Article

Medicaid and Mortality: New Evidence From Linked Survey and Administrative Data*

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Abstract

We use large-scale federal survey data linked to administrative death records to investigate the relationship between Medicaid enrollment and mortality. Our analysis compares changes in mortality for near-elderly adults in states with and without Affordable Care Act Medicaid expansions. We identify adults most likely to benefit using survey information on socioeconomic status, citizenship status, and public program participation. We find that, prior to the ACA expansions, mortality rates across expansion and nonexpansion states trended similarly, but beginning in the first year of the policy, there were significant reductions in mortality in states that opted to expand relative to nonexpanders. Individuals in expansion states experienced a 0.132 percentage point decline in annual mortality, a 9.4 percent reduction over the sample mean, as a result of the Medicaid expansions. The effect is driven by a reduction in disease-related deaths and grows over time. A variety of alternative specifications, methods of inference, placebo tests, and sample definitions confirm our main result.

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... I estimate this impact using the following event study model while controlling for individual and survey-wave fixed effects (Miller, Johnson, and Wherry 2021;Cunningham 2021): ...
... Hence, each estimate of β k gives the change in monthly income in each of the non-government industries relative to the government sector during the monthk, as measured from February 2020. If income for a non-government industry was trending similarly prior to March 2020, then the estimated coefficients associated with event times k ¼ À 14 to k ¼ À 2 should be small and not statistically significant (Miller, Johnson, and Wherry 2021;Miller and Wherry 2019). ...
... In addition to the event study model, I also obtain the Difference-in-Differences estimates using the following model to summarize the effect of the pandemic across all the months following the arrival of COVID-19 (Wooldridge 2010;Miller, Johnson, and Wherry 2021): ...
Article
I use a nationally representative data-set from India to estimate the heterogeneous impact of the COVID-19 pandemic on individual income in different industries. The difference-in-differences estimates show that the impact varies across industries, and in the case of some industries there is no statistically significant impact of the pandemic on individual income.
... It was first used by John Snow in 1855 to show that cholera propagates through water, and it has since then been employed in uncountable contexts including epidemiology, economics, demography and political science. In very recent times it has been used to show that the Affordable Care Act which expanded Medicaid eligibility in the US produced a reduction in mortality in the states where it was present (Miller et al., 2021). ...
... where D is a binary variable indicating whether a given country went into a moderate or severe crisis (belongs to group 2 or 3) and the t coefficients represent the deviation in the evolution of life expectancy observed between the treated and the control group. Note that the year before the crisis has been set as reference category in the model (we follow here Miller et al., 2021). If the t coefficients are not significantly different from the reference value before the crisis (t < 0) and then make a jump at the onset of the crisis (t ≥ 0) this will prove the robustness of the DD procedure. ...
... (3) beyond its usual purpose of checking the robustness of the DD procedure (we follow in that, again, Miller et al., 2021). In the next section ("Unemployment changes during and after the Great Recession") we will use the estimates of the t coefficients to assess the effect of the economic crisis on unemployment in Europe (to this end we will use as dependent variable the unemployment rates provided by the World Bank). ...
Article
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Some European countries, such as Greece and Spain, were severely hit by the 2008 economic crisis whereas others, such as Germany, were practically spared by it. This divergence allowed us to implement a difference in differences research design which offered the possibility to observe the long-lasting effects produced by the crisis on European life expectancy. Our analysis-based on Eurostat data from 2001 to 2019-shows that life expectancy increased faster, after the onset of the crisis, in those countries where the rise in unemployment was more intense. Furthermore, our results show that this gain in life expectancy persisted, and sometimes further increased, until 2019 when most macroeconomic variables had returned to their pre-crisis values. Previous research has identified that mortality behaves procycli-cally in developed countries: when the economy slows down mortality decreases and vice versa. Our findings show, by contrast, that life expectancy behaves asymmetrically: it responded to an increase but not to a decrease in unemployment. This calls for a reconsideration of the causal mechanisms linking together the economic cycle and mortality in developed countries.
... There is less evidence on those close to 65, the eligible age for Medicare. A few studies examined the ACA Medicaid expansion effects on low-income individuals aged 50-64 years (Courtemanche et al., 2017;McInerney et al., 2020;Miller et al., 2021;Semprini et al., 2020;Tipirneni et al., 2021;Van Houtven et al., 2020;Wehby & Lyu, 2018). For this age group, there is evidence of an increase in Medicaid coverage and a drop in uninsured rate (Courtemanche et al., 2017;McInerney et al., 2020;Miller et al., 2021;Tipirneni et al., 2021;Wehby & Lyu, 2018), better self-rated health status (Semprini et al., 2020), reduction in any work limitations from health (Tipirneni et al., 2021), improvement in activities of daily living (McInerney, 2020), and reduction in disease-related deaths (Miller et al., 2021). ...
... A few studies examined the ACA Medicaid expansion effects on low-income individuals aged 50-64 years (Courtemanche et al., 2017;McInerney et al., 2020;Miller et al., 2021;Semprini et al., 2020;Tipirneni et al., 2021;Van Houtven et al., 2020;Wehby & Lyu, 2018). For this age group, there is evidence of an increase in Medicaid coverage and a drop in uninsured rate (Courtemanche et al., 2017;McInerney et al., 2020;Miller et al., 2021;Tipirneni et al., 2021;Wehby & Lyu, 2018), better self-rated health status (Semprini et al., 2020), reduction in any work limitations from health (Tipirneni et al., 2021), improvement in activities of daily living (McInerney, 2020), and reduction in disease-related deaths (Miller et al., 2021). There is also an increase in use of long-term care (Van Houtven et al., 2020) and higher likelihood of hospitalizations (Tipirneni et al., 2021), suggesting previously unmet needs. ...
... A few studies examined the ACA Medicaid expansion effects on low-income individuals aged 50-64 years (Courtemanche et al., 2017;McInerney et al., 2020;Miller et al., 2021;Semprini et al., 2020;Tipirneni et al., 2021;Van Houtven et al., 2020;Wehby & Lyu, 2018). For this age group, there is evidence of an increase in Medicaid coverage and a drop in uninsured rate (Courtemanche et al., 2017;McInerney et al., 2020;Miller et al., 2021;Tipirneni et al., 2021;Wehby & Lyu, 2018), better self-rated health status (Semprini et al., 2020), reduction in any work limitations from health (Tipirneni et al., 2021), improvement in activities of daily living (McInerney, 2020), and reduction in disease-related deaths (Miller et al., 2021). There is also an increase in use of long-term care (Van Houtven et al., 2020) and higher likelihood of hospitalizations (Tipirneni et al., 2021), suggesting previously unmet needs. ...
Article
Background and Objectives Little is known on effects of the Affordable Care Act (ACA) Medicaid expansions on health care access and health status of adults closest to 65. This study examines the effects of ACA Medicaid expansion on access and health status of poor adults aged 60-64 years. Research Design and Methods The study employs a difference-in-differences design comparing states that expanded Medicaid in 2014 under the ACA and non-expansion states over six years post expansion. The data are from the 2011-2019 Behavioral Risk Factor Surveillance System for individuals aged 60–64 years below the Federal Poverty Level. Results Having any health care coverage rate increased by 8.5 percentage-points (p<0.01), while the rate of forgoing a needed doctor’s visit due to cost declined by 6.6 percentage points (p<0.01). Similarly, rates of having a personal doctor/provider and completing a routine checkup increased by 9.1 (p<0.01) and 4.8 (p<0.1) percentage-points, respectively. Moreover, days not in good physical health in the past 30 declined by 1.5 days (p<0.05), with suggestive evidence for decline in days not in good mental health and improvement in self-rated health. Discussion and Implications The ACA Medicaid expansions have improved health care access and health status of poor adults aged 60-64 years. Expanding Medicaid in the states that have not yet done so would reduce barriers to care and address unmet health needs for this population. Bridging coverage for individuals 60-64 years old by lowering Medicare eligibility age could have long-term effects on wellbeing and health services utilization.
... For example, the expansion increased adults' health insurance coverage, access to healthcare, and preventive healthcare (Courtemanche et al., 2017;Johnston et al., 2018;Kaestner et al., 2017;McMorrow et al., 2017;Miller & Wherry, 2017;Simon et al., 2017;Sommers et al., 2015;Soni et al., 2020;Wehby & Lyu, 2018;Wherry & Miller, 2016). Although the effects on self-assessed health and health behaviors are mixed (Cotti et al., 2019;Courtemanche et al., 2018aCourtemanche et al., , 2018bCourtemanche et al., , 2019McMorrow et al., 2017;Simon et al., 2017;Sommers et al., 2015), mortality has declined, driven by fewer disease-related and other health conditions amenable to gaining health insurance such as diabetes (Borgschulte & Vogler, 2020;Goldin et al., 2021;Miller, Johnson, et al., 2021;Sommers et al., 2012). The expansions were also linked with improvements in behavioral health and health care utilization, documented by greater use of substance abuse treatments (Grooms & Ortega, 2019;Maclean & Saloner, 2019;Meinhofer & Witman, 2018), and reductions in both violent and property crime (He & Barkowski, 2020;Vogler, 2020). ...
... Nevertheless, following past ACA literature on this topic (Miller, Johnson, et al., 2021), we include the results from the Goodman-Bacon decomposition that essentially examines all 2 Â 2 DD analysis independently (Goodman-Bacon, 2021). The decomposition provides weights and coefficients to isolate the effect from treatment timing variation ("Earlier Group Treatment" vs. "Later Group Control" and "Later Group Treatment" vs. "Earlier Group Control") and from comparisons of "Treatment" versus "Never Treated" (see Figure S4). ...
Article
Publicly funded adult health insurance through the Affordable Care Act (ACA) has had positive effects on low‐income adults. We examine whether the ACA's Medicaid expansions influenced child development and family functioning in low‐income households. We use a difference‐in‐differences framework that exploits cross‐state policy variation and focus on children in low‐income families from a nationally representative, longitudinal sample followed from kindergarten to fifth grade. The ACA Medicaid expansions improved children's reading test scores by ~2% (0.04 SD). Potential mechanisms for these effects within families are more time spent reading at home, less parental help with homework, and eating dinner together. We find no effects for children's math test scores or socioemotional skill development.
... One of the most definitive ways of assessing health outcomes is to examine mortality, including trends over time and differences between and within population groups [ 4 , 9 ]. Much of the existing evidence in this area originates from the US, where the evidence points to a protective effect of public and private health insurance on survival [10][11][12][13][14][15] . Using similar data and methods to those employed in this paper, McWilliams et al. [12] compared mortality over an eight year follow-up period amongst respondents to the US Health and Retirement Survey (HRS) who were privately insured and those who were uninsured. ...
... A related literature has used expansions in public health insurance in the US to identify the effect of public health insurance on mortality [4] . For example, Miller et al. [13] used state-level variation in the adoption of the Affordable Care Act (ACA) to examine the impact of public health insurance on mortality. They found that amongst the population aged 55-64 years of age, mortality declined in the first year of the ACA expansion and continued to decline (at an increasing rate) for three years thereafter, suggesting that prolonged exposure to Medicaid (the public health insurance for low income individuals in the US) resulted in increasing health improvements. ...
