filling the Gap
The results presented above reflect the effects of joint policies of expanding subsidies and filling the Medicaid coverage gap. An alternative way to analyze this issue is to estimate the cost of filling the gap for those below 100 percent of FPL, building on an existing policy that has previously expanded subsidies. In option 1 above, federal spending for people in the Medicaid gap increases by $16.6 billion as they become eligible for subsidies. However, spending on health grows somewhat less — $15.1 billion — largely because the cost of premium tax credits falls for people already in the subsidized nongroup market. Premium tax credits are smaller, because the new enrollees have lower expected health costs than the currently insured population, and those lower costs are spread among all participants in the nongroup market, lowering premiums across the board. These lower premiums lead to a small increase in enrollment among those not eligible for premium tax credits.
In the second and third options, federal spending for people in the gap increases by more ($17.2 billion and $18.1 billion, respectively), since the subsidies for the new enrollees are more generous than in the first option and slightly more people enroll. The increase in overall federal health spending in these options ($22.5 billion in option 2 and $27.9 in option 3) is greater than the additional spending for people in the gap for two reasons. First, the more generous subsidies apply also to people outside the gap (those with incomes above 100 percent of FPL), who are eligible for assistance with nongroup premiums. As they do under option 1, premiums fall as more people enter the market, but because subsidies are greater, the government pays more of the remaining costs (and affordability for households improves). Second, the more generous subsidies increase enrollment significantly for those above 100 percent of FPL, which increases the total cost of subsidies.
As shown in Exhibit 5, the 10-year costs of just filling the gap, building on existing subsidies, are $199 billion, $207 billion, and $217 billion, respectively. The cost of increasing the federal match in expansion states increases these amounts to $344 billion, $352 billion, and $362 billion, respectively.