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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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... For instance, Miller et. al. [MJW21] estimates that between 2014 and 2017, in the states that chose to expand Medicaid, there were approximately 19,200 fewer deaths among low-income adults in the age group 55-64; moreover, they estimate that there were approximately 15,600 preventable deaths in states that chose not to opt in. States that have not taken on expanded eligibility, compared to those that did opt in, have uninsurance rates that are nearly twice as large [TDD24]. ...
... For instance, the 2008 Oregon Medicaid expansion studies [Fin+12;Bai+13] estimated that the effect of Medicaid expansion reduced uninsurance rates by about 25% in low-income adults. Some past work [MJW21] has reported that Medicaid expansion had reduced mortality rates, whereas another paper [BBS18] reported that infant mortality had risen in non-Medicaid expansion states and dropped in Medicaid expansion states between 2014 and 2016. ...
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Panel data consists of a collection of N units that are observed over T units of time. A policy or treatment is subject to staggered adoption if different units take on treatment at different times and remains treated (or never at all). Assessing the effectiveness of such a policy requires estimating the treatment effect, corresponding to the difference between outcomes for treated versus untreated units. We develop inference procedures that build upon a computationally efficient matrix estimator for treatment effects in panel data. Our routines return confidence intervals (CIs) both for individual treatment effects, as well as for more general bilinear functionals of treatment effects, with prescribed coverage guarantees. We apply these inferential methods to analyze the effectiveness of Medicaid expansion portion of the Affordable Care Act. Based on our analysis, Medicaid expansion has led to substantial reductions in uninsurance rates, has reduced infant mortality rates, and has had no significant effects on healthcare expenditures.
... Health coverage expansion in lowand middle-income countries is frequently discussed [4]; however, it is also a critical issue for high-income nations with contribution-based national health insurance (NHI) or fragmented healthcare systems (for example, the USA) [5,6]. The focus on expansion of health coverage in lowincome countries is on improving healthcare access [7,8], while high-income countries concentrate on its health effects, such as reduction in mortality rates [9,10]. ...
... However, these studies cannot be used to draw causal inferences about the effects of the policy. Recent research indicates that insurance coverage reduced mortality between waves periods, supporting our findings [9,10]. A review study concluded that expanding health insurance coverage reduced the financial burden and improved access to care [5], while another review determined that causal inference studies, including randomized controlled trials and DIDs, demonstrate that health-benefit expansion reduces mortality [6]. ...
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Background Universal health coverage (UHC) ensures affordability of a variety of essential health services for the general population. Although UHC could mitigate the harmful effects of coronavirus disease 2019 (COVID-19) on patients and their socioeconomic position, the debate on UHC’s scope and ability to improve health outcomes is ongoing. This study aimed to identify the impact of UHC policy withdrawal on the health outcomes of South Korea’s severely ill COVID-19 patients. Methods We used a propensity score matching (PSM) and difference-in-differences combined model. This study’s subjects were 44,552 hospitalized COVID-19 patients contributing towards health insurance claims data, COVID-19 notifications and vaccination data extracted from the National Health Information Database and the Korea Disease Control and Prevention Agency from 1 December 2020 to 30 April 2022. After PSM, 2460 patients were included. This study’s exposures were severity of illness and UHC policy change. The primary outcome was the case fatality rate (CFR) for COVID-19, which was defined as death within 30 days of a COVID-19 diagnosis. There were four secondary outcomes, including time interval between diagnosis and hospitalization (days), length of stay (days), total medical expenses (USD) and the time interval between diagnosis and death (days). Results After the UHC policy’s withdrawal, the severely ill patients’ CFR increased to 284 per 1000 patients [95% confidence interval (CI) 229.1–338.4], hospitalization days decreased to 9.61 days (95% CI −11.20 to −8.03) and total medical expenses decreased to 5702.73 USD (95% CI −7128.41 to −4202.01) compared with those who were not severely ill. Conclusions During the pandemic, UHC may have saved the lives of severely ill COVID-19 patients; therefore, expanding services and financial coverage could be a crucial strategy during public health crises.
... Rural White midlife female mortality has experienced a dramatic increase over the past 30 years; largely attributable to deaths of despair related to drugs, alcohol, and suicide.12 While fears of Medicaid expansion increasing opioid prescribing and subsequent overdose have largely gone unsupported and/or refuted by research,4,7,9,40,41 it is possible that this prior work occurred too soon to detect an effect. Further, whether or not overdose would serve as a rural-specific factor remains to be seen due to the mortality increases we observed among both urban and rural White populations.Beyond local Medicaid acceptance and drug overdoses, it is also important to recall that we are analyzing all-cause mortality. ...
... An important next step for the research is to further disaggregate the effects of Medicaid expansion by cause of death and age group.Through our use of restricted data, a doubly robust study design, and separate models for each population group, we have provided the most robust estimates on the varying impact of Medicaid expansion on all-cause mortality to date-finding considerable heterogeneity and rising mortality for rural Americans. Although troubling, these results should not be taken as suggesting that Medicaid nor Medicaid expansion are misguided programs, both have led to notable and well-documented improvements in mortality, poverty, and quality of life among many populations.[1][2][3][4][5][6][7][8][9][10]22 Rather, this analysis joins prior scholarship documenting considerable heterogeneity in the experience of Medicaid and Medicaid expansion among different populations and geographic areas. ...
Article
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Purpose To determine the differential impact of Medicaid expansion on all‐cause mortality between Black, Latino/a, and White populations in rural and urban areas, and assess how expansion impacted mortality disparities between these groups. Methods We employ a county‐level time‐varying heterogenous treatment effects difference‐in‐difference analysis of Medicaid expansion on all‐cause age‐adjusted mortality for those 64 years of age or younger from 2009 to 2019. For all counties within the 50 US States and the District of Columbia, we use restricted‐access vital statistics data to estimate Average Treatment Effect on the Treated (ATET) for all combinations of racial and ethnic group (Black, Latino/a, White), rurality (rural, urban), and sex. We then assess aggregate ATET, as well as how the ATET changed as time from expansion increased. Findings Medicaid expansion led to a reduction in all‐cause age‐adjusted mortality for urban Black populations, but not rural Black populations. Urban White populations experienced mixed effects dependent on years after expansion. Latino/a populations saw no appreciable impact. While no effect was observed for rural Black and Latino/a populations, rural White all‐cause age‐adjusted mortality unexpectedly increased due to Medicaid expansion. These effects reduced rural‐ and urban‐specific Black‐White mortality disparities but did not shrink the rural‐urban mortality gap. Conclusions The mortality‐reducing impact of Medicaid expansion has been uneven across racial and ethnic groups and rural‐urban status; suggesting that many populations—particularly rural individuals—are not seeing the same benefits as others. It is imperative that states work to ensure Medicaid expansion is being appropriately implemented in rural areas.