Article
Most developed countries provide publicly-financed insurance for many health services for their populations although there is considerable variation across countries in the types of services covered, eligible population groups and whether co-payments are levied. The Irish healthcare system, with a complex mix of public and private financing of healthcare services, offers a useful case study for an examination of the impact of type of health insurance cover on population health. In this paper, we investigate the extent to which type of health insurance cover is associated with all-cause, cause-specific, and amenable mortality using data on a representative survey of the population aged 50+ from the Irish Longitudinal Study on Ageing (TILDA) matched to administrative data on death registrations. The results show that those without public or private health insurance have a higher risk of all-cause and cancer mortality. However, there is no evidence that type of health insurance cover affects mortality risk from causes that are considered amenable to healthcare intervention, although this analysis was based on a much smaller sample size. This analysis provides important evidence for a country that is implementing reforms to its financing and delivery structures in order to move towards a system of universal healthcare.
... This policy removed categorical eligibility restrictions, increased income eligibility thresholds to 138% of the Federal Poverty Level, and provided generous coverage for behavioral health services. Although this policy has been shown to increase coverage and general service use, improve financial stability, and improve overall health (Antonisse et al., 2018;Miller et al., 2021), there is somewhat mixed evidence suggesting that Medicaid expansion has improved behavioral health (Zuvekas et al., 2020(Zuvekas et al., , 2021. Medicaid expansion appears to improve some measures of mental health for specific enrollee groups, such as those with chronic conditions (Antonisse et al., 2018;Winkelman & Chang, 2018), but there is limited evidence that measures of SUD-related outcomes are impacted by this policy (Abouk et al., 2020;Averett et al., 2019). ...
Article
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We study the effects of changing Medicaid reimbursement rates for primary care services on behavioral health outcomes—defined here as mental illness and substance use disorders. Medicaid enrollees are at elevated risk for these, and other, chronic conditions and are likely to have unmet treatment needs. We apply two‐way fixed‐effects regressions to survey data specifically designed to measure behavioral health outcomes over the period 2010–2016. We find that higher primary care reimbursement rates reduce mental illness and substance use disorders among non‐elderly adult Medicaid enrollees, although we interpret findings for substance use disorders with some caution as they may be vulnerable to differential pre‐trends. Overall, our findings suggest positive spillovers from a policy designed to target primary care services to behavioral health outcomes.
... For a review and synthesis of the literature, see Antonisse et al. 2018, Mazurenko et al. 2018). In addition, Miller et al. (2021) show that Medicaid coverage decreased annual mortality by 0.132 percentage points. More recent work has also emerged in the domains of behavioral health, reproductive health and racial disparities. ...
Thesis
This dissertation investigates whether healthcare decisions and health behaviors are affected by institutions and incentives, focusing on the legal system (Chapter 1), health insurance coverage (Chapter 2), and soda taxes (Chapter 3). Chapter 1 investigates to what extent physician decisions to abandon ineffective treatment practices are affected by medical malpractice standard of care definitions. In some states the standard of care requires doctors to follow customary practice of the community in which they practice and in others physicians must adhere to national customs. Local and national practice can and often do differ. Legal scholars hypothesize that local standards of care reduce the incentive for physicians to keep abreast of medical advances, slowing the adoption of new treatments and the de-adoption of ineffective ones. This chapter analyzes state court cases to categorize state standard of care definitions as based on local or national custom. Next the chapter examines the effects of these definitions on patient care, focusing on the physician's decision to discontinue the use of vertebroplasty - a surgical procedure to alleviate pain after vertebral fractures - after two influential studies questioned its effectiveness. I find that while de-adoption occurred rapidly in all states regardless of the legal standard of care, rural areas reduced vertebroplasty use by less in locality states than they would have had a national standard of care applied. Chapter 2 (joint with Helen Levy) examines the effect of Medicaid insurance coverage on healthcare utilization for seriously ill patients who are hospitalized after seeking care in an emergency room. Two channels exist through which Medicaid coverage may affect healthcare use: on the extensive margin more people may gain Medicaid coverage, and because they are now insured they may be more likely to seek care. On the intensive margin, conditional on seeking care, insurance coverage through Medicaid may affect “treatment intensity,” or “how much” patients are treated. Focusing on non-deferrable admissions allows us to estimate intensive margin effects without the confounding effects of selection into treatment and changes in patient composition. We find that the 2014 Medicaid Expansions increased the share of patients covered by Medicaid, which was partially offset by a decrease in the share of patients with private coverage. We find no statistically significant effects of Medicaid coverage on treatment intensity or on mortality. The coefficients were imprecisely estimated because the analysis does not separately identify effects from the coverage gain channel and the crowd-out channel, and these effects likely operate in opposing directions: positive and negative, respectively. The last chapter evaluates the effects of sugar-sweetened beverage taxes on prices and consumption, comparing taxes in Berkeley and Philadelphia within the same study and using the same methods so that measured differences can be more easily attributed to local supplier and consumer responses rather than to differences in methodology. In Berkeley (Philadelphia), 6% (57%) of the tax on regular soda was passed on to consumers and in Philadelphia 67% of the tax was passed through for diet soda. In both cities pass-through declines with beverage size. Consumption of regular soda in Berkeley (Philadelphia) decreased by 7.6% (28%) and in Philadelphia consumption of diet soda decreased by 33%. In Philadelphia I find evidence of cross-border shopping: stores in neighboring regions lowered prices and purchases of soda from these stores increased.
... The expansion of Medicaid approved by 38 states and the District of Columbia under the Affordable Care Act (ACA) has been associated with improved coverage, access to care, and health for many nonelderly adults newly eligible for coverage, 3 including reduced mortality among middleaged adults. 4 But Medicaid expansion has also had spillover or "welcome mat" effects on many people who were previously eligible but only enrolled in coverage after the ACA's implementation and outreach efforts. ...
... The Affordable Care Act (ACA) Medicaid expansions have covered over 18 million low-income adults and improved access to health care, as of December 2020. 1 Since the first expansions in 2014 with 26 states and Washington D.C., 14 additional states have expanded by December 2021. 2 There is clear evidence that the 2014 Medicaid expansions have increased coverage and access, [3][4][5][6][7][8][9][10][11][12][13][14][15] and growing evidence that these expansions also improved health status. [15][16][17][18] However, there is much less evidence for states that expanded after 2014 particularly recent expansions. ...
Article
Full-text available
Virginia expanded Medicaid under the Affordable Care Act beginning in January 2019, which substantially increased income eligibility up to 138% of the federal poverty level (FPL) for both childless adults and parents. In this study, we examined the effects of Virginia’s Medicaid expansion in 2019 on health insurance coverage, access to care, and health status by employing a difference-in-differences and a synthetic control design. The study included data on health insurance from the 2016–2020 American Community Survey (ACS) and data on access to care and health status come from the 2016–2020 Behavioral Risk Factors Surveillance System (BRFSS). The samples from ACS and BRFSS were limited to non-elderly adults with income below 138% of the FPL. Separate models were estimated for individuals below 100% of FPL, and those within 100–138% of FPL. The Virginia Medicaid expansion was associated with a 9–11 percentage-point increase in Medicaid coverage rate and a 7–8 percentage-point increase in the insured rate among individuals below 100% FPL, in the first two years of expansion. There was a larger increase in Medicaid coverage among individuals within 100–138% of FPL which also led to a larger increase in the insured rate in 2020. Both income groups showed no changes in private coverage after the expansion in Virginia. We also found a decline in delaying necessary medical visits due to cost for individuals below 100% FPL in 2019 and for individuals within 100–138% FPL in 2020. There was overall no discernable change in health status outcomes. Virginia’s 2019 Medicaid expansion substantially increased insurance coverage among poor adults with suggestive early evidence for improved access. The findings highlight the missed opportunity for other states that have not yet decided to expand their Medicaid programs to improve coverage and access among their low-income individuals.
... One concern with self-reported health data is that it may not accurately measure changes in physical health. Miller et al. (2021) argue that changes in self-reported heath may reflect evolving awareness of health problems or interactions with health professionals, rather than actual changes in physical health. As such, we exploit information on physician-diagnosed diseases to objectively measure respondents' health. ...
Technical Report
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We estimate the causal effect of air pollution on energy poverty using Chinese panel data. Exploiting exogeneous variations in PM2.5 concentrations due to atmospheric thermal inversions to proxy air pollution, we find that poor air quality increases energy poverty at both the intensive and extensive margins. Specifically, we find that a one-standard-deviation increase in PM2.5 concentrations (22.06 μg/m3) increases the share of income spent on energy by 1.01 percentage points, accounting for 15.71 per cent of the income share that a representative Chinese household spends on energy. The probability of being into energy poverty, in response to the same change, increases by 4.19 – 8.38 percentage points, which corresponds to a 22.57 – 34.01 per cent increase in the proportion of households in energy poverty evaluated at the mean. Our results are robust to employing different specifications, controlling for a wide set of weather variables, different strategies for addressing endogeneity and alternative ways of measuring energy poverty and air pollution. We find that the channels through which air pollution causes energy poverty are via people spending more time indoors, air pollution impairing health, and air pollution having an adverse effect on household income. Back-of-the-envelope calculations suggest that reducing PM2.5 emissions to the annual standard of 35 μg/m3, which is mandated by the central government, would lift 9.30 – 18.59 million households out of energy poverty.
... The expansion increased access to and use of health care, even among hard-to-reach subpopulations [3][4][5]. Studies find that the expansion led to improvements in self-reported health [6], reduced hospital readmissions [7], and reduced mortality rates [8]. It also made health care more affordable and improved financial security [9,10]. ...
Article
Full-text available
The Affordable Care Act’s Medicaid expansion to individuals with adults under 138 percent of the federal poverty level led to insurance coverage for millions of Americans in participating states. This study investigates Medicaid expansion’s potential spillover participation in the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program). In addition to providing public insurance, the policy connects individuals to SNAP, affecting social determinants of health such as hunger. We use difference-in-differences regression to estimate the effect of the Medicaid expansion on SNAP participation among approximately 414,000 individuals from across the United States. The Current Population Survey is used to answer the main research question, and the SNAP Quality Control Database allows for supplemental analyses. Medicaid expansion produces a 2.9 percentage point increase (p = 0.002) in SNAP participation among individuals under 138 percent of federal poverty. Subgroup analyses find a larger 5.0 percentage point increase (p = 0.002) in households under 75 percent of federal poverty without children. Able-Bodied Adults Without Dependents (ABAWDs) are a category of individuals with limited access to SNAP. Although they are a subset of adults without children, we found no spillover effect for ABAWDs. We find an increase in SNAP households with $0 income, supporting the finding that spillover was strongest for very-low-income individuals. Joint processing of Medicaid and SNAP applications helps facilitate the connection between Medicaid expansion and SNAP. Our findings contribute to a growing body of evidence that Medicaid expansion does more than improve access to health care by connecting eligible individuals to supports like SNAP. SNAP recipients have increased access to food, an important social determinant of health. Our study supports reducing administrative burdens to help connect individuals to safety net programs. Finally, we note that ABAWDs are a vulnerable group that need targeted program outreach.
... However, randomised trials are not the only source of experimental evidence in a broader sense. For example, Miller et al. (2021) study the effect of states expanding their public health insurance for lowincome adults in 2014 on mortality in a sample of 566,000 individuals aged 55 to 64 that were likely to be affected by the expansion. By comparing individuals in expansion and non-expansions states before and after expansion, they find that expansion-state individuals were more likely to be insured and had a lower mortality after expansion, equivalent to a 0.35 percentage-point reduction per year of insurance coverage. ...
