Welcome Mats and On‐Ramps for Older Adults: The Impact of the Affordable Care Act's Medicaid Expansions on Dual Enrollment in Medicare and Medicaid

For many low‐income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out‐of‐pocket costs and additional benefits. We examine whether Medicaid participation by low‐income adults age 65 and up increased as a result of Medicaid expansions to working‐age adults under the Affordable Care Act (ACA). Previous literature documents so‐called “welcome mat” effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working‐age adults increased Medicaid participation among low‐income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an “on‐ramp” effect; that is, low‐income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non‐expansion states. This on‐ramp effect is an important mechanism behind welcome mat effects among some older adults.     

The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions

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.     

Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply

We examined the effect of the expansion of Medicaid eligibility under the Affordable Care Act on health insurance coverage and labor supply of low‐educated and low‐income adults. We found that the Medicaid expansions were associated with large increases in Medicaid coverage, for example, 50 percent among childless adults, and corresponding decreases in the proportion uninsured. There was relatively little change in private insurance coverage, although the expansions tended to decrease such coverage slightly. In terms of labor supply, estimates indicated that the Medicaid expansions had little effect on work effort despite the substantial changes in health insurance coverage. Most estimates suggested that the expansions increased work effort, although not significantly.     

Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non‐Expansion States

The Affordable Care Act (ACA) aimed to achieve nearly universal health insurance coverage in the United States through a combination of insurance market reforms, mandates, subsidies, health insurance exchanges, and Medicaid expansions, most of which took effect in 2014. This paper estimates the causal effects of the ACA on health insurance coverage in 2014 using data from the American Community Survey. We utilize difference‐in‐difference‐in‐differences models that exploit cross‐sectional variation in the intensity of treatment arising from state participation in the Medicaid expansion and local area pre‐ACA uninsured rates. This strategy allows us to identify the effects of the ACA in both Medicaid expansion and non‐expansion states. Our preferred specification suggests that, at the average pre‐treatment uninsured rate, the full ACA increased the proportion of residents with insurance by 5.9 percentage points compared to 2.8 percentage points in states that did not expand Medicaid. Private insurance expansions from the ACA were due to increases in both employer‐provided and non‐group coverage. The coverage gains from the full ACA were largest for those without a college degree, non‐whites, young adults, unmarried individuals, and those without children in the home. We find no evidence that the Medicaid expansion crowded out private coverage.     

Public Health Insurance and Medical Spending: The Incidence of the ACA Medicaid Expansion

This paper examines the incidence of the cost burden associated with expanding public health insurance to low-income adults in the context of the Affordable Care Act. Using data from the Medical Expenditures Panel Survey (MEPS), I exploit exogenous variation in Medicaid eligibility rules across states, income groups and time. I find that public insurance eligibility reduced mean out-of-pocket spending by 19.6 percent among targeted households, but it did not causally increase total expenditures among beneficiaries. Rather, Medicaid expansion shifted the burden of payment from eligible households and private insurance (21.5 percent reduction) to taxpayers in the form of public insurance (46.6 percent increase). The efficiency of these public funds can be summarized by a mean Marginal Value of Public Funds of 0.70 in the full sample, 0.99 among households with at least one pre-existing condition, and 1.26 in states with an above-median number of public hospitals.     

The Effect of the Affordable Care Act Medicaid Expansion on Migration

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.     

Deadbeats and turnips in child support reform

Child support reforms have focused almost exclusively on punitive measures, driven by the stereotypical image of a “deadbeat dad” who can afford to pay child support but refuses to do so. This image fits some noncustodial fathers, but ignores the diverse nature of this population. We show that lack of income is a significant barrier to child support payments for 16 to 33 percent of young noncustodial fathers, whom we call “turnips” after the common saying that “You can't get blood from a turnip.” Furthermore, the characteristics of turnips are similar to those of custodial mothers who are long-term welfare recipients—both are disproportionately composed of young, poorly educated, never-married minorities with little work experience. These findings suggest that a new approach to child support enforcement is needed, one that offers these fathers flexible child support orders that both reflect their current economic circumstances and provide employment and training assistance to enable them to meet their child support obligations in the future.     

