Child Support and the Affordable Care Act's Medicaid Expansions

A quickly developing literature has shown that the Affordable Care Act's (ACA) Medicaid expansions have improved health insurance coverage, health, and financial well‐being among low‐income adults without dependent children. This population includes noncustodial parents. With substantial overlap in the population that is typically obligated to pay child support and the population that has strongly benefited from the expansions, there may be potential implications for child support enforcement. In this paper, I examine the effect of public health insurance eligibility to low‐income adults on child support outcomes. I find that the ACA Medicaid expansions increased child support distributed to custodial families as arrears by 8.5 percent. Evidence also suggests current support distributions increased by about 2 percent. There were no significant effects on paying toward a child support order. Among unmarried mothers, the likelihood of child support receipt increased by 8 percent. These results imply that access to public health insurance can increase the ability of noncustodial parents to pay child support.     

Access to Healthcare and Criminal Behavior: Evidence from the ACA Medicaid Expansions

I investigate the causal relationship between access to healthcare and crime following state decisions to expand Medicaid coverage after the Affordable Care Act. I combine state-level crime data from the Federal Bureau of Investigation Uniform Crime Reports for the years 2009 through 2018 with variation in insurance eligibility generated by the Medicaid expansion. Using a difference-in-differences design, my findings indicate that states that expanded Medicaid have experienced a 5.3 percent reduction in annual reported violent crime rates relative to nonexpansion states. This effect is explained by decreases in aggravated assaults and corresponds to 17 fewer incidents per 100,000 people. The estimated decrease in reported crime amounts to an annual cost savings of approximately $4 billion.     

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.     

Medicaid participation among the eligible elderly

This study uses data from the Survey of Income and Program Participation to address three issues: (1) what were the 1987 rates of Medicaid participation and private insurance coverage among elderly predicted to be categorically eligible and medically needy?; (2) how did these rates change between 1987 and 1992?; and (3) which factors influence insurance choices among persons who are categorically eligible for Medicaid? The 1987 Medicaid participation rates were 64 percent for the categorically eligible, but only 11 percent among the medically needy. Participation among the categorically eligible declined to 59 percent by 1992, but the difference was insignificant. In both years, about 23 percent of all categorically eligible persons had private insurance, but among those who do not participate in Medicaid, the rate rises to 48 percent.     

Administrative Easing: Rule Reduction and Medicaid Enrollment

Administrative burden is widely recognized as a barrier to program enrollment, denying legal entitlements to many potentially eligible individuals. Building on recent research in behavioral public administration, this article examines the effect of voluntary state reductions in administrative burden (administrative easing) on Medicaid enrollment rates using differential implementation of the Affordable Care Act. Using a novel data set that includes state-level data on simplified enrollment and renewal procedures for Medicaid from 2008 to 2017, the authors examine how change in Medicaid enrollment is conditioned by the adoption of rule-reduction procedures. Findings show that reductions in the administrative burden required to sign up for Medicaid were associated with increased enrollments. Real-time eligibility and reductions in enrollment burden were particularly impactful at increasing enrollment for both children and adults separate from increases in Medicaid income eligibility thresholds. The results suggest that efforts to ease the cognitive burden of enrolling in entitlement programs can improve take-up.     

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 Food Stamp Program and Supplemental Security Income

The Food Stamp Program (FSP) and Supplemental Security Income (SSI) are important parts of national public assistance policy, and there is considerable overlap in the populations that the programs serve. About half of all SSI recipients reside in FSP recipient households. This article uses Social Security administrative data and the Food Stamp Quality Control samples for federal fiscal years 2001-2006 to study the prevalence of food stamp receipt among households with SSI recipients, the contribution of FSP to household income, and the importance of various FSP features in contributing to the well-being of recipient households. The prevalence of FSP participation among households that include SSI recipients is estimated to have grown steadily over the entire 2001-2006 period, rising from 47.4 percent in 2001 to 55.6 percent in 2006. This growth has occurred across all age groups of SSI recipients. The FSP contribution to household income has grown as well. In 2001, FSP increased the income of the households of SSI/FSP recipients by 13 percent; by 2006 the increase was 16.8 percent. Almost 80 percent of the food stamp recipient households that include SSI recipients receive increased benefits because of excess housing costs. In 2006, 44 percent of SSI recipients lived in households that did not receive food stamps. Given available information, it is difficult to gauge the FSP eligibility of nonparticipating households and, therefore, to assess the potential benefit of outreach efforts. Currently available measures of FSP take-up probably overstate participation among eligible households that include SSI recipients, and there is some evidence that enhanced state promotion of the FSP raises participation among households with SSI recipients. We conclude with recommendation for review and renewal of collaboration between the Food and Nutrition Service of the U.S. Department of Agriculture (the agency responsible for administering the FSP) and the Social Security Administration in ensuring that eligible SSI recipients utilize FSP benefits.     