... Researchers have examined Medicaid's effect on healthcare utilization[Anderson et al., 2012, Card et al., 2008, Finkelstein et al., 2012, Kolstad and Kowalski, 2012, Miller and Wherry, 2017, Taubman et al., 2014, health outcomes[Goodman-Bacon, 2018, Baicker et al., 2013, Card et al., 2009, Currie and Gruber, 1996, Finkelstein et al., 2012, Miller et al., 2019, and financial health, especially for enrolleesFinkelstein et al. [2019],Brevoort et al. [2018],Hu et al. [2018].4 This conventional policy wisdom is revealed in the text of the Affordable Care Act, which increased eligibility for formal Medicaid insurance a reduced supplemental payments. ...
... One concern with self-reported health data is that they may not accurately measure changes in physical health. Miller et al. (2021) argue that changes in self-reported heath may reflect evolving awareness of health problems or interactions with health professionals, rather than actual changes in physical health. As such, we exploit information on physician-diagnosed diseases to objectively measure respondents' health. ...
... Recent studies find that Medicaid expansion is associated with improved access to care, diagnosis and treatment of a range of diseases (e.g., cancer and opioid use disorder), and the affordability of care (e.g., Barbaresco et al. 2015;Wherry and Miller 2016;Soni et al. 2017;Decker, Lipton, and Sommers 2017;Martin et al. 2017;Meinhofer and Witman 2018;. Better health outcomes and survival rates have also been found in expansion states compared to nonexpansion states (Barbaresco et al. 2015;Gao 2017;Swaminathan et al. 2018;Miller, Johnson, and Wherry 2019). ...
Article
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This paper examines the impacts of the Affordable Care Act (ACA)'s Medicaid expansion and tort reforms on the medical liability system. Medicaid expansion increased the demand for medical services, but in doing so it may also increase physicians' medical liability. By studying malpractice costs to insurers, medical practitioners, and hospitals in the United States in 2010–2018, we find insurers in Medicaid expansion states experienced higher medical liability costs than those in nonexpansion states. Medical practitioners paid higher premiums in expansion states but the premium increase was not enough to fully offset rising costs. In addition, we do not find that tort reforms mitigated ACA‐induced malpractice liability costs. We show this is because Medicaid expansion increased malpractice costs mainly by increasing claim frequency while tort reforms generally reduce claim severity. We also find little evidence that hospitals paid higher malpractice insurance premiums to insurers or self‐insurance programs, or incurred higher out‐of‐pocket medical liability losses after Medicaid expansion.
... Nevertheless, we need to further test and explore the parallel trends assumption. As is common in the literature, we estimate a regression model that includes treatment leads and lags (Miller et al., 2019;Cunningham, 2020). To do this, we follow Cerulli and Ventura (2019) and use a binary time-varying treatment to classify municipalities as metal and non-metal mining (same as Fig. 5). ...
Article
This paper analyzes the local impact of a natural resource shock on female and male wages as well as the gender wage gap. We contrast three hypotheses using the Dutch disease theory and gender-based segregation patterns in the labor market. Using household level data aggregated at a municipality-level from 2000 to 2015, we examine the case of Chile that was exposed to the Metal Mining Prices Super-Cycle between 2003 and 2011. We exploit the spatial heterogeneity in the exposure to the shock, and find a positive and significant impact on wages for both men and women. We also provide evidence of a significant reduction in the gender wage gap in municipalities more exposed to the commodity shock in comparison to municipalities with less exposure. In addition, we use spatial econometric specifications and find evidence suggesting the existence of spatial spillovers between neighboring municipalities.
... Maternal access to Medicaid improves mothers' mental health measured by CES-D scores and Kessler scales (Guldi and Hamersma 2021;McMorrow et al. 2016). Another complementary recent working paper investigates how the aggregate social safety net affects maternal mental health and health behaviors (Schmidt,and Watson 12 Generally, Medicaid is found to increase access to and use of health care (Finkelstein et al. 2012;Baicker et al. 2013;Currie and Gruber 1996a) including for mental health (McMorrow et al. 2016;Frank, Goldman, and Hogan 2003); improve health of young children (Goodman-Bacon 2018;Baicker et al. 2013;Currie, Decker, and Lin 2008); reduce mortality for near elderly adults (Miller, Johnson, and Wherry 2021); and reduce financial burden including bankruptcy (Gross and Notowidigdo 2011), although the harm from losing coverage may be larger than the benefit of gaining coverage (Argys et al. 2020). Additionally, Medicaid is associated with higher levels of family wealth (Jackson, Agbai, and Rauscher 2021). ...
... As a result of the conducted research, it was found out that ensuring high public confidence in medical workers and specific medical organizations contributes to an increase in the number of appeals at the initial stage of the onset of symptoms of the disease, timely provision of medical care, and, therefore, a decrease in mortality and an increase in the actual quality of medical services. Similar conclusions were obtained in the article (Miller et al., 2021). This article is devoted to the analysis of the results of a largescale US federal survey related to the identification of the relationship between the state's entry into the Medicaid program and mortality in this state after joining the program. ...
Article
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Background of the study: In the current situation of the global COVID-19 pandemic the role of a strong medical cluster operating in a specific territory in a specific region or even in a country is incredibly increasing. A strong regional medical cluster in these conditions determines the level of health of the population, the ability to cope with the serious challenges of the pandemic and minimize its negative consequences, both the health of citizens and the economy of the region. Purpose of the article: The purpose of this paper is to determine the factors that have the strongest impact on the competitiveness of medical organizations in the region in the new conditions of a pandemic and its consequences, as well as to identify promising mechanisms for its assessment and ranking. Methods: In this work, methods of statistical, strategic and matrix analysis are used, on the basis of which the factors of competitiveness of healthcare organizations in the region can be determined and ranked, which makes it possible, by ranking, to identify the most significant of them during the COVID-19 pandemic and its consequences. Findings & Value added: The results of this study made it possible to test new mechanisms for assessing the competitiveness of healthcare institutions in the new conditions of a pandemic and to study the influence of the most significant factors of competitiveness on the regional and global competitiveness of the region in the conditions of COVID-19.
... 2 Objective and quantitative data regarding the granular ramifications of Medicaid expansion can inform policy interventions involving public health insurance. Although previous studies have reported overall population-level improvement in health-related outcomes, [3][4][5] including allcause mortality and within specific disease groups, 6,7 full national outcomes studies have been limited to insurance eligibility, or 1-year or 2-year mortality outcomes following Medicaid expansion, and none have provided in-depth analyses on potential state-level variability. [8][9][10][11] Additionally, the lag-time of potential effects of Medicaid expansion might not yet be apparent in these previous reports as the majority of adult mortality can be linked to chronic medical conditions. ...
Article
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Background The expansion of the Medicaid public health insurance programme has varied by state in the USA. Longer-term mortality and factors associated with variability in outcomes after Medicaid expansion are under-studied. We aimed to investigate the association of state Medicaid expansion with all-cause mortality. Methods This was a population-based, national, observational cohort study capturing all reported deaths among adults aged 25–64 years via death certificate data in the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database in the USA from Jan 1, 2010, to Dec 31, 2018. We obtained national demographic and mortality data for adults aged 25–64 years, and state-level demographics and 2010–18 mortality estimates for the overall population by linking federally maintained registries (CDC WONDER, Behavioral Risk Factor Surveillance System, Health Resources and Services Administration, US Census Bureau, and Bureau of Labor Statistics). States were categorised as Medicaid expansion or non-expansion states as classified by the Kaiser Family Foundation. Multivariable difference-in-differences analysis assessed the absolute difference in the annual, state-level, all-cause mortality per 100 000 adults after Medicaid expansion. Findings Among 32 expansion states and 17 non-expansion states, Medicaid expansion was associated with reductions in all-cause mortality (−11·8 deaths per 100 000 adults [95% CI −21·3 to −2·2]). There was variability in changes in all-cause mortality associated with Medicaid expansion by state (ranging from −63·8 deaths per 100 000 adults [95% CI −134·1 to −42·9] in Delaware to 30·4 deaths per 100 000 adults [–39·8 to 51·4] in New Mexico). State-level proportions of women (−17·8 deaths per 100 000 adults [95% CI −26·7 to −8·8] for each percentage point increase in women residents) and non-Hispanic Black residents (−1·4 deaths per 100 000 adults [–2·4 to −0·3] for each percentage point increase in non-Hispanic Black residents) were associated with greater adjusted reductions in all-cause mortality among expansion states. Interpretation After 4 years of implementation, Medicaid expansion remains associated with significant reductions in all-cause mortality, but reductions are variable by state characteristics. These results could inform policy makers to provide broad-based equitable improvements in health outcomes. Funding University of Southern California Research Center for Liver Diseases.
... Thus, we do not focus exclusively on low-income families, and we use a less restrictive low-income cutoff following Kaestner et al. (2017), who use an income cutoff equal to 300 percent of the poverty level. The low-education sample is useful to examine in that most persons with less than a high school diploma will have relatively low incomes, and adult education levels are largely fixed before the Affordable Care Act (Miller et al., 2021). The single-person household sample is useful in that their Medicaid eligibility is determined by their own income and not the presence or income of other household members. ...
Article
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Plain English Summary Medicaid expansion via the Affordable Care Act did not increase self-employments rates, but it did increase health insurance coverage rates of low-income entrepreneurs. We compare states that expanded Medicaid to those that did not and examine how self-employment rates and health insurance rates changed over time. Self-employment rates followed similar trends in expansion and non-expansion states suggesting no differential effect of Medicaid expansion. Health insurance coverage rates for the self-employed increased in both expansion and non-expansion states due to various provisions of the Affordable Care Act, but Medicaid expansion states experienced larger increases. This has implications for entrepreneurship research and policy. The major social cost of poor health insurance access for the self-employed is not that it reduces self-employment but that it reduces health insurance coverage rates among the self-employed. Improved health insurance access can improve the health and well-being of the self-employed and their families.
... However, we did not consider these programs in our analysis given either the limited scope of the program (TANF) or relative lack of cross-state variation in generosity during the study period (SNAP). research finds variation in Medicaid policy impacted spatial patterns in both all-cause and drug overdose mortality (Sommers, Baicker & Epstein 2012;Venkataramani & Chatterjee 2019;Miller, Johnson, Wherry 2021). While generosity of (and eligibility for) UI varies across state lines, it is a time-limited social benefit. ...
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The decline of manufacturing employment is frequently invoked as a key cause of worsening U.S. population health trends, including rising mortality due to ‘deaths of despair’. Increasing automation—the use of industrial robots to perform tasks previously done by human workers—is one major structural force driving the decline of manufacturing jobs and wages. In this study we examine the impact of automation on age-sex specific mortality. Using exogenous variation in automation to support causal inference, we find that increases in automation over the period 1993–2007 led to substantive increases in all-cause mortality for both men and women aged 45-54. Disaggregating by cause, we find evidence automation is associated with increases in drug overdose deaths, suicide, homicide and cardiovascular mortality although patterns differ across age-sex groups. We go on to examine heterogeneity in effects by safety net program generosity, labor market policies, and the supply of prescription opioids.
... Nationwide studies observed a decline in all-cause mortality following the ACA Medicaid expansions, but not in cause-specific mortality rates (cardiovascular, respiratory, suicide, and opioid overdose) (12) while a separate analysis found only small, insignificant effects (13). Emerging evidence suggests that Medicaid expansion may have reduced excessive mortality for minorities, in part, by reducing amenable mortality (10,14). These reforms also seem to have reduced maternal mortality rates, particularly for latematernal deaths and Black mothers (15,16). ...
