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.     

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.     

Insurance Subsidies,the Affordable Care Act,and Financial Stability

This paper measures the effects of subsidies in the Affordable Care Act on adverse financial outcomes using administrative tax data and credit data on financial outcomes. Using a difference-in-differences design with propensity score reweighting, I find that at $100 per capita, ACA premium tax credits and cost-sharing reduction subsidies reduced consumer bankruptcies and severe auto delinquency by 8 percent and 7 percent, respectively, and substantially reduced right-tail delinquent debt and third-party collections. The value of recipients’ risk protection against medical debt payments amounts to approximately 16 to 21 percent of the cash costs of the subsidies, while the subsidies provided substantial indirect transfers to external parties.     

Medicaid,the States and Health Care Reform

Health care reform in the US is relying extensively on Medicaid for achieving universal health coverage. This article addresses the question of whether Medicaid is an appropriate foundation for reducing the ranks of the uninsured, given its dependence on economic conditions and the vulnerability of state budgets, along with the ever-changing preferences of governors and legislators. This article assesses the effects of the ebb and flow of Medicaid policy-making on at‐risk populations and what this implies for the Affordable Care Act. By establishing a nationwide income floor at 133% of the Federal Poverty Level, the legislation eliminates eligibility inequities across the states. However, it is argued that when state budgets are strained, as they undoubtedly will be when the reform bill is fully implemented, local officials will downsize benefit packages, raise co-payments, mandate more managed care, and reduce provider payments, negatively affecting the availability, scope, and quality of services.     

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.     

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.     

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.     

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.     

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.     

Medicaid Section 1115 Waivers: Shifting Health Care Reform to the States

This article focuses on recent developments in state Medicaidprograms and the role ojSection 1115 waivers in this process.The evidence presented here demonstrates quite clearly thatthe states are using Section 1115 waivers to experiment witha broad range of innovative health-care service delivery, reimbursement,and eligibility concepts. This has allowed the states to reconfiguretheir Medicaid systems. More important, perhaps, the use ofSection 1115 waivers has also increased the role ofof the statesin the American health-care policy process.     

Health Insurance in Transition: The Health Insurance Portability and Accountability Act of 1996

The Health Insurance Portability and Accountability Act (HIPAA)of 1996 (PL. 104–191) brings the federal government fullyinto insurance regulation for the first time. Despite the Republicanmajority's rhetoric about state control, election-year politicstrumped federalism. HIPAA's immediate impact oncoverage maybe modest, but its ultimate significance is great because itcreates a template for more farreaching federal involvementin regulating insurance. HIPAA amends the Employee RetirementIncome Security Act (ERISA), the Public Health Service Act,and the Internal Revenue Code, creating a complicatedstructuredictated by efforts to avoid an unfunded mandate. The historyof insurance regulation and the activity surrounding the enactmentof PL. 104–191 suggest that HIPAA continues an incrementalprocess of transition between state insurance regulation andfederal oversight driven by recent and accelerating changesin the structure of the health-care marketplace.     

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.     

Attitude Responsiveness and Partisan Bias: Direct Experience with the Affordable Care Act

This study evaluates the competing influences of motivated reasoning and personal experience on policy preferences toward the Affordable Care Act. Using cross-sectional and panel survey data, the findings reveal that healthcare attitudes are responsive to information that individuals receive through personal experience. Individuals who experienced a positive change in their insurance situation are found to express more positive views toward the health reform law, while individuals who lost their insurance or experienced an otherwise negative personal impact on their insurance situations express more negative views. The results point to personal experience as a source of information that can influence individuals’ preferences. However, although attitudes are responsive to the quality of one’s personal interactions with the healthcare system, the results also suggest that partisan bias is still at work. Republicans are more likely to blame the health reform law for negative changes in their health insurance situations, while Democrats are more likely to credit the law for positive changes in their situations. These motivated attributions for their personal situations temper how responsive partisans’ attitudes are to information acquired through personal experience.     

Child Care Subsidies and Employment Behavior Among Very‐Low‐Income Populations in Three States

Using merged administrative data from welfare reform evaluations in three states, we estimate the effects of child care subsidy use on the length of time it takes for a welfare applicant to move into substantial employment. Findings show that the use of a child care subsidy during an unemployed or marginally employed spell of welfare receipt is associated with between a 0.6 and 1.7 quarter (or 11% to 34%) reduction in the time to substantial employment in two of the three state samples. The positive influence of subsidy use on transitions to substantial employment is strongest for those welfare applicants with the lowest earnings who are mixing welfare and work prior to subsidy receipt.     

Medicaid Managed Care for Children with Special Health Care Needs: Examining Legislative and Judicial Constraints on Privatization

Over the past decade, much has been written about the results of reinventing government. Most research has examined the effects of executive or managerial perspectives. Using David Rosenbloom's competing perspectives model, we examine Medicaid managed care programs for children with special health care needs to illustrate the influence of legislative and judicial institutional perspectives on the reinvention movement. Legislative and judicial responses to the reinvention of Medicaid managed care reveal the outer limits of what managed care and related executive reforms can accomplish in a Constitutional system that is based on checks and balances among competing institutional perspectives. Furthermore, relative to Medicaid managed care, legislative and judicial responses conserve public responsibility to society's most vulnerable populations. In the long run, the balance of institutional perspectives and values—not managerial innovation per se—will influence public administration.     

The Effects of Mandated Health Insurance Benefits for Autism on Out‐of‐Pocket Costs and Access to Treatment

As of 2014, 37 states have passed mandates requiring many private health insurance policies to cover diagnostic and treatment services for autism spectrum disorders (ASDs). We explore whether ASD mandates are associated with out‐of‐pocket costs, financial burden, and cost or insurance‐related problems with access to treatment among privately insured children with special health care needs (CSHCNs). We use difference‐in‐difference and difference‐in‐difference‐in‐difference approaches, comparing pre–post mandate changes in outcomes among CSHCN who have ASD versus CSHCN other than ASD. Data come from the 2005 to 2006 and the 2009 to 2010 waves of the National Survey of CSHCN. Based on the model used, our findings show no statistically significant association between state ASD mandates and caregivers’ reports about financial burden, access to care, and unmet need for services. However, we do find some evidence that ASD mandates may have beneficial effects in states in which greater percentages of privately insured individuals are subject to the mandates. We caution that we do not study the characteristics of ASD mandates in detail, and most ASD mandates have gone into effect very recently during our study period.