Extending the EITC to noncustodial parents: Potential impacts and design considerations

This paper examines the noncustodial parent earned income tax credit (NCP EITC), a new type of credit recently enacted in New York and Washington, D.C., and proposed by Senator Bayh and then‐Senator Obama in 2007. The NCP EITC offers an earned income tax credit to low‐income noncustodial parents who work and pay their full child support. This paper provides background information about the policy and presents national estimates of eligibility and benefits for an NCP EITC under three alternative policy scenarios. It also discusses several key design and implementation issues. © 2010 by the Association for Public Policy Analysis and Management.     

The impact of child SSI enrollment on household outcomes

We use data from the Survey of Income and Program Participation (SIPP) to investigate the impact that child Supplemental Security Income (SSI) enrollment has on household outcomes, including poverty, household earnings, and health insurance coverage. The longitudinal nature of the SIPP allows us to control for unobserved, time‐invariant differences across households by measuring outcomes in the same household in the months leading up to and immediately following the first reporting of child SSI income. Our regression analyses demonstrate that for every $100 increase in household SSI income, total household income increases by roughly $72, reflecting some modest offset of other transfer income and conditional household earnings. Our analyses further demonstrate that child SSI enrollment is associated with a statistically significant and persistent reduction in the probability that a child lives in poverty of roughly 11 percentage points. Additional analyses suggest that program enrollment has virtually no impact on health insurance coverage because most new SSI recipients have health insurance from Medicaid or another source at the time of enrollment. © 2007 by the Association for Public Policy Analysis and Management     

Unchanging child support orders in the face of unstable earnings

The underlying theory behind child support guidelines implies that child support orders should change when the incomes of noncustodial parents change. This paper documents changes in noncustodial fathers' earnings over a five‐year period and examines the relationship between the changes in earnings and modifications in child support orders. Using detailed longitudinal administrative data from Wisconsin, the authors examine the history of orders and earnings for fathers in couples who had their first child support ordered in 2000. A substantial proportion of fathers experience large changes in earnings, but relatively few of the associated child support orders are modified. Using discrete‐time multinomial event history models that consider time‐varying variables and control for censored observations, we find some evidence of changes in earnings being associated with changes in orders, all else equal, but the relationship is relatively weak and order changes are not proportional to earnings changes. The findings highlight the challenges and importance of developing policies that result in child support orders being more responsive to changes in fathers' incomes. © 2010 by the Association for Public Policy Analysis and Management.     

Health Insurance and Young Adult Financial Distress

We study how health insurance eligibility affects financial distress for young adults using the Affordable Care Act's (ACA) dependent coverage mandate─the part of the ACA that requires private health insurance plans to cover individuals up to their 26th birthday. We examine the effects of both gaining and losing eligibility by exploiting the mandate's implementation in 2010 and its automatic disenrollment mechanism at age 26. Our estimates show that increasing access to health insurance lowers young adults’ out-of-pocket medical expenditures and debt in third-party collections. However, reductions in financial distress are transitory, as they diminish after an individual loses access to parental insurance when they age out of the mandate at age 26.     

Reducing child support debt and its consequences: Can forgiveness benefit all?

As child support debt owed nationally persists at enormous levels, both noncustodial parents and the custodial families who are not receiving support suffer significant hardships, and states are forced to expend greater resources on collection and enforcement efforts. This paper presents findings from an evaluation of a demonstration program developed to help noncustodial parents with large child support debts reduce their debt while simultaneously increasing child support paid to families, through gradual forgiveness of arrears conditional on payment of current child support obligations. The evaluation employs a randomized experimental design, nonexperimental analyses using propensity score matching and multilevel modeling techniques, and focus groups and follow‐up interviews. Results show a pattern of effects that suggests individuals responded to the program as intended. State‐ and family‐owed child support debt balances decreased for program participants, and participants paid more toward their child support obligations and arrears and made more frequent child support payments. The study findings suggest promise for the effectiveness of this program model in reducing child support debt burdens and in increasing families' receipt of child support, and they also point to ways in which the implementation of the program might be improved. © 2011 by the Association for Public Policy Analysis and Management.     