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Objectives: To investigate the association of state-level Medicaid expansion and non-elderly mortality rates from 1999 to 2018 in Northeastern urban settings. Methods: This quasi-experimental study utilized a synthetic control method to assess the association of Medicaid expansion on non-elderly urban mortality rates [1999–2018]. Counties encompassing the largest cities in the Northeastern Megalopolis (Washington D.C., Baltimore, Philadelphia, New York City, and Boston) were selected as treatment units ( n = 5 cities, 3,543,302 individuals in 2018). Cities in states without Medicaid expansion were utilized as control units ( n = 17 cities, 12,713,768 individuals in 2018). Results: Across all cities, there was a significant reduction in the neoplasm (Population-Adjusted Average Treatment Effect = −1.37 [95% CI −2.73, −0.42]) and all-cause (Population-Adjusted Average Treatment Effect = −2.57 [95%CI −8.46, −0.58]) mortality rate. Washington D.C. encountered the largest reductions in mortality (Average Treatment Effect on All-Cause Medical Mortality = −5.40 monthly deaths per 100,000 individuals [95% CI −12.50, −3.34], −18.84% [95% CI −43.64%, −11.67%] reduction, p = < 0.001; Average Treatment Effect on Neoplasm Mortality = −1.95 monthly deaths per 100,000 individuals [95% CI −3.04, −0.98], −21.88% [95% CI −34.10%, −10.99%] reduction, p = 0.002). Reductions in all-cause medical mortality and neoplasm mortality rates were similarly observed in other cities. Conclusion: Significant reductions in urban mortality rates were associated with Medicaid expansion. Our study suggests that Medicaid expansion saved lives in the observed urban settings.
... Finkelstein et al. (2012) find that randomly selected recipients of Medicaid in Oregon reported better physical and mental health after a year with health insurance, but find no clinical evidence of better health. Miller, Johnson, and Wherry (2019) show that mortality among the nearelderly fell by almost 10 percent in states that participated in the Affordable Care Act Medicaid expansion, compared to states that did not. Abaluck et al. (2020) find that, conditional on being insured, specific health insurance plans affect beneficiaries' mortality rates. ...
Article
Life expectancy varies substantially across local regions within a country, raising conjectures that place of residence affects health. However, population sorting and other confounders make it difficult to disentangle the effects of place on health from other geographic differences in life expectancy. Recent studies have overcome such challenges to demonstrate that place of residence substantially influences health and mortality. Whether policies that encourage people to move to places that are better for their health or that improve areas that are detrimental to health are desirable depends on the mechanisms behind place effects, yet these mechanisms remain poorly understood.
... Later expansions of Medicaid (in the late 1980s and early 1990s) to pregnant women and newborns with slightly higher incomes also coincided with reductions in infant mortality (Currie and Gruber 1996). States that expanded eligibility for Medicaid under the Affordable Care Act saw declines in mortality and morbidity among near-elderly adults (Miller, Johnson, and Wherry 2021). ...
Article
The twenty-first century has been a period of rising inequality in both income and health. In this paper, we find that geographic inequality in mortality for midlife Americans increased by about 70 percent between 1992 and 2016. This was not simply because states like New York or California benefited from having a high fraction of college-educated residents who enjoyed the largest health gains during the last several decades. Nor was higher dispersion in mortality caused entirely by the increasing importance of “deaths of despair,” or by rising spatial income inequality during the same period. Instead, over time, state-level mortality has become increasingly correlated with state-level income; in 1992, income explained only 3 percent of mortality inequality, but by 2016, state-level income explained 58 percent. These mortality patterns are consistent with the view that high-income states in 1992 were better able to enact public health strategies and adopt behaviors that, over the next quarter-century, resulted in pronounced relative declines in mortality. The substantial longevity gains in high-income states led to greater cross-state inequality in mortality.
... Many studies have estimated the effects of Massachusetts' healthcare reform on medical care utilization, health, household finance, and labor market outcomes(Courtemanche & Zapata, 2014;Dillender et al., 2016;Kolstad & Kowalski, 2012, 2016Mazumder & Miller, 2016;Miller, 2012Miller, , 2013Sommers et al., 2014). A large number of studies have investigated the effects of the ACA Medicaid expansion on medical care utilization, labor supply, household finances, physical and mental health, and mortality(Allen et al., 2017;Borgschulte & Vogler, 2020;Ghosh et al., 2017;Hu et al., 2018;Kaestner et al., 2017;Leung & Mas, 2018;Miller et al., 2021;Simon et al., 2017;Sommers et al., 2015Sommers et al., , 2017Wherry & Miller, 2016).5 Ferrer-i-Carbonell and Frijters(2004)find that assuming either the cardinality or ordinality of a happiness measure in the German socioeconomic panel survey makes little difference when estimating determinants of happiness.6 We exclude individuals who reside in Guam, Puerto Rico, and the Virgin Islands from the sample; however, the results are robust when including these sample individuals.7 ...
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We study the role of access to health insurance coverage as a determinant of individuals' subjective well-being (SWB) by analyzing large-scale healthcare reforms in the United States. Using data from the Behavioral Risk Factor Surveillance System and Panel Study of Income Dynamics, we find that the 2006 Massachusetts reform and 2014 Affordable Care Act Medicaid expansion improved the overall life satisfaction of Massachusetts residents and low-income adults in Medicaid expansion states, respectively. The results are robust to various sensitivity and falsification tests. Our findings imply that access to health insurance plays an important role in improving SWB. Without considering psychological benefits, the actual benefits of health insurance may be underemphasized.
... Adjusted difference-in-differences regression results for effects of Medicaid expansion on administrative spending, cess to care, improved health status, reduced mortality, and financial implications. 13,14,34,35 In addition, a few studies have begun to consider more nuanced variations in Medicaid programs beyond simple expansion or not, [6][7][8]10,36 and findings from our study reinforce the need for such approaches. Although we did not find an effect of expansion on administrative spending in states that expanded via waiver or the traditional ACA expansion mechanism, this lack of an effect helps provide some evidence regarding the administrative spending related to waivers. ...
Article
With the passage of the Affordable Care Act, states were given the option to expand their Medicaid programs. Since then, thirty-eight states and Washington, D.C., have done so. Previous work has identified the widespread effects of expansion on enrollment and the financial implications for individuals, hospitals, and the federal government, yet administrative expenditures have not been considered. Using data from all fifty states for the period 2007-17, our study estimated the effects of Medicaid expansion overall, as well as differing effects by the size and nature of the expansions. Using a quasi-experimental approach, we found no overall effect of expansion on administrative spending. However, the size of the expansion may have produced differing effects. States with small expansions experienced some increases in administrative spending, whereas states with large expansions experienced some decreases in administrative spending, including a $77 reduction in per enrollee administrative spending compared with nonexpansion states. As more states consider expanding their Medicaid programs, our findings provide evidence of potential effects.
Article
Government responses to the COVID‐19 pandemic had an unprecedented impact on mobility patterns with implications for public safety and crime dynamics in countries across the planet. This paper explores the effect of stay‐at‐home guidelines on thefts and robberies at the neighborhood level in a Latin American city. We exploit neighborhood heterogeneity in the ability of working adults to comply with stay‐at‐home recommendations and use difference‐in‐differences and event‐study designs to identify the causal effect of COVID‐19 mobility restrictions on the monthly number of thefts and robberies reported to police across neighborhoods in Montevideo (Uruguay) in 2020. Our results show that neighborhoods with a higher share of residents with work‐from‐home jobs experienced a larger reduction in reported thefts in relation to neighborhoods with a lower share of residents with work‐from‐home jobs. In contrast, both groups of neighborhoods experienced a similar reduction in the number of reported robberies. These findings cast light on opportunity structures for crime but also on how crime during the pandemic has disproportionately affected more vulnerable areas and households.
Article
In response to the growing concern over diabetes, state-mandated health insurance benefits for diabetes have become popular since the late 1990s. However, little is known about whether these mandates improve the health of people with diabetes. In this paper, I use data from the restricted-use Multiple Cause of Death Mortality database and the Behavioral Risk Factor Surveillance System to investigate the effects of these mandates on diabetes-related mortality rates, along with the underlying mechanisms behind the estimated effects. Using a difference-in-differences framework that leverages variation in the enactment of mandates both across states and over time, I find that approximately 3.1 fewer diabetes-related deaths per 100,000 occur annually in mandate states than in non-mandate states. The mechanism analysis suggests higher utilization of the mandated medical benefits caused these mortality improvements. These findings can inform the ongoing policy debate on strengthening or weakening coverage mandates, including Essential Health Benefits under the Affordable Care Act.
Article
Objective: To evaluate the impact of hospitals' participation in the Medicare Shared Savings Program (MSSP) on their financial performance. Data sources: Centers for Medicare & Medicaid Services Hospital Cost Reports and MSSP Accountable Care Organizations (ACO) Provider-Level Research Identifiable File from 2011 to 2018. Study design: We used an event-study design to estimate the temporal effects of MSSP participation on hospital financial outcomes and compared within-hospital changes over time between MSSP and non-MSSP hospitals while controlling for hospital and year fixed effects and organizational and service-area characteristics. The following financial outcomes were evaluated: outpatient revenue, inpatient revenue, net patient revenue, Medicare revenue, operating margin, inpatient revenue share, Medicare revenue share, and allowance and discount rate. Data collection/extraction methods: Secondary data linked at the hospital level. Principal findings: Controlling for trends in non-MSSP hospitals, MSSP participation was associated with differential increases in net patient revenue by $3.28 million (p < 0.001), $3.20 million (p < 0.01), and $4.20 million (p < 0.01) in the second, third, and fourth year and beyond after joining MSSP, respectively. Medicare revenue differentially increased by $1.50 million (p < 0.05), $2.24 million (p < 0.05), and $4.47 million (p < 0.05) in the first, second, and fourth year and beyond. Inpatient revenue share differentially increased by 0.29% (p < 0.05) in the second year and 0.44% (p < 0.05) in the fourth year and beyond. Medicare revenue share differentially increased by 0.17% (p < 0.01), 0.25% (p < 0.01), 0.32% (p < 0.01), and 0.41% (p < 0.01) in consecutive years following MSSP participation. MSSP participation was associated with 0.33% (p < 0.05) and 0.39% (p < 0.05) differential reduction in allowance and discount rate in the second and third years. Conclusions: MSSP participation was associated with differential increases in net patient revenue, Medicare revenue, inpatient revenue share, and Medicare revenue share, and a differential reduction in allowance and discount rate.
Article
Background: Life expectancy in the United States has declined since 2014 but characterization of disparities within and across metropolitan areas of the country is lacking. Methods: Using census tract-level life expectancy from the 2010 to 2015 US Small-area Life Expectancy Estimates Project, we calculate 10 measures of total and income-based disparities in life expectancy at birth, age 25, and age 65 within and across 377 metropolitan statistical areas (MSAs) of the United States. Results: We found wide heterogeneity in disparities in life expectancy at birth across MSAs and regions: MSAs in the West show the narrowest disparities (absolute disparity: 8.7 years, relative disparity: 1.1), while MSAs in the South (absolute disparity: 9.1 years, relative disparity: 1.1) and Midwest (absolute disparity: 9.8 years, relative disparity: 1.1) have the widest life expectancy disparities. We also observed greater variability in life expectancy across MSAs for lower income census tracts (coefficient of variation [CoV] 3.7 for first vs. tenth decile of income) than for higher income census tracts (CoV 2.3). Finally, we found that a series of MSA-level variables, including larger MSAs and greater proportion college graduates, predicted wider life expectancy disparities for all age groups. Conclusions: Sociodemographic and policy factors likely help explain variation in life expectancy disparities within and across metro areas.
