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 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.     

Examining Policy Implementation in Health Care: Rule Abidance and Deviation in Emergency Medical Services

Passage of the Patient Protection and Affordable Care Act (ACA) has served to refocus attention on the complexity of health care delivery in the United States, with particular attention to concepts of quality, access, and outcomes. This article argues that our understanding of the ACA must be informed by an examination of policy implementation in health care, including the core public function of emergency medical services (EMS). Key concepts of implementation in frontline service—notably, rule abidance and deviation—are examined from the perspective of street‐level EMS workers. Results indicate that the intersection of rules, patient needs, and professional culture creates instances of both rule abidance and deviation, both of which contribute substantively to concepts of quality in a health care setting.     

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.     

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.     

Nativity differences in neighborhood quality among New York city households

Abstract

This article adds to the literature on locational attainment of immigrants by evaluating how immigrant households in New York City compare with native‐born households with respect to neighborhood characteristics. It also examines whether the relationship between immigrant status and neighborhood quality varies by race/ethnicity and place of birth.

Overall, foreign‐born households are more likely than native‐born households to live in neighborhoods with less access to medical care, higher rates of tuberculosis, and higher concentrations of poverty. Multivariate analyses reveal that all but one of these disadvantages disappear for foreign‐born households as a group. However, island‐born Puerto Ricans and immigrants—especially Dominicans, Caribbeans and Africans, and Latin Americans—are more likely to reside in lower‐quality neighborhoods than native‐born white households. Equally important, native‐born blacks and Hispanics are also disproportionately disadvantaged relative to native‐born whites, suggesting that a racial hierarchy exists in the locational attainment of households in New York City.     

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.     

Devolution and the Social Welfare of Elderly Immigrants: Who Will Bear the Burden?

Growing ethnic diversity translates into rising numbers of individuals facing socioeconomic disadvantage, creating a context in which detailed examinations of public policy are critical for understanding the health care needs of immigrant populations in the United States. Although many scholars document the link between social disadvantage and increased morbidity and mortality, additional analyses are needed to identify specific public policies associated with decreased access to social goods and public services. The implications of the latest welfare bill, the Personal Responsibility and Work Reconciliation Act of 1996, on the health and social welfare of the aging Hispanic population provides a unique opportunity for such inquiry. On the basis of demographic trends and recent analyses of data from the Hispanic Established Populations for Epidemiologic Study of the Elderly, the results suggest that older, Mexican–origin immigrants are likely to become an even greater administrative responsibility of state and local governments.     

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.     

Spillover Effects: Immigrant Policing and Government Skepticism in Matters of Health for Latinos

To what extent do people become less trusting of the government under threatening policy contexts? The authors find evidence that Secure Communities, a bureaucratic program that enhances immigrant policing through collaboration between local law and immigration enforcement agencies, spurs mistrust among Latinos but not non‐Latinos. This article focuses on the politics of immigration and health, two issue areas marked by large‐scale bureaucratic developments over the last 50 years. The authors argue that a major consequence of expanding immigrant policing is its trickle‐down effect on how individuals view public institutions charged with the provision of public goods, such as health information. The results indicate that Latinos in locales where immigrant policing is most intense express lower levels of trust in government as a source of health information. Through a policy feedback lens, the findings suggest that the state's deployment of immigrant policing conveys more widespread lessons about the trustworthiness of government .     

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 AFFORDABLE CARE ACT'S EFFECTS ON PATIENTS,PROVIDERS, AND THE ECONOMY: WHAT WE'VE LEARNED SO FAR

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.     

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.     

Institutional conditions for the integration of immigrants in welfare states: A comparison of the literature on Germany,France, Great Britain,and the Netherlands

Abstract. In this paper we analyse the literature on a particular aspect of immigrant integration in Western European welfare states: the extent to which this can be explained by conditions set by institutions, social rights and rights of residence. Our focus is on health care, old age insurance, housing and vocational training, and on the circumstances under which migrants have access to benefits from the general systems of social security. In particular, the assignment of a legal position by the rights of residence plays an essential role. The various legal groups have access to social benefits depending on their status of residence. The institutional framework of each welfare states is also relevant to the access that people have to social benefits. In the countries analysed, Germany, France, Great Britain, and the Netherlands, the individual security systems are organised according to different political concepts, each of them allowing immigrants access to their benefits to a different degree. On the whole, the degree and kind of governmental regulations seem to be crucially important for the integration of immigrants into the welfare state.     

Expanding access to health care for Social Security Disability Insurance beneficiaries: early findings from the accelerated benefits demonstration

Most Social Security Disability Insurance (DI) beneficiaries must complete a 5-month waiting period before they become entitled to DI cash benefits and an additional 24-month waiting period before Medicare benefits begin. The Accelerated Benefits (AB) demonstration is a randomized experiment designed to test the effects of providing newly entitled DI beneficiaries who do not have health insurance with a generous health benefits package during the Medicare waiting period. This article presents early findings on the prevalence of health insurance coverage among newly entitled beneficiaries and the characteristics of those without health insurance. It also examines the effects of AB on health care utilization, the extent to which AB reduces unmet medical needs, and the costs of providing the AB health benefits package.     

“Keep Your Government Hands Off My Medicare!”: An Analysis of Media Effects on Tea Party Health Care Politics

This article analyzes the political effects of American media coverage on Tea Party health care politics. It suggests that the American media's inability to critique the neoliberal assumptions that lay at the foundation of Tea Party ideology have served—however inadvertently—to excite ideological confusion in American health care debates, especially those surrounding the Patient Protection and Affordable Care Act (ACA). Specifically, this article shows that media failure to make sense of the ideological and statistical basis of Tea Party opposition to the ACA, as well as a general unwillingness to mediate disagreement, have barred mainstream media from helping Americans see that the ACA is largely consistent with neoliberal orthodoxy, and certainly far from “socialist.” As a result, the media has served to legitimate rather than critique positions that stand at the center of Tea Party ideology.     

Inclusionary housing in California and New Jersey: A comparative analysis

Abstract

Many people have argued that inclusionary housing (IH) is a desirable land use strategy to address lower‐income housing needs and to further the geographic dispersal of the lower‐income population. In an attempt to evaluate the effectiveness of IH, this article examines the experiences of New Jersey and California, two states where IH has been applied frequently over an extended period.

While the concept of regional “fair share” is central to both states’ experiences, the origins of the programs, their applications, and their evolutions are quite dissimilar. IH originated in New Jersey from the famous Mount Laurel cases and in California from housing affordability crises and a legislatively mandated housing element. The experiences of both states indicate that IH can and should be part of an overall affordable housing strategy but that it is unlikely to become the core of such a strategy.