Drawbacks and aftermath of the Affordable Care Act: ex-ante moral hazard and inequalities in health care access

Background: Following the introduction of the Affordable Care Act, various studies have tried to identify the effects of the reform, without reaching a clear consensus. The aim of this study was to investigate whether expansion of the Medicaid program has led to less inequality in access to health care and to a higher level of ex-ante moral hazard. Design and Methods: The analysis was conducted on two-year longitudinal data (2014-2015) regarding a cohort of 15,898 individuals from a Medical Expenditure Panel Survey (MEPS). After a data cleaning procedure, a sample of 9,255 individuals was selected for the inequality part of the study and 2,307 for the ex-ante moral hazard analysis. Propensity score matching with nearest- neighbour and kernel matching algorithms, difference-in-difference models and concentration index, corrected according to Erreygers methodology, were adopted. Results: The analysis showed that disparities were reduced between social classes although the ex-ante moral hazard is a real problem with the Affordable Care Act since individuals covered by public insurance tended to abuse the public service. Among those who benefited from the Act, a reduction in preventive behaviours was observed: there was an increase in smoking and a decrease in level of physical activity. As far as concerns access to health care, there was a decrease in inequality in emergency visits, inability to get care and getting care when needed among beneficiaries of the reform. Conclusions: This study demonstrates that the extension of Medicaid has had a dual effect of reducing disparities in access to health care but, at the same time, it seems to have induced people to take less care of themselves.