Article
Importance: Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending. Objective: To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity. Evidence review: Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included. Findings: Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity. Conclusions and relevance: Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.
Article
Low‐carbon development is associated with eco‐industrial parks (EIPs), but whether a causal relationship exists is unknown. A growing body of evidence from environmental engineering studies suggests that EIPs reduce carbon emissions, but few economic studies have assessed the causality, channels, and heterogeneity of this relationship. This study uses the staggered difference‐in‐difference method to construct a quasi‐natural experiment to assess the impact of national‐level EIPs on low‐carbon development. The empirical results reveal that EIPs help achieve low‐carbon development in China. Specifically, EIPs reduce the carbon intensity of the pilot cities by 7.2%. The channel analysis reveals that EIPs advance technological innovation, stimulate the Porter effect, and upgrade the industrial structure. Regional heterogeneity analysis further reveals that EIPs are more conducive to low‐carbon development in pilot cities in southern China, cities along the coast, and cities on the east of the Hu line. Further analysis shows that EIPs depress the peak of the environmental Kuznets curve and help achieve the turning point early. Moreover, this study offers fresh cases and patterns for the construction of EIPs in China. This study contributes to an in‐depth understanding of the role of EIPs in the low‐carbon transition in the largest developing country and provides inspiration for further policy optimization.
Article
Power is an important factor in assessing the likely validity of a statistical estimate. An analysis with low power is unlikely to produce convincing evidence of a treatment effect even when one exists. Of greater concern, a statistically significant estimate from a low-powered analysis is likely to misstate the true effect size, including finding estimates of the wrong sign or that are several times too large. Yet statistical power is rarely reported in published economics work. This is in part because many modern research designs are complex enough that power cannot be easily ascertained using simple formulae. Power can also be difficult to estimate in observational settings. Using an applied example–the link between gaining health insurance and mortality–we conduct a simulated power analysis to outline the importance of power and ways to estimate power in complex research settings. We find that standard difference-in-differences and triple differences analyses of Medicaid expansions using county or state mortality data would need to induce reductions in population mortality of at least 2% to be well powered. While there is no single, correct method for conducting a simulated power analysis, our manuscript outlines how applied researchers can conduct simulations appropriate to their settings.
Article
The objective of this empirical exercise was to examine how drug providers in states that implemented the Medicaid expansion in 2014 reacted to the expansion compared with providers in states where Medicare was not expanded. Medicaid beneficiaries have been susceptible to higher cost and lower quality of health care. The Affordable Care Act increased access to drugs for uninsured people. Numerous studies highlighted the effects of the Medicaid expansion on beneficiaries. However, there is a gap in the literature that looks at prescription behavior of physicians during the Medicaid expansion that compared expanded states versus nonexpanded states. A difference-in-differences regression was used to estimate the average treatment effect of implementing the Medicaid expansion on each of the 6 outcomes of interest: (1) total cost of prescribing drugs, (2) number of total drug claims for non-Medicaid beneficiaries, (3) number of drug claims for Medicaid beneficiaries, (4) number of beneficiaries, (5) number of beneficiaries who were 65 years old or older, and (6) ratio of brand-name drugs. To address potential estimation biases, a matching procedure was used to ensure that pre- and post-Medicaid period trends were parallel. Our results provide evidence that, on average, the Medicaid expansion led each provider in expanded states prescribed more drugs for beneficiaries with low-income subsidies, whereas prescribed less drugs for other beneficiaries including those over 65 years old. The authors also show the proportion of brand-name drugs prescribed by a provider in expanded states declined due to the implementation of the Medicaid expansion. These results suggests that the Medicaid expansion has contributed to increasing access to health care by low-income citizens who were in need of prescriptions.
Article
Importance: In the US, suicide is the 10th leading cause of death and a serious mental health emergency. National programs that address suicide list access to mental health care as key in prevention, and more large-scale policies are needed to improve access to mental health care and address this crisis. The Patient Protection and Affordable Care Act (ACA) Medicaid Expansion Program was implemented in several states with the goal of increasing access to the health care system. Objective: To compare changes in suicide rates in states that expanded Medicaid under the ACA vs states that did not. Design, setting, and participants: In this cross-sectional study, state-level mortality rates were obtained from the National Center for Health Statistics for US individuals aged 20 to 64 years from January 1, 2000, to December 31, 2018. Data analysis was performed from April 18, 2021, to April 15, 2022. Exposures: Changes in suicide mortality rates among nonelderly adults before and after Medicaid expansion in expansion and nonexpansion states were compared using adjusted difference-in-differences analyses via hierarchical bayesian linear regression. Main outcomes and measures: Suicide rates using death by suicide as the primary measure. Results: Of the total population at risk for suicide, 50.4% were female, 13.3% were Black, 79.5% were White, and 7.2% were of other races. The analytic data set contained suicide mortality data for 2907 state-age-year units covering the general US population. A total of 553 912 deaths by suicide occurred during the study period, with most occurring in White (496 219 [89.6%]) and male (429 580 [77.6%]) individuals. There were smaller increases in the suicide rate after 2014 in Medicaid expansion (2.56 per 100 000 increase) compared with nonexpansion states (3.10 per 100 000 increase). In adjusted difference-in-differences analysis, a significant decrease of -0.40 (95% credible interval, -0.66 to -0.14) suicides per 100 000 individuals was found, translating to 1818 suicides that were averted in 2015 to 2018. Conclusions and relevance: In this cross-sectional study, although suicide rates increased in both groups, blunting of these rates occurred among nonelderly adults in the Medicaid expansion states compared with nonexpansion states. Because this difference may be linked to increased access to mental health care, policy makers should consider suicide prevention as a benefit of expanding access to health care.
Article
We evaluate the impact of Affordable Care Act Medicaid expansion on coverage, access to care, and self‐reported health, for the vulnerable and chronically ill using data from the behavioral risk factor surveillance system (BRFSS). Using 5 years of post‐reform data between 2014 and 2018 and a difference‐in‐differences identification strategy, we find that the Medicaid expansion improved coverage and access to care among both those with and without chronic conditions. While the effect sizes are mostly larger for those with a chronic condition, the differences in magnitude are not statistically significant. We also find statistically significant improvements in self‐assessed health for those without chronic conditions. Finally, we find larger improvements in coverage and access to care among those with chronic conditions in states with higher‐than‐average pre‐ACA uninsured rates for those with chronic conditions, though these coverage and access gains did not translate into health improvements for this group.
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The decline of manufacturing employment is frequently invoked as a key cause of worsening U.S. population health trends, including rising mortality due to “deaths of despair.” Increasing automation—the use of industrial robots to perform tasks previously done by human workers—is one structural force driving the decline of manufacturing jobs and wages. In this study, we examine the impact of automation on age- and sex-specific mortality. Using exogenous variation in automation to support causal inference, we find that increases in automation over the period 1993–2007 led to substantive increases in all-cause mortality for both men and women aged 45–54. Disaggregating by cause, we find evidence that automation is associated with increases in drug overdose deaths, suicide, homicide, and cardiovascular mortality, although patterns differ by age and sex. We further examine heterogeneity in effects by safety net program generosity, labor market policies, and the supply of prescription opioids.
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We estimate the causal effect of extreme temperatures on out-of-pocket medical expenditure. To do so we match data from three waves of China Family Panel Studies, a nationally representative longitudinal survey for China, with daily weather records in the county in which the person lives. We find that both extreme cold and extreme heat increase expenditure and that the effect of hot days on out-of-pocket medical expenditure is collectively larger than that of cold days. Extreme temperatures increase time engaged in sedentary activities and contribute to sleep disruption and energy poverty, which adversely affect physical and mental health. Combining our preferred estimates with daily temperature projections from recent climate models, we find that out-of-pocket medical expenditure would increase by 2.290–6.149 per cent in the medium term (2041-2060), depending on whether measures are taken to curb greenhouse gas emissions. Our study highlights a growing, but previously neglected, burden stemming from climate change.
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Between 1995 and 2018, just over half of U.S. states enacted laws requiring private insurance plans cover medical care provided remotely. These telemedicine parity laws likely increase health care access, particularly in areas with few providers, by granting patients access to specialists or primary care providers located elsewhere. We estimate the effect of telemedicine parity laws on mortality rates of all causes and for causes of death due to conditions more frequently treated with telemedicine. Mortality rates decline postparity laws, driven by decreases in ischemic heart disease deaths. Ischemic heart disease mortality rates decline by about 6% in the difference‐in‐differences specification and 9% in the event study estimation. These effects are concentrated in counties located in the fringes of metropolitan areas. We also estimate declines in hospital admissions postparity law, consistent with improved health outcomes. Our results suggest that relaxing current telemedicine regulations would reduce mortality rates.
Article
Background Asthma disproportionately affects individuals with lower income. High un-insurance rates are a potential driver for this disparity. Previous studies have not examined the effect of the Affordable Care Act (ACA) on asthma related outcomes for individuals with low income. Research Question What is the impact of insurance status and the ACA on asthma outcomes for adults ages 18–64 in households with low income status? Study Design and Methods This study is a pooled cross-sectional observational study using National Health Interview Survey data from years 2011–2013 and 2016–2018. Individuals aged 18-64 with a history of asthma and low income were included. Survey weighted regression modeling and mediation analysis was used to explore the relationship of insurance status and asthma control. Univariate and multivariate survey weighted regression modeling is then used to evaluate the correlation of the ACA and asthma outcomes. Results We identified 4,043 individual observations. Having health insurance is correlated with improved asthma outcomes (OR 1.27). This relationship is completely mediated by cost barriers to medications and physician visits. While the ACA resulted in significant changes in insurance status (OR 2.4), there was no statistically significant change in asthma outcomes. Furthermore, cost barriers to both medications and physician visits persisted in the insured population, 21.9% and 30.6% respectively. Interpretation Insurance coverage is associated with improved asthma control for adults ages 18–64 in low socioeconomic households. The ACA reduced the rates of uninsured but did not have the same magnitude of effect on reducing cost barriers or health outcomes. The persistence of cost barriers may partially explain the lack of population level improvement in asthma control.
Article
Public health insurance programs like Medicaid provide in-kind resources that may improve health and reduce stress, altering time use patterns. Our study examines the effects of the Affordable Care Act (ACA)-facilitated Medicaid expansions on time spent on home production and childcare. Using time-diary data, we estimated difference-in-differences models comparing the time use patterns of individuals in states that expanded Medicaid versus non-expansion states, before and after implementation. Medicaid expansion increased the amount of time low-income adults spent on home production by 12 min per day (p < .05), equivalent to a 9.5% increase. This was driven by increased time spent on food preparation and housework. Medicaid expansion also increased time spent on childcare among low-income parents by 6.6 min per day (p < .10) or 7.7%. Expanding public health insurance eligibility for low-income populations may increase time spent on home production and childcare, which are associated with significant health benefits for children and adults.
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The problem of human sacrifice universality can be formulated as follows: is a human sacrifice a sociocultural universal and, if so, how can this be proved? One possible approach to solving this problem is to show how human sacrifice is realized in modern societies. The main purpose of this research is to substantiate the assumption that there are contemporary analogues of the candidate’s selection for the role of a human sacrifice. If they exist, this will be an additional argument in favor of the opinion that human sacrifice is universal. The elements of human sacrifice can be spread out in time and space, and also be implemented in a different order than in traditional rituals. The hypothesis was that the selection of candidates for the role of victims in such distributed sacrifice is implemented by life and health insurance. As a research method we used the analysis of possible statistical relationships between mortality and life expectancy of people, on the one hand, and the availability of different types of life and health insurance policies, on the other. Since the mortality rate among the military in active service is higher than among civilians, compulsory life and health insurance for military personnel can be viewed as an analogue of the selection of victims. In the case of civilian victims, the availability of voluntary life and health insurance policies for people is positively correlated with life expectancy, which is presumably associated with better medical care in cases of illness or accident. Voluntary insurance can be viewed as an analogue of negative selection: those not insured have a higher chance of becoming a victim.