... We used a placebo test to evaluate such an assumption. Following Miller et al. (2021), we hypothetically moved the treatment date from 2017 to either 2012 or 2013, thus calculating the Diff-in-Diffs using a post-treatment period from 2013 or 2014 onwards (respectively). In Table 7, the Diff-in-Diffs coefficient becomes statistically not significant, supporting the parallel trend assumption. ...
Article
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Industry 4.0 technologies radically change industrial processes. National governments have enacted innovation policies to support firms’ investments in new technologies and increase productivity growth. The Italian Industry 4.0 Plan (II4.0 Plan) was implemented with this purpose in 2017 and consisted of a horizontal fiscal plan. Using a new methodology that relies on firms’ financial accounts rather than survey data, we identify firms that benefited from the II4.0 Plan’s incentives and extend the analysis to the population of Italian firms. The results from a Difference-in-Differences regression approach show that the investments spurred by the II4.0 Plan positively affect firms’ labour productivity but heterogeneously among size classes, sectors and type of incentive. Hyper and super amortization and the credit for innovation drive the results. We frame our policy evaluation into the most recent discussion about innovation policies, raising some criticisms on the appropriateness of horizontal policies to foster digital transformation.
... By this date, 35 states and the District of Columbia had expanded Medicaid under the ACA [6]. A voluminous literature generally demonstrates that, compared to non-expanders, residents of Medicaid expansion states experienced better access to care [7][8][9] and improved health outcomes [10][11][12][13] during the pre-pandemic period and that these benefits disproportionately accrued to lowincome or minoritized populations [14][15][16]. ...
... In that case, the in- log (y i ) = α s + ∑ e iτ β τ + ∑e iτ δ τ + l + ε i By correctly interpreting the results from the event-study analysis, a strong argument can be made for the plausibility of the causal effect of the intervention. However, as we argue in the section 9 efforts to obtain good quality outputs from event-study analysis as those presented by Cunningham (2021) or Miller et al. (2021), often run up against the reality of limited available data availability. ...
Book
The publication introduces the reader to the methods of hedonic prices and their application to estimating the economic effects of public goods for the purposes of planning and managing territorial development. The publication focuses on selected types of public infrastructure: civic amenities, transport infrastructure, green infrastructure and public spaces and provides practical guidance that shows step by step how the economic effects of implemented and planned public infrastructure development can be estimated from available data.
... Thus, the identification of a treatment effect requires several assumptions such as a common trend between treatment and control groups. Following previous literature 85 , we substantiate this assumption with an eventstudy type regression. A range of robustness tests aims at alleviating the secondary threat, which could arise from tract-specific, but timevariant variables, which we have not observed. ...
Article
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Wildfires are having disproportionate impacts on U.S. households. Notably, in California, over half of wildfire-destroyed homes (54%) are in low-income areas. We investigate the relationship between social vulnerability and wildfire community preparedness using building permits from 16 counties in California with 2.9 million buildings (2013–2021) and the U.S. government’s designation of disadvantaged communities (DACs), which classifies a census tract as a DAC if it meets a threshold for certain burdens, such as climate, environmental, and socio-economic. Homes located in DACs are 29% more likely to be destroyed by wildfires within 30 years, partly driven by a gap in roof renewals, one of several important home hardening actions. Homes in DACs have 28% fewer roof renewals than non-DACs and post-wildfire, non-DAC homes have more than twice the increase in renewals (+17%) compared to DAC homes (+7%). Our research offers policy insights for narrowing this equity gap in renewals for wildfire-prone areas. We recommend increasing financial support for roof renewals and targeted awareness campaigns for existing programs which are not sufficiently emphasized in wildfire strategies, particularly in DACs.
... Similar to the methodology used in Miller, Johnson, and Wherry (2021), we use the estimation as our Equation (3) and present the estimated evolution of the treatment effect for Medicaid expansion in 2014 in Figure 1. Our parallel testing results suggest no significant difference in individuals' take-up rates between expansion and non-expansion states (pvalue = 0.56), regardless of their RTI ratio. ...
Article
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This study examines the impact of the Affordable Care Act (ACA) on health insurance coverage among rent‐burdened households—those spending more than 30% of their income on rent—and non‐rent‐burdened households. Using data from American Community Survey, we find that Medicaid take‐up rate increased 8.88 percentage points (pp) among rent‐burdened households and 7.54 pp among non‐rent‐burdened households in expansion states. Conditional on household income and demographic characteristics, rent‐burdened households exhibit a 1.5 pp higher likelihood of Medicaid enrollment, with an additional decline of 0.7 pp in employer‐sponsored insurance and 1.0 pp in directly purchased insurance enrollment. These effects were more pronounced among individuals aged over 26 and those in states without state‐run exchanges. The findings show the importance of tailored Medicaid policies to assist households facing housing burdens, especially for those ineligible for housing vouchers.
... With the objective of studying the impulse of the establishment of the experimental area on regional income differences, this paper abstracts the study of H1 to the policy impact on the indicators, consulting the existing literature, first of all, the parallel trend test is conducted on the existing data in order to determine that there exists no significant difference in the regional income differences from the provinces in the experimental group to the provinces in the control group, and that there is no advancement trend. This paper takes the building year of the policy zones in 2019 as base year, and constructs the Model as formula 2 [17]. ...
Article
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A growing body of research suggests that the digital economy may create opportunities to combat income inequality. However, these studies have focused more on the difference between countryside and city areas, neglecting the intervene of the state, regional differences and labour market in digital economy. Therefore, this paper collects data on the average income of different cities and the average wage of their digital economy workforce, and uses the Theil Index, DID and mediated-effects methods to study the setup of the National Pilot Zone for the Innovative Development of the Digital Economy as well as the status of income equality within the pilot zone. The paper also analyses heterogeneity based on geographic location, and uses a mediation effect model to measure the role of the income of digital economy practitioners in the impact of the National Pilot Zone for the Innovative Development of the Digital Economy on inter-regional income disparities. Study finds that the pilot zone widens the inter-regional income gap. This result is caused by the uneven spatial distribution between regions and industries. Labour wages in the relevant industries are also an important factor mediating the effect between developing the digital economy and the elimination of income inequality.