Homeowner Behavior,Health Status,and Medicaid Payment Eligibility: Evidence from the Deficit Reduction Act of 2005

This paper analyzes the effect of a change in the status of housing equity as a protected asset for Medicaid long‐term care payment eligibility. A difference‐in‐difference‐in‐differences strategy is employed to estimate the effect of the policy on the housing equity holdings of potentially treated individuals. Using a panel of unmarried homeowners, the policy induced treated individuals who were likely to require long‐term care to hold less housing equity by values of $82,000 to $193,000 relative to control individuals. This equates to relative reductions of 12 to 29 percent for treated individuals after the policy change. Similar effects are not observed when considering health measures less predictive of long‐term care services and for a sample of married households who were unlikely affected by the policy. These estimates confirm the importance of the housing asset as a shelter for Medicaid eligibility.     

Health insurance coverage of the unemployed: COBRA and the potential effects of Kassebaum-Kennedy.

We use the April 1993 Current Population Survey to examine the health insurance coverage decisions of the unemployed and to simulate the potential effects of the new Kassebaum-Kennedy legislation. After controlling for demographic characteristics, COBRA eligibility raises the probability of health insurance coverage by 0.095, while eligibility for spouse employer insurance increases the likelihood of coverage by 0.318, and eligibility for both increases the likelihood of coverage by 0.341. In our simulations, we find that had Kassebaum-Kennedy been in effect in April 1993, 9.0 percent of the unemployed would be eligible to take up coverage, and the coverage rate of the unemployed would have been increased by 0.85 percent to 1.5 percent from 41.6 percent. Our estimates of the effect of Kassebaum-Kennedy on health insurance coverage are much lower than those reported by the Government Accounting Office prior to the passage of the legislation.     

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.     

Has the Shift to Managed Care Reduced Medicaid Expenditures? Evidence from State and Local‐Level Mandates

From 1991 to 2009, the fraction of Medicaid recipients enrolled in HMOs and other forms of Medicaid managed care (MMC) increased from 11 percent to 71 percent. This increase was largely driven by state and local mandates that required most Medicaid recipients to enroll in an MMC plan. Theoretically, it is ambiguous whether the shift from fee‐for‐service into managed care would lead to an increase or a reduction in Medicaid spending. This paper investigates this effect using a data set on state‐ and local‐level MMC mandates and detailed data from the Centers for Medicare and Medicaid Services (CMS) on state Medicaid expenditures. The findings suggest that shifting Medicaid recipients from fee‐for‐service into MMC did not on average reduce Medicaid spending. If anything, our results suggest that the shift to MMC increased Medicaid spending and that this effect was especially present for risk‐based HMOs. However, the effects of the shift to MMC on Medicaid spending varied significantly across states as a function of the generosity of the state's baseline Medicaid provider reimbursement rates.     

State strategies for welfare reform: The Wisconsin story

Wisconsin is commonly cited as exemplar of the capability of states for reforming welfare. Wisconsin's welfare and caseload declined 22.5 percent between 1986 and 1994. I argue that the decline resulted from restriction of eligibility and benefits, a strong state economy, and large expenditures on welfare-to-work programs encouraged by an exceptional fiscal bargain with the federal government. Continued reduction of welfare utilization by means other than denying access are jeopardized by proposed changes in federal cost-sharing, a prospective state deficit, and the growing share of the caseload accounted for by residents of Milwaukee. Wisconsin Works, the state's plan for public assistance in a post-block grant world, continues benefit reduction and eligibility restriction but expands emphasis on employment. The special circumstances enjoyed by Wisconsin are unlikely to be duplicated elsewhere.     

The devil may be in the details: how the characteristics of SCHIP programs affect take-up.

In this paper, we explore whether the specific design of a state's program has contributed to its success in meeting two objectives of the Children's Health Insurance Program (SCHIP): increasing the health insurance coverage of children in lower income families and doing so with a minimum reduction in their private health insurance coverage (crowd-out). In our analysis, we use two years of Current Population Survey data, 2000 and 2001, matched with detailed data on state programs. We focus on two populations: the eligible population of children, broadly defined--those living in families with incomes below 300 percent of the federal poverty line (FPL)--and a narrower group of children, those who we estimate are eligible for Medicaid or SCHIP. Unique state program characteristics in the analysis include whether the state plan covers families; whether the state uses presumptive eligibility; the number of months without private coverage that are required for eligibility; whether there is an asset test; whether a face-to-face interview is required; and specific outreach activities. Our results provide evidence that state program characteristics are significant determinants of program success.     