Immigrant Health Care Access and the Affordable Care Act

In spite of major coverage expansions under the Patient Protection and Affordable Care Act (ACA), a large proportion of immigrants will continue to remain outside the scope of coverage. Because various provisions of the ACA seek to enhance access, advancing knowledge about immigrant access to health care is necessary. The authors apply the well‐known Andersen model on health care access to two measures—one focusing on perceptions of unmet health care needs and the other on physician visits during the last year. Using data from the New Jersey Family Health Survey, the authors find that prior to implementation of the ACA coverage expansions, immigrants in New Jersey reported lower levels of unmet health care needs despite poorer self‐rated health compared with U.S.‐born residents. The article concludes with a discussion of the use of Andersen model for studying immigrant health care access and the broader implications of the findings.     

Welfare and child support: Complements,not substitutes

In most states, child support paid on behalf of Temporary Assistance for Needy Families (TANF) participants is used to offset TANF and child support administrative expenditures; this policy primarily benefits taxpayers. In contrast, Wisconsin allowed most custodial parents to keep all support paid on their behalf. This policy, which treats welfare and child support as complements, was evaluated through an experimental design. This paper reports the key results of the experimental evaluation, using state administrative data to examine the effects on child support outcomes and governmental cost. We find that when custodial mothers keep all child support paid on their behalf, paternity establishment occurs more quickly, noncustodial fathers are more likely to pay support, and custodial families receive more support. These outcomes are achieved at no significant governmental cost. © 2008 by the Association for Public Policy Analysis and Management.     

Discouraging Disadvantaged Fathers’ Employment: An Unintended Consequence of Policies Designed to Support Families

Substantial declines in employment and earnings among disadvantaged men may be exacerbated by child support enforcement policies that are designed to help support families but may have the unintended consequence of discouraging fathers’ employment. Disentangling causal effects is challenging because high child support debt may be both a cause and a consequence of unemployment and low child support order compliance. We used childbirth costs charged in unmarried mothers’ Medicaid‐covered childbirths, from Wisconsin administrative records, as an exogenous source of variation to identify the impact of debt. We found that greater debt has a substantial negative effect on fathers’ formal employment and child support payments, and that this effect is mediated by fathers’ prebirth earnings histories.     

Disability benefit coverage and program interactions in the working-age population