... This may result in misclassification of whether this respondent was exposed to the anti-transgender laws in question and the length of the exposure. However, in general, we expect that this type of misclassification will bias our estimates towards zero 45 . Second, the non-probability sampling method in our surveys may contain sampling bias and may not accurately represent the full population. ...
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From 2018 to 2022, 48 anti-transgender laws (that is, laws that restrict the rights of transgender and non-binary people) were enacted in the USA across 19 different state governments. In this study, we estimated the causal impact of state-level anti-transgender laws on suicide risk among transgender and non-binary (TGNB) young people aged 13–17 (n = 35,196) and aged 13–24 (n = 61,240) using a difference-in-differences research design. We found minimal evidence of an anticipatory effect in the time periods leading up to the enactment of the laws. However, starting in the first year after anti-transgender laws were enacted, there were statistically significant increases in rates of past-year suicide attempts among TGNB young people ages 13–17 in states that enacted anti-transgender laws, relative to states that did not, and for all TGNB young people beginning in the second year. Enacting state-level anti-transgender laws increased incidents of past-year suicide attempts among TGNB young people by 7–72%. Our findings highlight the need to consider the mental health impact of recent anti-transgender laws and to advance protective policies.
... The Medicaid expansions significantly increased coverage and access to care for low-income individuals in expansion states [2][3][4][5][6] and improved health status [7][8][9]. Studies have found increases in Medicaid coverage and a drop in the uninsured rate, [2,[10][11][12][13] better self-rated health status [7], improvement in activities of daily living [14], reduction in any work limitations from health [15], and reduction in disease-related deaths [16] for the 50-64-year-old age group. ...
Article
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The access to care benefits of Affordable Care Act (ACA) Medicaid expansions are important for 45–64-year-old adults who are living below 100% of the Federal Poverty Level, a particularly vulnerable group in the United States (US). Gaining coverage from Medicaid expansions should improve access to healthcare and affect social determinants of health, including financial behavior. We analyzed data from 2009 to 2018 from the National Financial Capability Survey (NFCS) and utilize a difference-in-differences model to compare outcomes changes in states with and without expansion before and after the ACA Medicaid expansions. Overall, Medicaid expansion was associated with increased healthcare access for 45–64-year-olds, potentially resulting in better healthcare experience. Results indicate effects of the Medicaid expansion on the financial behavior of 45–64-year-olds, with evidence of credit card bills being paid in full, higher banking activities, and better financial preparedness. These findings have important implications for financial regulators and healthcare policymakers.
... 5 Some studies using observational or quasi-experimental designs have found that Medicaid coverage is associated with an improved health status, including lower risk of mortality, but such studies are subject to confounding factors and omitted variable bias. [6][7][8] The randomized controlled trial design used in the Oregon health insurance experiment eliminated such biases. However, some subgroups in the Oregon health insurance experiment might have had an improvement in cardiovascular risk factors, while the average treatment effect was diluted by other subgroups who did not benefit from Medicaid coverage. ...
Article
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Objectives To investigate whether health insurance generated improvements in cardiovascular risk factors (blood pressure and hemoglobin A 1c (HbA 1c ) levels) for identifiable subpopulations, and using machine learning to identify characteristics of people predicted to benefit highly. Design Secondary analysis of randomized controlled trial. Setting Medicaid insurance coverage in 2008 for adults on low incomes (defined as lower than the federal-defined poverty line) in Oregon who were uninsured. Participants 12 134 participants from the Oregon Health Insurance Experiment with in-person data for health outcomes for both treatment and control groups. Interventions Health insurance (Medicaid) coverage. Main outcomes measures The conditional local average treatment effects of Medicaid coverage on systolic blood pressure and HbA 1c using a machine learning causal forest algorithm (with instrumental variables). Characteristics of individuals with positive predicted benefits of Medicaid coverage based on the algorithm were compared with the characteristics of others. The effect of Medicaid coverage was calculated on blood pressure and HbA 1c among individuals with high predicted benefits. Results In the in-person interview survey, mean systolic blood pressure was 119 (standard deviation 17) mm Hg and mean HbA 1c concentrations was 5.3% (standard deviation 0.6%). Our causal forest model showed heterogeneity in the effect of Medicaid coverage on systolic blood pressure and HbA 1c . Individuals with lower baseline healthcare charges, for example, had higher predicted benefits from gaining Medicaid coverage. Medicaid coverage significantly lowered systolic blood pressure (−4.96 mm Hg (95% confidence interval −7.80 to −2.48)) for people predicted to benefit highly. HbA 1c was also significantly reduced by Medicaid coverage for people with high predicted benefits, but the size was not clinically meaningful (−0.12% (−0.25% to −0.01%)). Conclusions Although Medicaid coverage did not improve cardiovascular risk factors on average, substantial heterogeneity was noted in the effects within that population. Individuals with high predicted benefits were more likely to have no or low prior healthcare charges, for example. Our findings suggest that Medicaid coverage leads to improved cardiovascular risk factors for some, particularly for blood pressure, although those benefits may be diluted by individuals who did not experience benefits.
... HIV prevalence concentrated within Atlanta's downtown core is estimated at 1.34%, meeting the UNAIDS definition of a "generalized epidemic" [8]. Georgia remains one of 10 states yet to fully expand Medicaid coverage under the Affordable Care Act despite that Medicaid expansions are linked to reductions in mortality [9][10][11] and net savings on state budgets [12,13]. Furthermore, Congressional EHE appropriations fell below original budget requests in 2021 ($404M funded, $716M requested) and 2022 ($473M funded, $670M requested) [14,15]. ...
