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.     

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.     

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.     

Interstate Spillovers,Fiscal Decentralization,and Public Spending on Medicaid Home‐ and Community‐Based Services

This article examines the interstate spillover effect of Medicaid expenditures for home‐ and community‐based services (HCBS) and tests the relationship between fiscal decentralization and public spending. Based on the theory of interstate strategic interaction, an empirical model is specified that explicitly accounts for interdependence in states’ spending decisions. The model is estimated by applying spatial econometric methods to panel data for the 50 U.S. states for 2000–2010. Findings show a positive interdependence in state HCBS expenditures that is contingent on similarity in citizen ideology between states. Fiscal decentralization, measured by transfer dependence and revenue autonomy, is positively related to Medicaid HCBS spending.     

How Do Summer Youth Employment Programs Improve Criminal Justice Outcomes,and for Whom?

Cities across the U.S. have turned to summer youth employment programs (SYEPs) to improve the behavioral, economic, and academic outcomes of inner‐city youth. This paper evaluates the impact of the Boston Summer Youth Employment Program using both experimental and non‐experimental variation. Similar to previous studies of summer jobs programs in other cities, I make use of an embedded randomized controlled trial and find that the program reduces violent crime by 35 percent, as measured by the number of arraignments from administrative records during the 17 months after participation. In contrast to prior work, I also find a similar reduction in arraignments for property crimes (?29 percent). This study also provides exploratory evidence on the mechanisms driving these reductions in crime using self‐reported responses of participants from a pre‐/post‐program survey. The results provide suggestive evidence that the beneficial impacts on violent and property crime are largely driven by improved conflict resolution skills versus other factors that would increase the opportunity cost of crime. These findings give researchers some insights into the behavioral changes that occur during the program while also providing a look inside the “black box” as to how SYEPs affect youth outcomes in the long run.     

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.     

The role of prosecutorial independence and prosecutorial accountability in domestic human rights trials

A prosecutorial organ is always in charge of the investigation and prosecution of crime, which makes this institution a key gatekeeper to the courts. Empowered with prosecutorial discretion, a prosecutorial organ dictates what, when, and whom to prosecute. The institutional design of the prosecutorial organ varies across time and across countries, which raises an important, yet quite understudied question: Does institutional design matter for how states respond to human rights violations and, if so, how? In this article, I develop a theoretical framework that highlights the importance of prosecutorial independence and prosecutorial accountability. I argue that understanding the factors that impact the use of prosecutorial discretion in human rights cases can potentially provide a more complete understanding of why and when states fail to investigate, to prosecute, and to punish human rights violations committed by state agents.     

Informal caregiving as state Medicaid expenditure: an only slightly immodest proposal

States and Medicaid recipients would be better off if the federal Medicaid program allowed states to assign a dollar value to some unpaid care friends and family give to Medicaid recipients. The dollar value of this unpaid labor would then be counted as state spending in the calculation of federal match. The proposal, which would ease the pressure on tight state budgets, is entirely compatible with the recent federal-state compromise regarding provider taxes and donations and reinforces an important but overlooked Medicaid policy that cultivates and relies upon households to deliver care.     

The Medicaid Mandates of the 1980s: An Intergovernmental Perspective

Medicaid, the health care program for the poor, has undergone significant changes in the last fifteen years. Many of those changes relate to the intergovernmental nature of the program. Medicaid is jointly operated, with the federal and state governments sharing program costs. Despite a set of program guidelines dictated by the federal government, states have traditionally had substantial latitude in Medicaid decisions. However, a series of developments in the 1980s led to increasing constraints on state Medicaid discretion, including federal mandates to expand Medicaid coverage. This article examines the inception and effectiveness of the Medicaid mandates from the perspective of interstate equity of health care services for poor families.     

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.     

Stigma and other determinants of participation in TANF and Medicaid.

We developed a conceptual framework to examine the association between stigma, enrollment barriers (e.g., difficult application), knowledge, state policy, and participation in the Temporary Assistance to Needy Families (TANF) and adult Medicaid programs. Survey data from 901 community health center patients, who were potential and actual participants in these programs, indicated that while images of the Medicaid program and its recipients were generally positive, stigma associated with welfare stereotypes reduced both TANF and Medicaid enrollment. Expectations of poor treatment when applying for Medicaid, enrollment barriers, and misinformation about program rules were also associated with reduced Medicaid enrollment. States that enacted strict welfare reform policies were potentially decreasing TANF participation, while states with more simplified and generous programs were potentially increasing Medicaid participation. The results suggest that the image of the adult Medicaid program remains tied to perceptions about welfare and provides guidance to policymakers about how to improve participation rates.     

The Crime Preventers Scheme: A Community Policing Initiative for Regime Security in Uganda

ABSTRACT

For decades, Uganda has received substantial support from development partners to implement Security Sector Reforms (SSR). Using the crime preventers’ scheme that has been implemented by Uganda Police as an element of community policing, I argue that SSR achievements in the country seem unclear and limited. Based on an ethnographic study I illustrate that the widespread crime preventers’ scheme has had contrasting effects on the Ugandan security architecture. The scheme seems to have reduced the police-citizens social distance and augmented police presence while simultaneously cased operational excesses and is routinely used in regime security strategies. To provide a better conceptualization I ask and answer a number of questions; how and why has the crime preventers’ scheme been initiated? How is the scheme related to community policing as we know it? What is the political role of the crime preventers? What motivates people to become active members of the crime preventers’ scheme? How does the scheme empirically operate?     