Over three-fourths of the working-age population in the United States is insured for Disability Insurance (DI); this group is protected against a total loss of earned income typically associated with severe disability. However, little is known about the role the Supplemental Security Income (SSI) program plays in protecting against the financial consequences of severe disability for this population. We find that over one-third (36 percent) of the working-age population is covered by SSI in the event of a severe disability. Three important implications follow, which we discuss in sequence below: (1) SSI increases the overall coverage of the working-age population; (2) SSI enhances the bundle of cash benefits available to disabled individuals; and (3) interactions with other programs also enhance the safety net, most notably in the area of health insurance coverage. Ignoring these implications could lead to inaccurate inferences about disability program coverage, health insurance coverage, and the well-being of working-age individuals with disabilities. The first major finding is that SSI substantially increases overall cash benefit coverage. Thus SSI dramatically increases protection against the financial risk of disablement in the working-age population. While roughly 23 percent of the U.S. working-age population was not insured for DI in November 1996, SSI provides coverage for more than half of this seemingly "uncovered" population. An important innovation of our analysis is that we account for the possibility that many of those who appear ineligible for SSI based on current income could become eligible as a result of a disability shock that causes their earnings to drop. Thus the estimated proportion that is protected by SSI increases when the possibility of earnings loss because of disability is considered. Considering DI and SSI together, roughly 90 percent of the working-age population would be potentially covered for benefits in the event of a disability. Those who are covered by SSI--as opposed to those covered by DI alone-tend to be relatively young, less educated, and in relatively poor health. The remaining 10 percent or so are not covered by either DI or SSI. This group is economically vulnerable in some sense (they are poorer, older, and more likely to be women than those covered only by DI), but they are not as economically vulnerable in terms of income, resource holdings, and private health insurance coverage as those who are eligible for SSI. A disproportionate share of those who are not covered by either DI or SSI consists of married women. The second major finding is that SSI substantially enhances the bundle of available cash benefits. Roughly one-third of those covered by DI are initially covered by SSI as well. SSI enhances the bundle of available cash benefits through two mechanisms: (1) SSI provides cash payments during the 5-month DI waiting period, and (2) SSI supplements the DI benefit after the DI waiting period for people whose initial SSI payment is larger than the DI benefit. We find that the role of SSI cash payments is temporary for most of those who are initially covered by both SSI and DI: They would receive SSI during the DI waiting period, but would lose SSI eligibility afterwards because the higher DI benefit completely offsets the SSI benefit. However, a smaller group of DI beneficiaries with low DI benefit levels would continue to be covered by both SSI and DI after the DI waiting period because the relatively low DI benefit would not completely offset the SSI benefit. The third major finding is that interactions with other programs also substantially enhance the safety net. The most important interactions involve health insurance coverage. In the working-age population, Medicare is available to DI beneficiaries, but only after a 24-month waiting period. By contrast, SSI is an important pathway to Medicaid benefits for severely disabled adults with limited income and resources and has no waiting period. SSI can provide a pathway to health insurance coverage during the 24-month Medicare waiting period for some DI beneficiaries through providing access to Medicaid. Interactions with other programs, such as Temporary Assistance for Needy Families (TANF), Food Stamp, Unemployment Insurance (UI), workers' compensation (WC), and veterans' disability programs, modify the role of DI and SSI in protecting people against the adverse financial effects of disablement. The nature of the interactions with other programs differs depending on individual circumstances. Employment-related programs (including UI, WC, and veteran's disability programs) are particularly important for those who are covered by DI. By contrast, the means-tested programs (including TANF and Food Stamp) are more important for those who would be eligible for SSI. In conclusion, SSI plays a substantial role in protecting working-age people against the adverse financial consequences of disablement through three mechanisms: (1) providing coverage to many who are not DI insured; (2) providing additional cash benefits to many who are DI insured and also covered by SSI; and (3) enhancing the social safety net by interacting with other programs, most notably Medicaid. Through these mechanisms, the role of SSI is substantial enough that it cannot be safely ignored in econometric and policy research on DI.     

The Health Care Safety Net and the Affordable Care Act: Implications for Hispanic Immigrants

There are currently more than 11 million undocumented immigrants in the United States; the majority of them are of Hispanic origin. This article shows that Hispanic immigrants in the Greater Richmond, Virginia, area rely heavily on free clinics for basic health care services. Free clinics do not receive any public funding and thus face reduced government regulation. As a result, these clinics typically present fewer barriers to undocumented immigrants seeking care. Although free clinics function outside the mainstream of government funding for health care services, the Patient Protection and Affordable Care Act (ACA) of 2010 is so broad and far‐reaching in its scope and potential application that free clinics cannot escape its grasp once the new law is fully implemented. Because the ACA does not provide insurance coverage to undocumented immigrants, free clinics will remain their primary sources of care and treatment. Consequently, those responsible for implementing the ACA should consider the impact on free clinics.     

Personalizing solidarity? The role of self-tracking in health insurance pricing

Can data-driven innovations, working across an internet of connected things, personalize health insurance prices? The emergence of self-tracking technologies and their adoption and promotion in health insurance products has been characterized as a threat to solidaristic models of healthcare provision. If individual behaviour rather than group membership were to become the basis of risk assessment, the social, economic and political consequences would be far-reaching. It would disrupt the distributive, solidaristic character that is expressed within all health insurance schemes, even in those nominally designated as private or commercial. Personalized risk pricing is at odds with the infrastructures that presently define, regulate and deliver health insurance. Self-tracking can be readily imagined as an element in an ongoing bio-political redistribution of the burden of responsibility from the state to citizens but it is not clear that such a scenario could be delivered within existing individual private health insurance operational and regulatory infrastructures. In what can be gleaned from publicly available sources discussing pricing experience in the individual markets established by the Patient Protection and Affordable Care Act 2010 (ACA), widely known as ‘Obamacare’, it appears unlikely that it can provide the means to personalize price. Using the case of Oscar Health, a technology driven start-up trading in the ACA marketplaces, I explore the concepts, politics and infrastructures at work in health insurance markets.