Article
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Introduction Four counties within the Atlanta, Georgia 20‐county eligible metropolitan area (EMA) are currently prioritized by the US “Ending the HIV Epidemic” (EHE) initiative which aims for a 90% reduction in HIV incidence by 2030. Disparities driving Atlanta's HIV epidemic warrant an examination of local service availability, unmet needs and organizational capacity to reach EHE targets. We conducted a mixed‐methods evaluation of the Atlanta EMA to examine geographic HIV epidemiology and distribution of services, service needs and organization infrastructure for each pillar of the EHE initiative. Methods We collected 2021 county‐level data (during June 2022), from multiple sources including: AIDSVu (HIV prevalence and new diagnoses), the Centers for Disease Control and Prevention web‐based tools (HIV testing and pre‐exposure prophylaxis [PrEP] locations) and the Georgia Department of Public Health (HIV testing, PrEP screenings, viral suppression and partner service interviews). We additionally distributed an online survey to key local stakeholders working at major HIV care agencies across the EMA to assess the availability of services, unmet needs and organization infrastructure (June−December 2022). The Organizational Readiness for Implementing Change questionnaire assessed the organization climate for services in need of scale‐up or implementation. Results We found racial/ethnic and geographic disparities in HIV disease burden and service availability across the EMA—particularly for HIV testing and PrEP in the EMA's southern counties. Five counties not currently prioritized by EHE (Clayton, Douglas, Henry, Newton and Rockdale) accounted for 16% of the EMA's new diagnoses, but <9% of its 177 testing sites and <7% of its 130 PrEP sites. Survey respondents (N = 48; 42% health agency managers/directors) reported high unmet need for HIV self‐testing kits, mobile clinic testing, HIV case management, peer outreach and navigation, integrated care, housing support and transportation services. Respondents highlighted insufficient existing staffing and infrastructure to facilitate the necessary expansion of services, and the need to reduce inequities and address intersectional stigma. Conclusions Service delivery across all EHE pillars must substantially expand to reach national goals and address HIV disparities in metro Atlanta. High‐resolution geographic data on HIV epidemiology and service delivery with community input can provide targeted guidance to support local EHE efforts.
... As there is evidence that expanding health insurance coverage can prolong lives, escalating health insurance reimbursement including new medical technologies is important [14,15]. However, the reality is that there are various limitations to expanding health insurance benefits. ...
... The expansion of Medicaid, arguably the centerpiece of the ACA's coverage provisions, has been responsible for a substantial decline in the uninsured rate among working-age Americans (Butler, 2016). The implications of this expansion for the health system and population health have been extensively studied (Buchmueller et al., 2016;Peng, 2017;Huh, 2021;Zhang and Zhu, 2021;Neprash et al., 2021;Miller et al., 2021;Nikpay, 2022), adding to other work on the effects of eligibility changes in public health insurance programs (De La Mata, 2012;Arenberg et al., 2024 From 2014 to 2016, the federal government paid 100% of the medical costs of the new adult group, declining to 95% in 2017, 94% in 2018, 93% in 2019, 90% in 2020, and remaining at 90% in perpetuity. These enhanced federal reimbursement rates, which, unlike the FMAP rates for most of the rest of the Medicaid population, are not dependent on state average income, were designed to ease the fiscal burden on states and increase political support for the law. ...
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Under the ACA, the federal government paid a substantially larger share of medical costs of newly eligible Medicaid enrollees than previously eligible ones. States could save up to 100% of their per-enrollee costs by reclassifying original enrollees into the newly eligible group. We examine whether this fiscal incentive changed states' enrollment practices. We find that Medicaid expansion caused large declines in the number of beneficiaries enrolled in the original Medicaid population, suggesting widespread reclassifications. In 2019 alone, this phenomenon affected 4.4 million Medicaid enrollees at a federal cost of $8.3 billion. Our results imply that reclassifications inflated the federal cost of Medicaid expansion by 18.2%.
... A growing literature examines the general effects of the ME and found positive effects on insurance coverage, health outcomes, and access and use of care services [7][8][9][10][11][12], admission to mental health treatment [13], reduction on mortality rates [14], foster care admissions [15], unpaid bills, and the amount of debt sent to third-party collection agencies [16]. Negative effects are also reported, for example, longer waiting times for appointments [17], cost-related barriers for senior citizens, delaying care, paying drug prescriptions, less access to specialist doctors, or lack of continuity of care for cost reasons [18]. ...
Article
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Background The Affordable Care Act (ACA), enacted in 2010, aimed to improve healthcare coverage for American citizens. This study investigates the impact of Medicaid expansion (ME) under the ACA on the racial and ethnic composition of nursing home admissions in the U.S., focusing on whether ME has led to increased representation of racial/ethnic minorities in nursing homes. Methods A difference-in-differences estimation methodology was employed, using U.S. county-level aggregate data from 2000 to 2019. This approach accounted for multiple time periods and variations in treatment timing to analyze changes in the racial and ethnic composition of nursing home admissions post-ME. Additionally, two-way fixed effects (TWFE) regression was utilized to enhance robustness and validate the findings. Results The analysis revealed that the racial and ethnic composition of nursing home admissions has become more homogeneous following Medicaid expansion. Specifically, there was a decline in Black residents and an increase in White residents in nursing homes. Additionally, significant differences were found when categorizing states by income inequality, and poverty rate levels. These findings remain statistically significant even after controlling for additional variables, indicating that ME influences the racial makeup of nursing home admissions. Conclusions Medicaid expansion has not diversified nursing home demographics as hypothesized; instead, it has led to a more uniform racial composition, favoring White residents. This trend may be driven by nursing home preferences and financial incentives, which could favor residents with private insurance or higher personal funds. Mechanisms such as payment preferences and local cost variations likely contribute to these shifts, potentially disadvantaging Medicaid-reliant minority residents. These findings highlight the complex interplay between healthcare policy implementation and racial disparities in access to long-term care, suggesting a need for further research on the underlying mechanisms and implications for policy refinement.
... We estimated this using the quasi-experimental event study design (also referred as the staggered difference-in-differences (DiD) design) that allows us to assess the effect of the COVID-19 pandemic on surgical mortality while adjusting for potential confounders. [24][25][26][27][28][29][30] The event study design is an extension of DiD; rather than testing for a difference in means before (January) and after (March-November) the intervention between treatment (patients who received a surgical procedure in 2020) vs control groups (patients who received a surgical procedure in 2016-2019), the event study design elucidates between-group differences for each discrete time-period (ie, month). Thus, we compare changes in mortality during months before (January 2020) and after (March-November 2020) the pandemic affected the health systems (using patients who received a surgical procedure in February as the reference group). ...