Does the Federal Government Learn from the States? Medicaid and the Limits of Expertise in the Intergovernmental Lobby

State programmatic expertise is an important asset to federalsystems, but this expertise is not always informative to federaldecision-makers. I argue the degree to which state expertiseis informative to federal decision-makers depends on how wellthe policy interests of state and federal levels are aligned.I illustrate variation in these conditions using case studiesof congressional politics over the Medicaid program. I thenapply a statistical test, which demonstrates that states’programmatic expertise regarding Medicaid is less persuasiveto congressional committee members compared to other witnesseswho are equally knowledgeable. The results suggest a "failureof federalism," where the public good potential of state programmaticexpertise often is not realized in the federal system.     

The economic impacts of the tobacco settlement.

Recent litigation against the major tobacco companies culminated in a master settlement agreement (MSA) under which the participating companies agreed to compensate most states for Medicaid expenses. Here the terms of the settlement are outlined and its economic implications analyzed using data from Massachusetts. The financial compensation to Massachusetts (and other states) under the MSA is substantial. However, this compensation is dwarfed by the value of the health impacts induced by the settlement. Specifically, Medicaid spending will fall, but only by a modest amount. More importantly, the value of health benefits ($65 billion through 2025 in 1999 dollars) from increased longevity is an order of magnitude greater than any other impacts or payments. The net efficiency implications of the settlement turn mainly on a comparison of the value of these health benefits relative to a valuation of the foregone pleasure of smoking. To the extent that the value of the health benefits is not offset by the value of the pleasure foregone, the economic impacts of the MSA will include a share of these health benefits.     

Medicaid matters: children's health and Medicaid eligibility expansions.

In the late 1980s, a series of federal laws were enacted which expanded Medicaid eligibility to more of the nation's children. States had a great amount of discretion in how fast and how far these expansions were implemented. As a result, there was great variation among the states in defining who was eligible for the program. This variation provides a rare opportunity to disentangle the effect of Medicaid from a child's socioeconomic status. Using data from the National Health Interview Survey, we address whether the Medicaid expansions improved the health and functional status of children. Econometric models were developed using fixed-effects regressions, and were estimated separately for white, black, and Hispanic children. White children experienced statistically significant reductions in acute health conditions and functional limitations. Black and Hispanic children showed some evidence of improved health conditions and functional status, but this evidence is inconclusive in the study sample. This may be due to differences in their access to appropriate health services or to the smaller sample size of minorities in each geographic area. The findings are also relevant to the implementation of the Children' Health Insurance Program (CHIP), the latest federal effort to expand access to health care to poor and near poor children. In many states, CHIP is being implemented in whole or in part through further Medicaid expansions.     

THE RELATIONSHIP BETWEEN CRIME AND INCARCERATION AMONG THE AMERICAN STATES1

Data from the 50 states for 1975 are analyzed to try to separate the presumed reciprocal effects on each other of crime rates and incarceration rates. Two-stage least-squares regression shows no significant effect of crime on incarceration nor of incarceration on crime. Incarceration rates are affected mainly by the percentage of blacks in the state population. Crime rates are significantly influenced by urbanization, region, mean income, and unemployment.     

ASEAN and the securitization of transnational crime in Southeast Asia

This article studies the securitization of transnational crime by the Association of Southeast Asian Nations (ASEAN) since 1996–97. It first introduces transnational crime as a criminal matter before positioning it within the international security debate through an elaboration of the Copenhagen School and its securitization theory. It then examines whether transnational crime has been articulated in security terms in the ASEAN rhetoric. The article demonstrates that the member states have made statements in which they make claims about security in the context of crime. Yet, there is little evidence that this has encouraged regional policy-makers to adopt common security responses. ASEAN has failed to implement joint actions due to domestic circumstances but also because of its own consensus model and resistance to institutional reforms. Finally, the article suggests that the problem of transnational crime could be dealt with more effectively if it was approached primarily as a criminal matter rather than as a security issue.     

The Impact of Welfare Reform on Medicaid

Welfare reform did not usher in comprehensive Medicaid reform,if "reform" is defined as dismantling the basic framework ordesign of the nations's health-care system for the poor. Instead,it left much of the previous Medicaid system intact. However,welfare reform has contributed to changes in the Medicaid-eligiblepopulations, greater variability and experimentation with stateMedicaid initiatives, and greater sate control over Medicaidprogram decisions. Thus, the welfare-reform movement clarifieda major trend in contemporary American politics—the increasein state discretion and flexibility in social welfare policymaking.The states are now at the center of Medicaid decisionmaking,and they are in a key position to determine the future directionof heath-care assistance for the poor in the United States.     

State Medicaid Budgeting in Hard Times: Implications for Long-Term Care

This qualitative analysis compares the annual Medicaid budgeting processes in Utah and Illinois from the late 1970s until 1985, explaining why Utah cut the proportion spent on nursing homes and Illinois did not. It posits rational, organizational, and political process interpretations of each state's choices. The states implemented Medicaid rationing (through preadmission screening, rate freezes and adjustments, and expansion of alternatives) in significantly different ways. Utah reduced utilization of nursing homes while Illinois contained rates. Such diverse policy choices have aggravated disparities among the states in access to and quality of long-term care. Rational planning for our aging society will have to overcome these growing disparities among state policies.