The series for Medicare Advantage alone isn't enough to disentagle the effects of ACA, since you can claim ACA mandated effects became embedded in the firms' future calculations. The raw data is indicative only for the 2008-2010 period, maybe, and during that period there was still steady growth in HMO enrolment. Why would HMO's be particularly relevant? The income effect of a recession pushes down spending, meaning less comprehensive coverage and higher deductibles and out-of-pocket limits. If consumers are incurring higher risk, they probably want the certainty of an HMO.
Perhaps disentanglement is problematic, but arguing that ACA is a primary cause for declining cost growth during the Great Recession is like arguing that blustery downdrafts are the reason Isaac Newton took an apple to the noggin.
It's never easy to predict what any policy does for an entire country, especially one with 300 million people. When I made that point, it was about whether the ACA changes behaviour in people to become enrolled. Not surprisingly, they did. I focused on counties by state borders since there would be less economic variation between the two sides.
I didn't argue that ACA doesn't affect behavior. When DC launches healthcare.gov and they tell the citizens that the individual mandate is going to exact its pound of flesh, Americans will rush to sign up, especially if DC tells them the government might give them subsidies. The individual mandate, which is largely unpopular and of questionable constitutional authority, and rising employment rates did most of the work. The "good" government policy (Medicaid expansion) contributed 1% to the decline, according to the data.
The heterogeneity is well known, but as a reform supporter I will blame particular people for refusing federal aid for the Medicaid expansion. But there's something else in this paragraph, though; a belief, almost, that a heterogeneous policy is worse than no policy at all. This is something with which I disagree, especially given that the current act was already a compromise between Congress majorities with the Republican administration.
Even Republican take free money. The government will only help the citizens, as long as the state of residency is willing to help the government hide the true cost of the program from the CBO. In this case, ACA expansion pays 90% of the cost, which is much better than regular Medicaid, but still problematic for many states. Makes you wonder why DC would jeopardize expansion over such a paltry sum. It looks like they really wanted to watch people genuflect at the altar of ACA, and in McConnell's case, it worked like a charm, but as Senate Minority Leader, he probably got every waiver on his list.
In Texas, Medicaid expansion would allegedly cost over $1B per year, which would require 5% bump in general fund revenues. It's not cheap. Texas is supposedly seeking a waiver to only expand for children. I also heard other scuttlebutt that Texas will expand Medicaid only if they get a waiver to put all Medicaid block-grant funds into an exchange, to which the Federal government allegedly replied, only if the exchange is a state-run exchange according to the ACA regs.
Some states are more willing to let the federal government run their show, and some states get preferential treatment from DC. It's just a game. No one cares about the citizens. Everyone cares about who gets to control them.