Article
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Objectives To examine changes in the 30-day surgical mortality rate after common surgical procedures during the COVID-19 pandemic and investigate whether its impact varies by urgency of surgery or patient race, ethnicity and socioeconomic status. Design We used a quasi-experimental event study design to examine the effect of the COVID-19 pandemic on surgical mortality rate, using patients who received the same procedure in the prepandemic years (2016–2019) as the control, adjusting for patient characteristics and hospital fixed effects (effectively comparing patients treated at the same hospital). We conducted stratified analyses by procedure urgency, patient race, ethnicity and socioeconomic status (dual-Medicaid status and median household income). Setting Acute care hospitals in the USA. Participants Medicare fee-for-service beneficiaries aged 65–99 years who underwent one of 14 common surgical procedures from 1 January 2016 to 31 December 2020. Main outcome measures 30-day postoperative mortality rate. Results Our sample included 3 620 689 patients. Surgical mortality was higher during the pandemic, with peak mortality observed in April 2020 (adjusted risk difference (aRD) +0.95 percentage points (pp); 95% CI +0.76 to +1.26 pp; p<0.001) and mortality remained elevated through 2020. The effect of the pandemic on mortality was larger for non-elective (vs elective) procedures (April 2020: aRD +0.44 pp (+0.16 to +0.72 pp); p=0.002 for elective; aRD +1.65 pp (+1.00, +2.30 pp); p<0.001 for non-elective). We found no evidence that the pandemic mortality varied by patients’ race and ethnicity (p for interaction=0.29), or socioeconomic status (p for interaction=0.49). Conclusions 30-day surgical mortality during the COVID-19 pandemic peaked in April 2020 and remained elevated until the end of the year. The influence of the pandemic on surgical mortality did not vary by patient race and ethnicity or socioeconomic status, indicating that once patients were able to access care and undergo surgery, surgical mortality was similar across groups.
Article
Importance The Affordable Care Act (ACA) expanded Medicaid and Marketplace insurance to nonelderly adults in 2014, but whether these policies improved outcomes later in life is unknown. Objective To examine whether exposure to ACA expansions during middle age (50-64 years) was associated with changes in health, utilization, and spending after these adults entered Medicare at 65 years of age. Design, Setting, and Participants This serial analysis of the Health and Retirement Study cohort linked to Medicare enrollment and claims data from January 1, 2010, to December 31, 2018. Adults aged 65 to 68 years entering Medicare after the ACA (exposed to ACA expansions during middle age) were compared with adults entering Medicare before the ACA (4452 person-years). Interrupted time series analyses were used to assess overall changes associated with exposure to ACA expansions and difference-in-differences analyses to isolate changes associated with Medicaid expansion among low-income adults (incomes ≤400% of the federal poverty level for any ACA coverage and ≤138% for Medicaid expansion coverage). Data were analyzed from March 1, 2023, to May 1, 2024. Exposures ACA coverage expansion overall in 2014 and Medicaid expansion as of 2018. Main Outcomes and Measures Health (self-reported overall, activities of daily living [ADL], instrumental ADL, and depressive symptoms), utilization (outpatient visits, emergency department visits, and hospital admission), and costs (self-reported out-of-pocket and Medicare costs). Results Among the analytic sample of 2782 participants (mean age, 66.4 [95% CI, 66.3-66.5] years), a weighted 59.1% (95% CI, 55.3%-62.7%) were female. In interrupted time series analyses, reductions across cohorts were found in use of chronic disease medications (−5.0 [95% CI, −9.8 to −0.3] percentage points), hospitalizations per year (−0.2 [95% CI, −0.4 to −0.03]), and out-of-pocket costs (−417[95417 [95% CI, −694 to −139])butnosignificantchangesacrosscohortsinhealthstatus,outpatientoremergencyvisits,orMedicarecosts.Indifferenceindifferencesanalysesrelativetononexpansionstates,greaterreductionswerefoundinthenumberofADLlimitations(0.4[95139]) but no significant changes across cohorts in health status, outpatient or emergency visits, or Medicare costs. In difference-in-differences analyses relative to nonexpansion states, greater reductions were found in the number of ADL limitations (−0.4 [95% CI, −0.8 to −0.02]) and lesser reductions in out-of-pocket costs (900 [95% CI, 275275-1526]) in Medicaid expansion states but otherwise similar changes in other outcomes. Conclusions and Relevance This study found modest evidence of reductions in out-of-pocket costs and improvements in health among adults entering Medicare after the ACA. Insurance coverage and financial assistance should be preserved and enhanced to improve health and health care access among vulnerable older adults.
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Disparities between Black and White Americans in health care coverage and health outcomes are pervasive in the United States. In this paper, we describe the evolution of the market-based approach to health insurance and health care delivery in the United States and its implications for racial disparities. First, we discuss the history of the United States’ predominantly private health insurance system. Second, we illustrate the persistence and pervasiveness of disparities through three present-day epidemics: maternal mortality, opioid use, and Covid-19. Through the epidemic case studies, we highlight the systemic roots of racial inequality in health care. Finally, we conclude with a brief discussion of potential policy approaches for reducing disparities in the health care system.
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I study the impact of the world’s largest publicly funded health insurance plan for the poor on credit markets. India launched a health insurance plan that covered 500 million beneficiaries. The fact that opposition-ruled states did not implement the program for political reasons allows me to compare border districts of implemented and nonimplemented states within a difference-in-differences framework. I find that loan delinquency reduced significantly in implemented districts. Increased liquidity for loan repayment seems to be the mechanism at work. I rule out the federal-level ruling party’s influence as an explanation. This paper was accepted by Kay Giesecke, finance. Supplemental Material: The online appendix and data files are available at https://doi.org/10.1287/mnsc.2023.01039 .
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We use clinical data on more than 240,000 surgeries and quasi-experimental methods to examine how physicians respond to the surprise release of a performance “report card.” Such feedback interventions are commonly used to encourage physicians to improve performance yet show limited evidence of success. Our results show that these limited effects mask heterogeneous behavioral responses to feedback valence. In particular, physicians improve more from positive feedback than from negative feedback, with negative feedback even reducing performance for a nontrivial share of patients. Experiments with laypersons replicate these results and show that struggles with negative feedback can be mitigated by giving incentives directly tied to improvement and by adding qualitative information that helps individuals interpret past performance. These results are consistent with behavioral models that suggest cognitive and emotional difficulties limit how well individuals use negative feedback. Thus, feedback interventions in healthcare should be carefully designed to mitigate these counterproductive behavioral responses. This paper was accepted by Ranjani Krishnan, accounting. Funding: We acknowledge generous funding provided by Tilburg University and the University of Massachusetts Amherst to run the laboratory experiments. Supplemental Material: The online appendices and data files are available at https://doi.org/10.1287/mnsc.2023.01340 .