The Influence of Federal Mandates on State Medicaid and AFDC Decision-Making

This article focuses on the influence of federal Medicaid mandateson state AFDC and Medicaid policy decision-making. The resultsconfirm certain concerns about federal mandates: the benefitsof federal Medicaid mandates (eligibility expansions to pregnantwomen and infants) appear to be offset by state reductions inAFDC and other Medicaid policy areas. In particular, federalMedicaid mandates had a negative effect on AFDC and MedicallyNeedy financial eligibility levels and Medicaid optional benefitcoverage—areas where states maintained discretionary power.A political-economic theory is used to test the impact of federalMedicaid mandates where a different political process is postulatedfor each policy dimension. The model is estimated using paneldata and a heteroskedastic, timewise autoregressive model.     

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.     

The economic impact of state restrictions on abortion: parental consent and notification laws and Medicaid funding restrictions.

State-legislative support for liberalized abortion policies, the availability of abortion providers, and actual abortion rates vary widely across states. This article uses national data to examine the impact of the following three major, enforceable state abortion restrictions as of 1988 on the access to and use of abortion services: state restrictions on Medicaid financing of abortions for low-income women (36 states), state requirements for parental consent or parental notification for minors to obtain abortions (11 states), and state restrictions on insurance coverage of abortion for public employees (8 states). The impact of state abortion restrictions is becoming an increasingly important policy issue as the number and types of restrictions which can be enforced in the US increase rapidly. The Supreme Court in Webster v. Reproductive Health Services (1989) upheld a Missouri law banning abortions in public hospitals and the involvement of public employees in the performance of abortions; states via this ruling may also enforce mandatory testing for viability after a specified point in the pregnancy. The Supreme Court then in Planned Parenthood of Southeastern Pennsylvania v. Casey (1992) effectively ruled that states can enforce a 24-hour waiting period and a state-prescribed talk on abortion for women seeking abortion. Analysis of the data found that there are significantly fewer hospitals, clinics, and private physicians' offices providing abortions in states with parental consent or notification laws. Moreover the rate of minors' abortions per 1000 teen pregnancies is 16% lower, and the rate of minors' abortions per 1000 women aged 15-19 is 25% lower in states with such laws compared to states without the laws. Data from abortion clinics and referral services in Massachusetts, Minnesota, and Rhode Island suggest that 20-55% of minors are going to court instead of informing their parents. 35% of minors who contacted a clinic in Massachusetts and 49% in Rhode Island went out of state for abortions. As for Medicaid restrictions, there are significantly fewer hospitals, clinics, and private physicians' offices providing abortions in states which restrict funding of abortions as compared to states which do not. State restrictions on insurance coverage of abortion for public employees do not appear to be associated with statistically significant differences in abortion rates or abortion availability.     

Thick Red Tape and the Thin Blue Line: A Field Study on Reducing Administrative Burden in Police Recruitment

Police departments struggle to recruit officers, and voluntary drop-off of candidates exacerbates this challenge. Using four years of administrative data and a field experiment conducted in the Los Angeles Police Department, the authors analyze the impact of administrative burden on the likelihood that a candidate will remain in the recruitment process. Findings show that reducing friction costs to participation and simplifying processes improve compliance, as behavioral public administration would predict. Applicants who were offered simpler, standardized processes completed more tests and were more likely to be hired. Later reductions to perceived burden led to an 8 percent increase in compliance, with a 60 percent increase in compliance within two weeks. However, removing steps that would have allowed for better understanding of eligibility kept unqualified candidates in the process for longer, reducing organizational efficiency. These results extend the field's understanding of how administrative burden can impact the selection of talent into government.     

Income, assets, and health insurance: economic resources for meeting acute health care needs of the aged.

In this article, the authors use data from the Survey of Income and Program Participation (SIPP) to examine the relationship between economic resources and acute health care needs among the aged. The circumstances of individuals who rely on Medicare as their only form of health insurance are considered in detail because they are potentially more vulnerable when faced with health care expenses. Particular attention is given to the amount of family income and personal contingency assets held by this group and the level of out-of-pocket liability for acute care they might have been expected to face in 1984. The authors point out that their research findings would be strengthened by linkage of a more current SIPP data set to Medicare program records and the development of Medicaid eligibility simulation capability in the SIPP context.     

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.