Article
This paper investigates the impact of the Affordable Care Act Medicaid expansions on marital behavior. We use data from the American Community Survey from 2008 to 2019 and estimate difference-in-differences models to test for effects on marriage and divorce outcomes. We find that expansions led to a 0.95% reduction in marriage stock and a 2.22% increase in divorce stock, with effects being larger among low educated individuals. We believe that two factors play a role as underlying mechanisms: (1) reduced reliance on spousal insurance coverage and (2) deciding to forego marriage or get divorced to meet eligibility restrictions.
Article
Health inequality can affect economic productivity, labor force participation, or the intergenerational transmission of poverty. Health disparities based on socioeconomic ranking are widely documented, but there is also growing evidence of disparities based on geographic locality. This paper investigates a potential contributing factor to socioeconomic and geographic-based health inequality: access to secondary health care. We exploit bus line introductions to Arab towns in Israel, which substantially increased secondary health care access among a mostly disadvantaged population, and find that older adult reporting of chronic health conditions increased in the short term. However, this effect fades away in the long run. We argue that greater chronic condition rates in the short term reflect higher diagnosis rates resulting from increased access to health care professionals rather than health deterioration. This effect weakens in the long run when the benefits of greater access to health care offset the higher diagnosis rates.
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From January through June 2019, 30.7 million persons of all ages (9.5%) were uninsured at the time of interview. • Among adults aged 18–64, 13.7% were uninsured at the time of interview, 20.4% had public coverage, and 67.7% had private health insurance coverage. • Among children aged 0–17 years, 4.4% were uninsured, 41.6% had public coverage, and 55.8% had private health insurance coverage. • Among adults aged 18–64, men (15.4%) were more likely than women (12.1%) to be uninsured. • Among adults aged 18–64, Hispanic adults (27.2%) were more likely than non-Hispanic black (13.6%), non-Hispanic white (9.8%), and non-Hispanic Asian (7.4%) adults to be uninsured. • Among adults aged 18–64, 4.6% (9.0 million) were covered by private health insurance plans obtained through the Health Insurance Marketplace or state-based exchanges.
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The Affordable Care Act (ACA) dramatically expanded health insurance, but questions remain regarding its effects on health. We focus on older adults for whom health insurance has greater potential to improve health and well-being because of their greater health care needs relative to younger adults. We further focus on low-income adults who were the target of the Medicaid expansion. We believe our study provides the first evidence of the health-related effects of ACA Medicaid expansion using the Health and Retirement Study (HRS). Using geo-coded data from 2010 to 2016, we estimate difference-in-differences models, comparing changes in outcomes before and after the Medicaid expansion in treatment and control states among a sample of over 3,000 unique adults aged 50 to 64 with income below 100% of the federal poverty level. The HRS allows us to examine morbidity outcomes not available in administrative data, providing evidence of the mechanisms underlying emerging evidence of mortality reductions due to expanded insurance coverage among the near-elderly. We find that the Medicaid expansion was associated with a 15 percentage point increase in Medicaid coverage which was largely offset by declines in other types of insurance. We find improvements in several measures of health including a 12% reduction in metabolic syndrome; a 32% reduction in complications from metabolic syndrome; an 18% reduction in the likelihood of gross motor skills difficulties; and a 34% reduction in compromised activities of daily living (ADLs). Our results thus suggest that the Medicaid expansion led to improved physical health for low-income, older adults.
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Using data from the Behavioral Risk Factor Surveillance System, we examine the causal impact of the Affordable Care Act on health-related outcomes after 3 years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from 2 sources: (1) local area prereform uninsured rates from 2013 and (2) state participation in the Medicaid expansion. Including the third postreform year leads to 2 important insights. First, gains in health insurance coverage and access to care from the policy continued to increase in the third year. Second, an improvement in the probability of reporting excellent health emerged in the third year, with the effect being largely driven by the non-Medicaid expansions components of the policy.
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Objective: This study aims to evaluate the trends in cancer (CA) admissions and surgeries after the Affordable Care Act (ACA) Medicaid expansion. Methods: This is a retrospective study using HCUP-SID analyzing inpatient CA (pancreas, esophagus, lung, bladder, breast, colorectal, prostate, and gastric) admissions and surgeries pre- (2010-2013) and post- (2014) Medicaid expansion. Surgery was defined as observed resection rate per 100 cancer admissions. Nonexpansion (FL) and expansion states (IA, MD, and NY) were compared. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID). Results: There were 317, 858 patients in our sample which included those with private insurance, Medicaid, or no insurance. Pancreas, breast, colorectal, prostate, and gastric CA admissions significantly increased in expansion states but decreased in nonexpansion states. (IRR 1.12, 1.14, 1.11, 1.34, 1.23; P < .05) Lung and colorectal CA surgeries (IRR 1.30, 1.25; P < .05) increased, while breast CA surgeries (IRR 1.25; P < .05) decreased less in expansion states. Government subsidized, or self-pay patients had greater odds of undergoing lung, bladder, and colorectal CA surgery (OR 0.45 vs 0.33; 0.60 vs 0.48; 0.47 vs 0.39; P < .05) in expansion states after reform. Conclusions: In states that expanded Medicaid coverage under the ACA, the rate of surgeries for colorectal and lung CA increased significantly, while breast CA surgeries decreased less. Parenthetically, these cancers are subject to population screening programs. We conclude that expanding insurance coverage results in enhanced access to cancer surgery.
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The Affordable Care Act (ACA) completed its second open enrollment period in February 2015. Assessing the law's effects has major policy implications. To estimate national changes in self-reported coverage, access to care, and health during the ACA's first 2 open enrollment periods and to assess differences between low-income adults in states that expanded Medicaid and in states that did not expand Medicaid. Analysis of the 2012-2015 Gallup-Healthways Well-Being Index, a daily national telephone survey. Using multivariable regression to adjust for pre-ACA trends and sociodemographics, we examined changes in outcomes for the nonelderly US adult population aged 18 through 64 years (n = 507 055) since the first open enrollment period began in October 2013. Linear regressions were used to model each outcome as a function of a linear monthly time trend and quarterly indicators. Then, pre-ACA (January 2012-September 2013) and post-ACA (January 2014-March 2015) changes for adults with incomes below 138% of the poverty level in Medicaid expansion states (n = 48 905 among 28 states and Washington, DC) vs nonexpansion states (n = 37 283 among 22 states) were compared using a differences-in-differences approach. Beginning of the ACA's first open enrollment period (October 2013). Self-reported rates of being uninsured, lacking a personal physician, lacking easy access to medicine, inability to afford needed care, overall health status, and health-related activity limitations. Among the 507 055 adults in this survey, pre-ACA trends were significantly worsening for all outcomes. Compared with the pre-ACA trends, by the first quarter of 2015, the adjusted proportions who were uninsured decreased by 7.9 percentage points (95% CI, -9.1 to -6.7); who lacked a personal physician, -3.5 percentage points (95% CI, -4.8 to -2.2); who lacked easy access to medicine, -2.4 percentage points (95% CI, -3.3 to -1.5); who were unable to afford care, -5.5 percentage points (95% CI, -6.7 to -4.2); who reported fair/poor health, -3.4 percentage points (95% CI, -4.6 to -2.2); and the percentage of days with activities limited by health, -1.7 percentage points (95% CI, -2.4 to -0.9). Coverage changes were largest among minorities; for example, the decrease in the uninsured rate was larger among Latino adults (-11.9 percentage points [95% CI, -15.3 to -8.5]) than white adults (-6.1 percentage points [95% CI, -7.3 to -4.8]). Medicaid expansion was associated with significant reductions among low-income adults in the uninsured rate (differences-in-differences estimate, -5.2 percentage points [95% CI, -7.9 to -2.6]), lacking a personal physician (-1.8 percentage points [95% CI, -3.4 to -0.3]), and difficulty accessing medicine (-2.2 percentage points [95% CI, -3.8 to -0.7]). The ACA's first 2 open enrollment periods were associated with significantly improved trends in self-reported coverage, access to primary care and medications, affordability, and health. Low-income adults in states that expanded Medicaid reported significant gains in insurance coverage and access compared with adults in states that did not expand Medicaid.
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This paper discusses two important limitations of the common practice of testing for preexisting differences in trends (“ pre-trends”) when using difference-in-differences and related methods. First, conventional pre-trends tests may have low power. Second, conditioning the analysis on the result of a pretest can distort estimation and inference, potentially exacerbating the bias of point estimates and under-coverage of confidence intervals. I analyze these issues both in theory and in simulations calibrated to a survey of recent papers in leading economics journals, which suggest that these limitations are important in practice. I conclude with practical recommendations for mitigating these issues. (JEL A14, C23, C51)
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The canonical difference-in-differences (DD) estimator contains two time periods, ”pre” and ”post”, and two groups, ”treatment” and ”control”. Most DD applications, however, exploit variation across groups of units that receive treatment at different times. This paper shows that the two-way fixed effects estimator equals a weighted average of all possible two-group/two-period DD estimators in the data. A causal interpretation of two-way fixed effects DD estimates requires both a parallel trends assumption and treatment effects that are constant over time. I show how to decompose the difference between two specifications, and provide a new analysis of models that include time-varying controls.
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We evaluate a randomized outreach study in which the IRS sent informational letters to 3.9 million households that paid a tax penalty for lacking health insurance coverage under the Affordable Care Act. Drawing on administrative data, we study the effect of this intervention on taxpayers’ subsequent health insurance enrollment and mortality. We find the intervention led to increased coverage during the subsequent two years and reduced mortality among middle-aged adults over the same time period. The results provide experimental evidence that health insurance coverage can reduce mortality in the United States.
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We use comprehensive patient-level discharge data to study the effect of Medicaid on the use of hospital services. Our analysis relies on cross-state variation in the Affordable Care Act’s Medicaid expansion, along with within-state variation across zip codes in exposure to the expansion. We find that the Medicaid expansion increased Medicaid visits and decreased uninsured visits. The net effect is positive for all visits, suggesting that those who gain coverage through Medicaid consume more hospital services than they would if they remained uninsured. The increase in emergency department visits is largely accounted for by “deferrable” medical conditions. Those who gained coverage under the Medicaid expansion appear to be those who had relatively high need for hospital services, suggesting that the expansion was well targeted. Lastly, we find significant heterogeneity across Medicaid expansion states in the effects of the expansion, with some states experiencing a large increase in total utilization and other states experiencing little change. Increases in hospital utilization were larger in Medicaid expansion states that had more residents gaining coverage and lower pre-expansion levels of uncompensated hospital care costs.
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We use administrative data from the IRS to examine long-term impacts of childhood Medicaid eligibility expansions on outcomes in adulthood at each age from 19-28. Greater Medicaid eligibility increases college enrollment and decreases fertility, especially through age 21. Starting at age 23, females have higher contemporaneous wage income, although male increases are imprecise. Together, both genders have lower mortality. These adults collect less from the earned income tax credit and pay more in taxes. Cumulatively from ages 19-28, at a 3% discount rate, the federal government recoups 58 cents of each dollar of its "investment" in childhood Medicaid.