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Objective This study investigates geographic variations in ADRD mortality in the US. By considering both state of residence and state of birth, we aim to discern the relative importance of these geospatial factors. Methods We conducted a secondary data analysis of the National Longitudinal Mortality Study (NLMS), that has 3.5 million records from 1973 to 2011 and over 0.5 million deaths. We focused on individuals born in or before 1930, tracked in NLMS cohorts from 1979 to 2000. Employing multi-level logistic regression, with individuals nested within states of residence and/or states of birth, we assessed the role of geographical factors in ADRD mortality variation. Results We found that both state of birth and state of residence account for a modest portion of ADRD mortality variation. Specifically, state of residence explains 1.19% of the total variation in ADRD mortality, whereas state of birth explains only 0.6%. When combined, both state of residence and state of birth account for only 1.05% of the variation, suggesting state of residence could matter more in ADRD mortality outcomes. Conclusion Findings of this study suggest that state of residence explains more variation in ADRD mortality than state of birth. These results indicate that factors in later life may present more impactful intervention points for curbing ADRD mortality. While early-life environmental exposures remain relevant, their role as primary determinants of ADRD in later life appears to be less pronounced in this study.
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Importance Department of Veterans Affairs (VA) health care spending has increased in the past decade, in part due to legislative changes that expanded access to VA-purchased care. Objective To understand how insurance coverage and enrollment in VA has changed between 2010 and 2021. Design, Setting, and Participants This cross-sectional study used data from surveys conducted from 2010 to 2021. Participants were respondents across 4 national surveys who reported being a US veteran and reported on health insurance enrollment. Data were analyzed from October 2023 to June 2024. Main Outcomes and Measures Self-reported health insurance coverage, reliance on VA insurance, and self-reported health. Results Among a total of 3 644 614 survey respondents (mean [SE] age, 60 [0.04] years; 91.3% [95% CI, 91.2%-91.5%] male) included, 52.2% (95% CI, 52.0%-52.4%) were out of the labor market and 63.1% (95% CI, 62.9%-63.3%) were married. In 2010, 94% of all veterans and 94% of veterans younger than age 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment increased over time, and by 2020, 97% of all veterans and 95% of veterans younger than 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment estimates were similar across the surveys. Approximately one-third of veterans reported being enrolled in VA health coverage. Of those who enrolled in VA insurance, more than 75% had more than 1 form of coverage, with Medicare and private insurance being the most common second insurance sources. VA insurance enrollment was negatively associated with income and health status. Veterans without insurance tended to be unemployed and younger. Conclusions and Relevance This study of veterans who responded to 4 national surveys found that veterans enrolled in VA health coverage had high rates of dual coverage. Further legislative efforts to increase access without recognizing the high rates of dual coverage may yield unintended consequences, such payer shifting.
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In 2023, one of the main standards for regulating Islamic banks in the world celebrated its 10th anniversary. It is difficult to find works in the academic literature discussing the reaction from the said regulation. We fill this gap and answer the research question of how the market responded to the introduction of the standard in the world. Having essentially the data of a quasi-experiment, we divide the sample into conventional (control group) and Islamic (pilot group) banks and estimate the effect of the intervention using the difference-in-differences method. Islamic banks have been known in the world practice as banks with a larger capital reserve than conventional ones. Interestingly, despite this fact, according to the results of the study, investors reacted positively to the additional capital correction.
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Research Summary Recognizing the role of complementors in creating value in interdependent platform ecosystems, strategy research has recently started to examine performance heterogeneity across complementors. However, research has thus far focused on the performance implications of dynamics unfolding within a particular ecosystem. We take a step toward exploring influences that arise beyond the focal ecosystem by focusing conceptually on multihoming. We argue that multihoming to another platform produces learning benefits that enhance a complementor's performance on the home platform, especially when dealing with a high level of interdependencies and having greater similarity to other complements. We find supportive evidence in our analysis of open‐source software platforms between 2012 and 2018 and discuss implications for research on platform ecosystems, multihoming, and open‐source software. Managerial Summary Prior studies viewed multihoming as an important strategy for complementors in platform ecosystems. However, little is known about the extent to which such expansion affects the performance of complementors on their home platforms. This study investigates this issue using data on software package complementors in a variety of platforms housed in GitHub, the world's largest repository of open‐source software. The findings show that following multihoming, a complementor experiences a performance improvement in the home platform even when compared to the performance change observed during the same period for another complementor with similar attributes but that remains in single‐homing. These findings underscore the strategic implications of multihoming as a significant driver of performance heterogeneity across complementors in platform ecosystems.
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This paper examines the impact of Medicaid expansions to parents and childless adults on adult mortality. Specifically, we evaluate the long‐run effects of eight state Medicaid expansions from 1994 through 2005 on all‐cause, healthcare‐amenable, non‐healthcare‐amenable, and HIV‐related mortality rates using state‐level data. We utilize the synthetic control method to estimate effects for each treated state separately and the generalized synthetic control method to estimate average effects across all treated states. Using a 5% significance level, we find no evidence that Medicaid expansions affect any of the outcomes in any of the treated states or all of them combined. Moreover, there is no clear pattern in the signs of the estimated treatment effects. These findings imply that evidence that pre‐ACA Medicaid expansions to adults saved lives is not as clear as previously suggested.
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We examine how supply-side health insurance generosity affects patient access, use, and health. Exploiting large, exogenous changes in Medicaid reimbursement rates for physicians, we find that increasing payments for new patient office visits reduces reports of providers turning away beneficiaries: closing the gap in payments between Medicaid and private insurers would reduce more than half of disparities in access among adults and would eliminate such disparities among children. We further find that higher physician reimbursement leads to more office visits, better self-reported health, and reduced school absenteeism among the program’s beneficiaries. (JEL G22, H51, I11, I13, I18, I38, J44)
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This study aimed to examine the impact of China's Green Finance Reform and Innovation Pilot Zone policy on urban employment trends. The policy was used as a quasi-natural experiment to understand its influence on the average annual employment dynamics across Chinese cities from 2013 to 2022. We employed a staggered Difference-in-Differences (DID) model to examine the policy's effect on urban employment carefully. Our findings indicate that the green finance pilot policy stimulated employment growth at the city level. Subsequently, we discuss the contrasting firm-level effects. Interestingly, the green finance pilot policy has a negative impact on firm-level employment growth. Moreover, the influence varies significantly depending on regional financial development, corporate factor intensity, and ownership structures. This difference between city-level and firm-level outcomes is due to labor shifting from firms with high environmental and social risks to those with lower risks and reallocating labor from secondary to tertiary industries. These findings suggest that green finance reforms have nuanced effects on employment. While they may dampen growth at the firm level, they could foster growth at the city level. Our study provides empirical insights that could help refine the green finance pilot policy and optimize urban industrial structures.
