Poster #65 - Do Anti-Discrimination Insurance Reforms Increase Coverage? Evidence from the ACA Gender Rating Ban

• In Event: Friday Poster Reception

Abstract

Prior to the Affordable Care Act (ACA), insurers in most U.S. states could use gender rating in the nongroup health insurance market, charging women higher premiums than men for otherwise similar coverage. The ACA banned gender rating nationwide beginning January 1, 2014, aiming to reduce price discrimination and improve women’s access to private coverage. However, the policy’s realized reach varied across states because of differences in pre-ACA regulation and post-ACA implementation, including the continued availability of transitional (“grandmothered”) noncompliant plans in some markets. This paper examines whether eliminating gender-based premium pricing increased nongroup coverage among women, particularly in states where gender rating had been most prevalent prior to reform. Using American Community Survey (ACS) microdata from 2010–2018, I estimate changes in nongroup insurance enrollment around 2014 using difference-in-differences and triple-differences designs that compare women to men across states with differing pre-ACA gender rating environments. To capture treatment intensity, I incorporate a state-level exposure measure based on pre-ACA market practices: the share of top-selling nongroup plans in each state that used gender rating prior to the ACA. This continuous exposure approach allows estimated effects to vary with the extent to which the policy changed pricing practices in each state. I also assess sensitivity of results to implementation heterogeneity by estimating models in a restricted sample of states that fully disallowed transitional plan renewals in the nongroup market. Across specifications, men exhibit little systematic change in nongroup coverage associated with pre-ACA gender rating regimes, while women show modest increases after 2014 in higher-exposure states. In triple-differences models with individual controls and state-specific trends, women in states that previously permitted gender rating experience larger post-2014 gains in nongroup coverage relative to men and relative to women in states that had already prohibited gender rating. Continuous-intensity estimates indicate that women’s coverage gains rise with baseline exposure, consistent with stronger responses where the reform introduced a larger change in pricing. Event-study patterns are generally supportive of similar pre-policy trends in higher-exposure groups, with estimated post-policy effects concentrated in the early post-2014 years. These findings contribute to the ACA literature by focusing on an underexamined regulatory mechanism—anti-discrimination pricing rules in private insurance markets—and by highlighting how baseline market practices and implementation heterogeneity shape the distributional effects of federal reforms. Overall, the results suggest that banning gender-based pricing can modestly increase women’s nongroup coverage where discriminatory pricing was most entrenched, though impacts depend on policy context and implementation.

Author

• Faezeh Khosravi, Georgia State University
  Presenting Author