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We estimate the effect of the Affordable Care Act Medicaid expansion on county-level mortality in the first four years following expansion using restricted-access microdata covering all deaths in the United States. To adjust for pre-expansion differences in mortality rates between treatment and control, we use a propensity-score weighting model together with techniques from machine learning to match counties in expansion and non-expansion states. We find a reduction in all-cause mortality in ages 20 to 64 equaling 11.36 deaths per 100,000 individuals, a 3.6 percent decrease. This estimate is largely driven by reductions in mortality in counties with higher pre-expansion uninsured rates and for causes of death likely to be influenced by access to healthcare. A cost-benefit analysis shows that the improvement in welfare due to mortality responses may offset the entire net-of-transfers expenditure associated with the expansion.
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Although the Affordable Care Act’s Medicaid expansion reduced uninsurance, less is known about its impact on mortality, especially in the context of the opioid epidemic. We conducted a difference-in-differences study comparing trends in mortality between expansion and nonexpansion states from 2011 to 2016 using the Centers for Disease Control and Prevention mortality data. We analyzed all-cause deaths, health care amenable deaths, drug overdose deaths, and deaths from causes other than drug overdose among adults aged 20 to 64 years. Medicaid expansion was associated with a 2.7% reduction ( p = .020) in health care amenable mortality, and a 1.9% reduction ( p = .042) in mortality not due to drug overdose. However, the expansion was not associated with any change in all-cause mortality (0.2% reduction, p = .84). In addition, drug overdose deaths rose more sharply in expansion versus nonexpansion states. The absence of all-cause mortality reduction until drug overdose deaths were excluded indicate that the opioid epidemic had a mitigating impact on any potential lives saved by Medicaid expansion.
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We estimate how the marginal propensity to consume (MPC) out of liquidity varies over the business cycle. Ten years after a Chapter 7 bankruptcy, the bankruptcy flag is removed from the filer’s credit report, generating an increase in credit score. In the year following flag removal, credit card limits increase by $778 and credit card balances increase by $290, implying an MPC of 0.37. Using cohorts of flag removals, we find that the MPC was 20 to 30 percent higher during the Great Recession, increased during the 2001 recession, and is positively correlated with the local unemployment rate. (JEL E21, E24, E32, G51)
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Studies have shown that Medicaid expansion has been associated with greater access to care, more preventive care, and improved chronic disease management.¹ Medicaid expansion has also improved financial well-being among low-income families.² While these are important findings, they are process measures that precede any potential changes in health. The critical question posed by many policy makers is whether Medicaid expansion improves health. Five years after implementation of the expansion an evidence base has begun to emerge.
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As we approach the tenth anniversary of the passage of the Affordable Care Act, it is important to reflect on what has been learned about the impacts of this major reform. In this paper, we review the literature on the impacts of the ACA on patients, providers, and the economy. We find strong evidence that the ACA's provisions have increased insurance coverage. There is also a clearly positive effect on access to and consumption of health care, with suggestive but more limited evidence on improved health outcomes. There is no evidence of significant reductions in provider access, changes in labor supply, or increased budgetary pressures on state governments, and the law's total federal cost through 2018 has been less than predicted. We conclude by describing key policy implications and future areas for research.
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Importance Medicaid expansion under the Patient Protection and Affordable Care Act led to one of the largest gains in health insurance coverage for nonelderly adults in the United States. However, its association with cardiovascular mortality is unclear. Objective To investigate the association of Medicaid expansion with cardiovascular mortality rates in middle-aged adults. Design, Setting, and Participants This study used a longitudinal, observational design, using a difference-in-differences approach with county-level data from counties in 48 states (excluding Massachusetts and Wisconsin) and Washington, DC, from 2010 to 2016. Adults aged 45 to 64 years were included. Data were analyzed from November 2018 to January 2019. Exposures Residence in a Medicaid expansion state. Main Outcomes and Measures Difference-in-differences of annual, age-adjusted cardiovascular mortality rates from before Medicaid expansion to after expansion. Results As of 2016, 29 states and Washington, DC, had expanded Medicaid eligibility, while 19 states had not. Compared with counties in Medicaid nonexpansion states, counties in expansion states had a greater decrease in the percentage of uninsured residents at all income levels (mean [SD], 7.3% [3.2%] vs 5.6% [2.7%]; P < .001) and in low income strata (19.8% [5.5%] vs 13.5% [3.9%]; P < .001) between 2010 and 2016. Counties in expansion states had a smaller change in cardiovascular mortality rates after expansion (146.5 [95% CI, 132.4-160.7] to 146.4 [95% CI, 131.9-161.0] deaths per 100 000 residents per year) than counties in nonexpansion states did (176.3 [95% CI, 154.2-198.5] to 180.9 [95% CI, 158.0-203.8] deaths per 100 000 residents per year). After accounting for demographic, clinical, and economic differences, counties in expansion states had 4.3 (95% CI, 1.8-6.9) fewer deaths per 100 000 residents per year from cardiovascular causes after Medicaid expansion than if they had followed the same trends as counties in nonexpansion states. Conclusions and Relevance Counties in states that expanded Medicaid had a significantly smaller increase in cardiovascular mortality rates among middle-aged adults after expansion compared with counties in states that did not expand Medicaid. These findings suggest that recent Medicaid expansion was associated with lower cardiovascular mortality in middle-aged adults and may be of consideration as further expansion of Medicaid is debated.
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This paper evaluates the impact of the Affordable Care Act Medicaid expansions four years after implementation using data from the 2010-2017 National Health Interview Survey. We find that low-income adults in states that implemented the Medicaid expansions experienced increases in insurance and Medicaid coverage and improvements in access to health care across several measures.
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Importance: The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion. Objective: To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis. Design, setting, and participants: Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017. Exposure: Living in a Medicaid expansion state. Main outcomes and measures: The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis. Results: A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, -0.8 percentage points; 95% CI, -1.1 to -0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, -0.2 percentage points; 95% CI, -0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of -0.6 percentage points (95% CI, -1.0 to -0.2). Mortality reductions were largest for black patients (-1.4 percentage points; 95% CI, -2.2, -0.7; P=.04 for interaction) and patients aged 19 to 44 years (-1.1 percentage points; 95% CI, -2.1 to -0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a -4.2-percentage-point (95% CI, -6.0 to -2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant. Conclusions and relevance: Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.
Article
This study examines how subsidized coverage affects prescription drug utilization among low-income non-elderly adults. Using the Affordable Care Act's Medicaid expansions as a source of variation and a national, all-payer pharmacy transactions database, we find that within the first 15 months of new health insurance availability, aggregate Medicaid-paid prescriptions increased 19 percent, amounting to nearly 9 new prescriptions a year, per new enrollee. We find no evidence of reductions in uninsured or privately-insured prescriptions, suggesting that new coverage did not simply substitute for other payment sources. The largest increases occurred for medications treating conditions such as diabetes and heart disease, suggesting greater price elasticity for chronic medications. Generics increased more than brand-name drugs; and utilization increased less in expansion states with higher Medicaid drug copayments. Overall, these findings suggest that prescription drug demand among low-income populations exhibits substantial price sensitivity, and insurance expansion can increase medication treatment for chronic conditions.
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Before the Affordable Care Act Medicaid expansion, nonelderly childless adults were not generally eligible for Medicaid regardless of their income, and Hispanics had much higher uninsured rates than other racial/ethnic subgroups. We estimated difference-in-differences models on Behavioral Risk Factor Surveillance data (2011-2016) to estimate the impacts of Medicaid expansion on racial/ethnic disparities in insurance coverage, access to care, and health status in this vulnerable subpopulation. Uninsured rates among all poor childless adults declined by roughly 9 percentage points more in states that expanded Medicaid. While expansion also had favorable impacts on most access and health outcomes among Whites in expansion states, there were relatively few such impacts among Blacks and Hispanics. Through 2016, Affordable Care Act Medicaid expansion was more effective in improving access and health outcomes among White low-income childless adults than mitigating racial/ethnic disparities.
Article
Monitoring and addressing racial and ethnic disparities in health and health care require the collection and analysis of reliable demographic information. With the intention of improving the measurement and monitoring of disparities, certain provisions of the Patient Protection and Affordable Care Act (ACA) of 2010 require states to collect, report, and analyze data on demographic characteristics of applicants and participants in Medicaid and other federally supported programs. In this large-scale study we link Medicaid records to the Census 2000, the 2010 Census, and the American Community Survey for years 2001-2009 to explore the extent to which pre-ACA Medicaid administrative records matched self-reported race and Hispanic origin in Census Bureau data. Record linkage allows comparison of demographic, socioeconomic and neighborhood characteristics between Medicaid participants with matching and non-matching race and Hispanic origin in census. Identification of the groups most likely to have non-matching and missing race and Hispanic origin data in Medicaid relative to census can inform strategies to improve the quality of demographic data collected from the Medicaid population.
Article
Background: The Affordable Care Act (ACA) of 2010 incentivized states to expand eligibility for their Medicaid programs. Many did so in 2014, and there has been great interest in understanding the effects of these expansions on access to health care, health care utilization, and population health. Objective: To estimate the longer-term (three-year) impact of Medicaid expansions on insurance coverage, access to care, preventive care, self-assessed health, and risky health behaviors. Design: A difference-in-differences model, exploiting variation across states and over time in Medicaid expansion, was estimated using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 2010-2016. Participants: Low-income childless adults aged 19-64 years in the BRFSS. Main measures: Outcomes included insurance coverage, access to care, several forms of preventive care (e.g., routine checkups, flu shots, HIV tests, dental visits, and cancer screening), risky health behaviors (e.g., smoking, alcohol abuse, obesity), and self-assessed health. Key results: The previously documented benefits of Medicaid expansions on insurance coverage, access to care, preventive care, and self-assessed health have persisted 3 years after expansion. There was no detectable effect on risky health behaviors. Conclusions: The Affordable Care Act was motivated in part by a desire to increase health insurance coverage, improve access to care, and increase use of preventive care. The Medicaid expansions facilitated by the ACA are helping to achieve those objectives, and the benefits have persisted 3 years after expansion.
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Event studies are frequently used to estimate average treatment effects on the treated (ATT). In estimating the ATT, researchers commonly use fixed effects models that implicitly assume constant treatment effects across cohorts. We show that this is not an innocuous assumption. In fixed effect models where the sole regressor is treatment status, the OLS coefficient is a non-convex average of the heterogeneous cohort-specific ATTs. When regressors containing lags and leads of treatment are added, the OLS coefficient corresponding to a given lead or lag picks up spurious terms consisting of treatment effects from other periods. Therefore, estimates from these commonly used models are not causally interpretable. We propose alternative estimators that identify certain convex averages of the cohort-specific ATTs, hence allowing for causal interpretation even under heterogeneous treatment effects. To illustrate the empirical content of our results, we show that the fixed effects estimators and our proposed estimators differ substantially in an application to the economic consequences of hospitalization.
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We use an event study approach to examine the economic consequences of hospital admissions for adults in two datasets: survey data from the Health and Retirement Study, and hospitalization data linked to credit reports. For non-elderly adults with health insurance, hospital admissions increase out-of-pocket medical spending, unpaid medical bills, and bankruptcy, and reduce earnings, income, access to credit, and consumer borrowing. The earnings decline is substantial compared to the out-of-pocket spending increase, and is minimally insured prior to age-eligibility for Social Security Retirement Income. Relative to the insured non-elderly, the uninsured non-elderly experience much larger increases in unpaid medical bills and bankruptcy rates following a hospital admission. Hospital admissions trigger fewer than 5 percent of all bankruptcies in our sample.