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Issue: Nine years since the Affordable Care Act’s Medicaid coverage expansions took effect, 10 states have yet to expand eligibility for their Medicaid programs. Some residents with low income are falling through the resulting “coverage gap” — their incomes are too high to qualify for their state’s Medicaid program but too low to qualify for marketplace plan subsidies, thereby impeding their access to health care. Goals: Assess how being in the Medicaid coverage gap affects insurance coverage and health care utilization. Methods: Analysis of the Behavioral Risk Factor Surveillance System, 2011–2013 and 2017–2019, to compare outcomes for people who potentially fall in the coverage gap (those with incomes between pre- and post-ACA eligibility levels) in comparable states that did and did not expand Medicaid. Key Findings and Conclusion: In expansion states, people who would otherwise be in the Medicaid coverage gap had increased health insurance coverage, lower rates of avoiding seeking medical care, and greater utilization of certain preventive care measures.
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Industry 4.0 technologies radically change industrial processes. National governments have enacted innovation policies to support firms' investments in new technologies and increase productivity growth. The Italian Industry 4.0 Plan (II4.0 Plan) was implemented with this purpose in 2017 and consisted of a horizontal fiscal plan. Using a new methodology that relies on firms' financial accounts rather than survey data, we identify firms that benefited from the II4.0 Plan's incentives and extend the analysis to the population of Italian firms. The results from a Difference-inDifferences regression approach show that the investments spurred by the II4.0 Plan positively affect firms' labour productivity but heterogeneously among size classes, sectors and types of incentive. Hyper and super amortisation and the credit for innovation drive the results. We frame our policy evaluation into the most recent discussion about innovation policies, raising some criticisms on the appropriateness of horizontal policies to foster the digital transition.
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Was the Affordable Care Act (ACA) effective in the U.S. territories? This paper explores this question by examining the impact of the ACA’s dependent mandate and Medicaid expansion in Puerto Rico. The dependent mandate led to a 4.3 percentage point increase in health insurance coverage for Puerto Rican young adults due to increased employer-sponsored insurance coverage, and the Medicaid Expansion increased Medicaid coverage by 2.4 percentage points. The impact of both policies in Puerto Rico is smaller than in the mainland, highlighting the importance of considering how federal legislation affects territories with economic and health environments dissimilar to the mainland.
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We are the first to investigate how health shocks relate to cash holdings. Using three waves of the China Health and Retirement Longitudinal Study over the period 2013–2018, we document that, for middle‐aged and elderly people living in rural China, the onset of an acute health condition is associated with a 3.0 percentage point higher probability of holding only cash as a safe asset, and a 2.3 percentage point higher proportion of safe assets held in the form of cash. These results are robust to using different samples and estimation methods. We also find that ex‐post reimbursement of medical expenses and lack of bank accessibility may drive the association between health shocks and cash holdings.
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We provide novel evidence on how firms and patients respond to vaccine recommendations. In 2014, the Advisory Committee on Immunization Practices recommended that elderly adults receive the pneumococcal vaccine Prevnar 13. Using a difference‐in‐differences strategy, we first show that, following the recommendation, the manufacturer (Pfizer) increased direct‐to‐consumer advertising. We then document increased Prevnar 13–related information‐seeking behavior, and we show that targeted adults were more likely to have received a pneumococcal vaccine and were more connected to the health care system. Overall, the recommendation increased both Medicare Part B drug expenditures and Pfizer sales by approximately $1 billion annually, with little to no observable health benefits.
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Steep declines in the uninsured population under the Affordable Care Act (ACA) will depend on high enrollment among newly Medicaid-eligible adults. We use the 2009 American Community Survey to model pre-ACA eligibility for comprehensive Medicaid coverage among nonelderly adults. We identify 4.5 million eligible but uninsured adults. We find a Medicaid participation rate of 67% for adults; the rate is 17 percentage points lower than the national Medicaid participation rate for children, and it varies substantially across socioeconomic and demographic subgroups and across states. Achieving substantial increases in coverage under the ACA will require sharp increases in Medicaid participation among adults in some states.
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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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In 2018, 30.4 million persons of all ages (9.4%) were uninsured at the time of interview—not significantly different from 2017, but 18.2 million fewer persons than in 2010. In 2018, among adults aged 18–64, 13.3% were uninsured at the time of interview, 19.4% had public coverage, and 68.9% had private health insurance coverage. In 2018, among children aged 0–17 years, 5.2% were uninsured, 41.8% had public coverage, and 54.7% had private health insurance coverage.  Among adults aged 45–64, the percentage who were uninsured increased from 9.3% in 2017 to 10.3% in 2018. Among adults aged 18–64, 68.9% (136.6 million) were covered by private health insurance plans at the time of interview in 2018. This includes 4.2% (8.4 million) covered by private health insurance plans obtained through the Health Insurance Marketplace or state-based exchanges. The percentage of persons under age 65 with private health insurance enrolled in a high-deductible health plan increased from 43.7% in 2017 to 45.8% in 2018.
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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 structure of marriage and child-rearing in U.S. households has undergone two marked shifts in the last three decades: a steep decline in the prevalence of marriage among young adults, and a sharp rise in the fraction of children born to unmarried mothers or living in single-headed households. A potential contributor to both phenomena is the declining labor-market opportunities faced by males, which make them less valuable as marital partners. We exploit large scale, plausibly exogenous labor-demand shocks stemming from rising international manufacturing competition to test how shifts in the supply of young ‘marriageable’ males affect marriage, fertility and children's living circumstances. Trade shocks to manufacturing industries have differentially negative impacts on the labor market prospects of men and degrade their marriage-market value along multiple dimensions: diminishing their relative earnings—particularly at the lower segment of the distribution—reducing their physical availability in trade-impacted labor markets, and increasing their participation in risky and damaging behaviors. As predicted by a simple model of marital decision-making under uncertainty, we document that adverse shocks to the supply of `marriageable' men reduce the prevalence of marriage and lower fertility but raise the fraction of children born to young and unwed mothers and living in in poor single-parent households. The falling marriage-market value of young men appears to be a quantitatively important contributor to the rising rate of out-of-wedlock childbearing and single-headed childrearing in the United States.
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We analyze the effect of rising Chinese import competition between 1990 and 2007 on local U.S. labor markets, exploiting cross-market variation in import exposure stemming from initial differences in industry specialization while instrumenting for imports using changes in Chinese imports by industry to other high-income countries. Rising exposure increases unemployment, lowers labor force participation, and reduces wages in local labor markets. Conservatively, it explains one-quarter of the contemporaneous aggregate decline in U.S. manufacturing employment. Transfer benefits payments for unemployment, disability, retirement, and healthcare also rise sharply in exposed labor markets.
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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 778andcreditcardbalancesincreaseby778 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.
