Preventing Financial Strain for Low- and Moderate-Income Adults: a Comparison of Medicaid, Marketplace, and Employer-Sponsored Insurance

J Gen Intern Med. 2022 Aug;37(10):2373-2381. doi: 10.1007/s11606-021-07100-0. Epub 2021 Sep 15.


Background: Medicaid expansion and subsidized private plans purchased on the Affordable Care Act's (ACA) Marketplaces accounted for most of the ACA's coverage gains.

Objective: Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans.

Design: Cross-sectional survey PARTICIPANTS: A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases.

Main measures: Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain.

Key results: Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes.

Conclusion: Medicaid offers better protections than Marketplace plans on most measures of access and financial strain.

MeSH terms

  • Adult
  • Chronic Disease
  • Cross-Sectional Studies
  • Humans
  • Insurance Coverage
  • Insurance, Health
  • Medicaid*
  • Middle Aged
  • Patient Protection and Affordable Care Act*
  • United States