Article
Objectives: To determine whether the 2014 Medicaid expansions facilitated by the Affordable Care Act affected overall and early-stage cancer diagnosis for nonelderly adults. Methods: We used Surveillance, Epidemiology, and End Results Cancer Registry data from 2010 through 2014 to estimate a difference-in-differences model of cancer diagnosis rates, both overall and by stage, comparing changes in county-level diagnosis rates in US states that expanded Medicaid in 2014 with those that did not expand Medicaid. Results: Among the 611 counties in this study, Medicaid expansion was associated with an increase in overall cancer diagnoses of 13.8 per 100 000 population (95% confidence interval [CI] = 0.7, 26.9), or 3.4%. Medicaid expansion was also associated with an increase in early-stage diagnoses of 15.4 per 100 000 population (95% CI = 5.4, 25.3), or 6.4%. There was no detectable impact on late-stage diagnoses. Conclusions: In their first year, the 2014 Medicaid expansions were associated with an increase in cancer diagnosis, particularly at the early stage, in the working-age population. Public Health Implications. Expanding public health insurance may be an avenue for improving cancer detection, which is associated with improved patient outcomes, including reduced mortality. (Am J Public Health. Published online ahead of print December 21, 2017: e1-e3. doi:10.2105/AJPH.2017.304166).
Article
The goal of the Affordable Care Act (ACA) was to achieve nearly universal health insurance coverage through a combination of mandates, subsidies, marketplaces, and Medicaid expansions, most of which took effect in 2014. We use data from the Behavioral Risk Factor Surveillance System to examine the impacts of the ACA on health care access, risky health behaviors, and self-assessed health after two years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from state participation in the Medicaid expansion and pre-ACA uninsured rates. Results suggest that the ACA led to sizeable improvements in access to health care in both Medicaid expansion and nonexpansion states, with the gains being larger in expansion states along some dimensions. However, we do not find clear effects on risky behaviors or self-assessed health.
Article
This paper provides new evidence that Medicaid’s introduction reduced infant and child mortality in the 1960s and 1970s. Mandated coverage of all cash welfare recipients induced substantial cross-state variation in the share of children immediately eligible for the program. Before Medicaid, higher- and lower-eligibility states had similar infant and child mortality trends. After Medicaid, public insurance utilization increased and mortality fell more rapidly among children and infants in high-Medicaid-eligibility states. Mortality among nonwhite children on Medicaid fell by 20 percent, leading to a reduction in aggregate nonwhite child mortality rates of 11 percent.
Article
Objective: Medicaid coverage for low-income women may play an important role in ensuring access to preventive care. This study examines how Medicaid eligibility expansions to nonelderly adults impact cervical cancer screening among low-income women. Data sources: We use data from the Behavioral Risk Factor Surveillance System from 2000 to 2010. The primary outcome of interest is whether women in the relevant guideline consistent age range reported having a Pap test in the previous year. Study design: We use a difference-in-differences approach with matched treatment and comparison states and a simulated eligibility approach based on a continuous measure of Medicaid generosity. Principal findings: Our results indicate that cervical cancer screening increased among low-income women in expansion states relative to comparison states. Increases in screening rates are largest among low-income Hispanic women. Conclusions: Medicaid expansions during the period from 2000 to 2010 were associated with improved cervical cancer screening rates, which is critical for early cervical cancer detection and prevention of cancer morbidity and mortality in women. The results suggest that more widespread Medicaid expansions may have positive effects on preventive health care for women.
Article
Major policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of the ACA's coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in "excellent" self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health.
Article
Previous research found that Medicaid expansions in New York, Arizona, and Maine in the early 2000s reduced mortality. I revisit this question with improved data and methods, exploring distinct causes of death and presenting a cost-benefit analysis. Differences-in-differences analysis using a propensity score control group shows that all-cause mortality declined by 6 percent, with the most robust reductions for health-care amenable causes. HIV-related mortality (affected by the recent introduction of antiretrovirals) accounted for 20 percent of the effect. Mortality changes were closely linked to county-level coverage gains, with one life saved annually for every 239 to 316 adults gaining insurance. The results imply a cost per life saved ranging from $327,000 to $867,000 which compares favorably with most estimates of the value of a statistical life.
Article
Policy-makers have argued that providing public health insurance coverage to the uninsured lowers long-run costs by reducing the need for expensive hospitalizations and emergency department visits later in life. In this paper, we provide evidence for such a phenomenon by exploiting a legislated discontinuity in the cumulative number of years a child is eligible for Medicaid based on date of birth. We find that having more years of Medicaid eligibility in childhood is associated with fewer hospitalizations and emergency department visits in adulthood for blacks. Our effects are particularly pronounced for hospitalizations and emergency department visits related to chronic illnesses and those of patients living in low-income neighborhoods. Furthermore, we find evidence suggesting that these effects are larger in states where the difference in the number of Medicaid-eligible years across the cutoff birthdate is greater. Calculations suggest that lower rates of hospitalizations and emergency department visits during one year in adulthood offset between 3 and 5 percent of the initial costs of expanding Medicaid.
Article
Background By September 2015, a total of 29 states and Washington, D.C., were participating in Medicaid expansions under the Affordable Care Act. We examined whether Medicaid expansions were associated with changes in insurance coverage, health care use, and health among low-income adults. Methods We compared changes in outcomes during the 2 years after implementation of the Medicaid expansion (2014 and 2015) relative to the 4 years before expansion (2010 through 2013) in states with and without expansions, using data from the National Health Interview Survey. The sample consisted of 60,766 U.S. citizens who were 19 to 64 years of age and had incomes below 138% of the federal poverty level. Outcomes included insurance coverage, access to and use of medical care in the past 12 months, and health status as reported by the respondents. Results A total of 29 states and Washington, D.C., expanded Medicaid by September 1, 2015. In year 2 after implementation, uninsurance rates were reduced in expansion states relative to nonexpansion states (difference-in-differences estimate, −8.2 percentage points; P<0.001) and rates of Medicaid coverage were increased (difference-in-differences estimate, 15.6 percentage points; P<0.001). Expansions were not associated with significant changes in the likelihood of a doctor visit or overnight hospital stay or health status as reported by the respondent. However, as compared with nonexpansion states, expansion states had a decrease in reports of inability to afford needed follow-up care (difference-in-differences estimate, −3.4 percentage points; P=0.002) and in reports of worry about paying medical bills (difference-in-differences estimate, −7.9 percentage points; P=0.002) and an increase in reports of medical care being delayed because of wait times for appointments (difference-in-differences estimate, 2.6 percentage points; P=0.02). Conclusions Medicaid expansion was associated with increased insurance coverage and access to care during the second year of implementation, but it was also associated with longer wait times for appointments, which suggests that challenges in access to care persist.
Article
Using premium subsidies for private coverage, an individual mandate, and Medicaid expansion, the Affordable Care Act (ACA) has increased insurance coverage. We provide the first comprehensive assessment of these provisions’ effects, using the 2012-2015 American Community Survey and a triple-difference estimation strategy that exploits variation by income, geography, and time. Overall, our model explains 60% of the coverage gains in 2014-2015. We find that coverage was moderately responsive to price subsidies, with larger gains in state-based insurance exchanges than the federal exchange. The individual mandate's exemptions and penalties had little impact on coverage rates. The law increased Medicaid among individuals gaining eligibility under the ACA and among previously-eligible populations (“woodwork effect”) even in non-expansion states, with no resulting reductions in private insurance. Overall, exchange premium subsidies produced 40% of the coverage gains explained by our ACA policy measures, and Medicaid the other 60%, of which 1/2 occurred among previously-eligible individuals.
Article
The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA-facilitated state-level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference-in-differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self-assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low-income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self-assessed health.
Article
This paper estimates the effect of US public health insurance programs for children on health. Previous work in this area has typically focused on the relationship between current program eligibility and current health. But because health is a stock variable which reflects the cumulative influence of health inputs, it would be preferable to estimate the impact of total program eligibility during childhood on longer-term health outcomes. I provide such estimates by using longitudinal data to construct Medicaid and CHIP eligibility measures that are observed from birth through age 18 and estimating the effect of cumulative program exposure on a variety of health outcomes observed in early adulthood. To account for the endogeneity of program eligibility, I exploit variation in Medicaid and CHIP generosity across states and over time for children of different ages. I find that an additional year of public health insurance eligibility during childhood improves a summary index of adult health by.079 standard deviations, and substantially reduces health limitations, chronic conditions and asthma prevalence while improving self-rated health.
Article
Background: Little is known about whether insurance expansion affects the location and type of emergency department (ED) use. Understanding these changes can inform state-level decisions about the Medicaid expansion under the Patient Protection and Affordable Care Act (ACA). Objective: To investigate the effect of the 2014 ACA Medicaid expansion on the location, insurance status, and type of ED visits. Design: Quasi-experimental observational study from 2012 to 2014. Setting: 126 investor-owned, hospital-based EDs. Participants: Uninsured and Medicaid-insured adults aged 18 to 64 years. Intervention: ACA expansion of Medicaid in January 2014. Measurements: Number of ED visits overall, type of visit (for example, nondiscretionary or nonemergency), and average travel time to the ED. Interrupted time-series analyses comparing changes from the end of 2013 to end of 2014 for patients from Medicaid expansion versus nonexpansion states were done. Results: There were 1.06 million ED visits among patients from 17 Medicaid expansion states, and 7.87 million ED visits among patients from 19 nonexpansion states. The EDs treating patients from Medicaid expansion states saw an overall 47.1% decrease in uninsured visits (95% CI, -65.0% to -29.3%) and a 125.7% (CI, 89.2% to 162.6%) increase in Medicaid visits after 12 months of ACA expansion. Average travel time for nondiscretionary conditions requiring immediate medical care decreased by 0.9 minutes (-6.2% [CI, -8.9% to -3.5%]) among all Medicaid patients from expansion states. We found little evidence of similar changes among patients from nonexpansion states. Limitation: Results reflect shifts in ED care at investor-owned facilities, which limits generalizability to other hospital types. Conclusion: Meaningful changes in insurance status and location and type of ED visits in the first year of ACA Medicaid expansion were found, suggesting that expansion provides patients with a greater choice of hospital facilities. Primary funding source: Robert Wood Johnson Foundation.
Article
The expansion of Medicaid to low-income nondisabled adults is a key component of the Affordable Care Act's strategy to increase health insurance coverage, but many states have chosen not to take up the expansion. As a result, for many low-income adults, there has been stark variation across states in access to Medicaid since the expansions took effect in 2014. This study investigates whether individuals migrate in order to gain access to these benefits. Using an empirical model in the spirit of a difference-in-differences, this study finds that migration from non-expansion states to expansion states did not increase in 2014 relative to migration in the reverse direction. The estimates are sufficiently precise to rule out a migration effect that would meaningfully affect the number of enrollees in expansion states, which suggests that Medicaid expansion decisions do not impose a meaningful fiscal externality on other states.
Article
Importance Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the “private option”). In addition, while coverage gains from the ACA’s Medicaid expansion are well documented, impacts on utilization and health are unclear. Objective To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA. Design, Setting, and Participants Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016. Exposures Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas. Main Outcomes and Measures Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health. Results Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (−11.6 percentage points; P < .001), reduced out-of-pocket spending (−29.5%; P = .02), reduced likelihood of emergency department visits (−6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (−7.1 percentage points with “fair/poor quality of care”; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences. Conclusions and Relevance In the second year of expansion, Kentucky’s Medicaid program and Arkansas’s private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.