Article
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.
Article
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.
Article
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.
Article
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.
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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.
Article
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.
Article
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 327,000to327,000 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.
Article
Background: In 2014, only 26 states and the District of Columbia chose to implement the Patient Protection and Affordable Care Act (ACA) Medicaid expansions for low-income adults. Objective: To evaluate whether the state Medicaid expansions were associated with changes in insurance coverage, access to and utilization of health care, and self-reported health. Design: Comparison of outcomes before and after the expansions in states that did and did not expand Medicaid. Setting: The United States. Participants: Citizens aged 19 to 64 years with family incomes below 138% of the federal poverty level in the 2010 to 2014 National Health Interview Surveys. Measurements: Health insurance coverage (private, Medicaid, or none); improvements in coverage over the previous year; visits to physicians in general practice and specialists; hospitalizations and emergency department visits; skipped or delayed medical care; usual source of care; diagnoses of diabetes, high cholesterol, and hypertension; self-reported health; and depression. Results: In the second half of 2014, adults in expansion states experienced increased health insurance (7.4 percentage points [95% CI, 3.4 to 11.3 percentage points]) and Medicaid (10.5 percentage points [CI, 6.5 to 14.5 percentage points]) coverage and better coverage than 1 year before (7.1 percentage points [CI, 2.7 to 11.5 percentage points]) compared with adults in nonexpansion states. Medicaid expansions were associated with increased visits to physicians in general practice (6.6 percentage points [CI, 1.3 to 12.0 percentage points]), overnight hospital stays (2.4 percentage points [CI, 0.7 to 4.2 percentage points]), and rates of diagnosis of diabetes (5.2 percentage points [CI, 2.4 to 8.1 percentage points]) and high cholesterol (5.7 percentage points [CI, 2.0 to 9.4 percentage points]). Changes in other outcomes were not statistically significant. Limitation: Observational study may be susceptible to unmeasured confounders; reliance on self-reported data; limited post-ACA time frame provided information on short-term changes only. Conclusion: The ACA Medicaid expansions were associated with higher rates of insurance coverage, improved quality of coverage, increased utilization of some types of health care, and higher rates of diagnosis of chronic health conditions for low-income adults. Primary funding source: None.
Article
Importance: The relationship between income and life expectancy is well established but remains poorly understood. Objectives: To measure the level, time trend, and geographic variability in the association between income and life expectancy and to identify factors related to small area variation. Design and setting: Income data for the US population were obtained from 1.4 billion deidentified tax records between 1999 and 2014. Mortality data were obtained from Social Security Administration death records. These data were used to estimate race- and ethnicity-adjusted life expectancy at 40 years of age by household income percentile, sex, and geographic area, and to evaluate factors associated with differences in life expectancy. Exposure: Pretax household earnings as a measure of income. Main outcomes and measures: Relationship between income and life expectancy; trends in life expectancy by income group; geographic variation in life expectancy levels and trends by income group; and factors associated with differences in life expectancy across areas. Results: The sample consisted of 1 408 287 218 person-year observations for individuals aged 40 to 76 years (mean age, 53.0 years; median household earnings among working individuals, $61 175 per year). There were 4 114 380 deaths among men (mortality rate, 596.3 per 100 000) and 2 694 808 deaths among women (mortality rate, 375.1 per 100 000). The analysis yielded 4 results. First, higher income was associated with greater longevity throughout the income distribution. The gap in life expectancy between the richest 1% and poorest 1% of individuals was 14.6 years (95% CI, 14.4 to 14.8 years) for men and 10.1 years (95% CI, 9.9 to 10.3 years) for women. Second, inequality in life expectancy increased over time. Between 2001 and 2014, life expectancy increased by 2.34 years for men and 2.91 years for women in the top 5% of the income distribution, but by only 0.32 years for men and 0.04 years for women in the bottom 5% (P < .001 for the differences for both sexes). Third, life expectancy for low-income individuals varied substantially across local areas. In the bottom income quartile, life expectancy differed by approximately 4.5 years between areas with the highest and lowest longevity. Changes in life expectancy between 2001 and 2014 ranged from gains of more than 4 years to losses of more than 2 years across areas. Fourth, geographic differences in life expectancy for individuals in the lowest income quartile were significantly correlated with health behaviors such as smoking (r = -0.69, P < .001), but were not significantly correlated with access to medical care, physical environmental factors, income inequality, or labor market conditions. Life expectancy for low-income individuals was positively correlated with the local area fraction of immigrants (r = 0.72, P < .001), fraction of college graduates (r = 0.42, P < .001), and government expenditures (r = 0.57, P < .001). Conclusions and relevance: In the United States between 2001 and 2014, higher income was associated with greater longevity, and differences in life expectancy across income groups increased over time. However, the association between life expectancy and income varied substantially across areas; differences in longevity across income groups decreased in some areas and increased in others. The differences in life expectancy were correlated with health behaviors and local area characteristics.
Article
In Project STAR, 11,571 students in Tennessee and their teachers were randomly assigned to classrooms within their schools from kindergarten to third grade. This article evaluates the long-term impacts of STAR by linking the experimental data to administrative records. We first demonstrate that kindergarten test scores are highly correlated with outcomes such as earnings at age 27, college attendance, home ownership, and retirement savings. We then document four sets of experimental impacts. First, students in small classes are significantly more likely to attend college and exhibit improvements on other outcomes. Class size does not have a significant effect on earnings at age 27, but this effect is imprecisely estimated. Second, students who had a more experienced teacher in kindergarten have higher earnings. Third, an analysis of variance reveals significant classroom effects on earnings. Students who were randomly assigned to higher quality classrooms in grades K-3-as measured by classmates' end-of-class test scores-have higher earnings, college attendance rates, and other outcomes. Finally, the effects of class quality fade out on test scores in later grades, but gains in noncognitive measures persist.
Article
This paper examines the long-term impact of exposure to Medicaid in early childhood on adult health and economic status. The staggered timing of Medicaid's adoption across the states created meaningful variation in cumulative exposure to Medicaid for birth cohorts that are now in adulthood. Analyses of the Panel Study of Income Dynamics suggest exposure to Medicaid in early childhood (age 0–5) is associated with statistically significant and meaningful improvements in adult health (age 25–54), and this effect is only seen in subgroups targeted by the program. Results for economic outcomes are imprecise and we are unable to come to definitive conclusions. Using separate data we find evidence of two mechanisms that could plausibly link Medicaid's introduction to long-term outcomes: contemporaneous increases in health services utilization for children and reductions in family medical debt.