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Impacts of insurance expansion on health cost, health access, and health behaviors: evidence from the medicaid expansion in the US

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International Journal of Health Economics and Management Aims and scope Submit manuscript

Abstract

Expansion of subsidized health insurance may result in both safer and riskier health behavior and outcomes. While having insurance lowers cost barriers to receive both usual and preventive care, the lower potential cost from adverse health events may also promote risky behavior. In this paper, I exploit expansion in the Medicaid program under the Affordable Care Act to estimate the impact of insurance expansion on health outcomes and behaviors for low-income individuals in the US. I find that expansion of coverage has significantly lowered cost and increased access, particularly among minority populations, but has had no significant impact on preventive health behaviors. At the same time, I also find no evidence of moral hazard or increase risky behavior like smoking and drinking among residents of expansion states.

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Notes

  1. Since we do not carry out any model prediction, linear regression model is a better choice (See Greene, 2002).

References

  • Abramowitz, J. (2020). The effect of ACA state Medicaid expansions on medical out-of-pocket expenditures. Medical Care Research and Review, 77(1), 19–33

    Article  Google Scholar 

  • Alcalá, H. E., Chen, J., Langellier, B. A., Roby, D. H., & Ortega, A. N. (2017). Impact of the Affordable Care Act on health care access and utilization among Latinos. The Journal of the American Board of Family Medicine, 30(1), 52–56

    Article  Google Scholar 

  • Baicker, K., Taubman, S. L., Allen, H. L., Bernstein, M., Gruber, J. H., Newhouse, J. P., & Finkelstein, A. N. (2013). The Oregon experiment—effects of Medicaid on clinical outcomes. New England Journal of Medicine, 368(18), 1713–1722

    Article  CAS  Google Scholar 

  • Barnett, M. L., & Sommers, B. D. (2017). A national survey of Medicaid beneficiaries’ experiences and satisfaction with health care. JAMA Internal Medicine, 177(9), 1378–1381

    Article  Google Scholar 

  • Blewett, L. A., Planalp, C., & Alarcon, G. (2018). Affordable Care Act impact in Kentucky: Increasing access, reducing disparities. American Journal of Public Health, 108(7), 924–929

    Article  Google Scholar 

  • Buchmueller, T. C., Levinson, Z. M., Levy, H. G., & Wolfe, B. L. (2016). Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage. American Journal of Public Health, 106(8), 1416–1421

    Article  Google Scholar 

  • Buchmueller, T. C., & Levy, H. G. (2020). The ACA’s impact on racial and ethnic disparities in health insurance coverage and access to care: An examination of how the insurance coverage expansions of the Affordable Care Act have affected disparities related to race and ethnicity. Health Affairs, 39(3), 395–402

    Article  Google Scholar 

  • Cawley, J., Moran, J., & Simon, K. (2010). The impact of income on the weight of elderly Americans. Health Economics, 19(8), 979–993

    Article  Google Scholar 

  • Chen, J., Vargas-Bustamante, A., Mortensen, K., & Ortega, A. N. (2016). Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical Care, 54(2), 140–146

    Article  Google Scholar 

  • Courtemanche, C. J., Fazlul, I., Marton, J., Ukert, B. D., Yelowitz, A., & Zapata, D. (2019c). The impact of the ACA on insurance coverage disparities after four years (No. w26157). National Bureau of Economic Research.

  • Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., & Zapata, D. (2017). Early impacts of the Affordable Care Act on health insurance coverage in Medicaid expansion and non-expansion states. Journal of Policy Analysis and Management, 36(1), 178–210

    Article  Google Scholar 

  • Courtemanche, C. J., Marton, J., Ukert, B., Yelowitz, A., & Zapata, D. (2018). Early effects of the Affordable Care Act on health care access, risky health behaviors, and self-assessed health. Southern Economic Journal, 84(3), 660–691

    Article  Google Scholar 

  • Courtemanche, C. J., Marton, J., Ukert, B., Yelowitz, A., & Zapata, D. (2019a). Effects of the Affordable Care Act on health behaviors after 3 years. Eastern Economic Journal, 45(1), 7–33

    Article  Google Scholar 

  • Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., Zapata, D., & Fazlul, I. (2019b). The three-year impact of the Affordable Care Act on disparities in insurance coverage. Health Services Research, 54, 307–316

    Article  Google Scholar 

  • Donahoe, J. T., Norton, E. C., Elliott, M. R., Titus, A. R., Kalousová, L., & Fleischer, N. L. (2019). The Affordable Care act medicaid expansion and smoking cessation among low-income smokers. American Journal of Preventive Medicine, 57(6), e203–e210

    Article  Google Scholar 

  • Ehrlich, I., & Becker, G. S. (1972). Market insurance, self-insurance, and self-protection. Journal of Political Economy, 80(4), 623–648

    Article  Google Scholar 

  • Gaffney, A., & McCormick, D. (2017). The Affordable Care Act: Implications for healthcare equity. The Lancet, 389(10077), 1442–1452

    Article  Google Scholar 

  • Gotanda, H., Jha, A. K., Kominski, G. F., & Tsugawa, Y. (2020). Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: Quasi-experimental difference-in-difference study. BMJ, 368.

  • Glantz, S. A. (2019). Estimation of 1-year changes in Medicaid expenditures associated with reducing cigarette smoking prevalence by 1%. JAMA Network Open, 2(4), e192307–e192307.

  • Greene, W. H. (2002). The behavior of the fixed effects estimator in nonlinear models. NYU Working Paper No. EC-02-05, Available at SSRN: https://ssrn.com/abstract=1292651.

  • Jacobs, L. R., & Callaghan, T. (2013). Why states expand Medicaid: Party, resources, and history. Journal of Health Politics, Policy and Law, 38(5), 1023–1050

    Article  Google Scholar 

  • Kaiser Family Foundation. (2017). Status of state action on the medicaid expansion decision http://kaiserf.am/2thsxUO. Accessed September 5 2017.

  • McMorrow, S., Kenney, G. M., Long, S. K., & Anderson, N. (2015). Uninsurance among young adults continues to decline, particularly in Medicaid expansion states. Health Affairs, 34(4), 616–620

    Article  Google Scholar 

  • Miller, S., & Wherry, L. R. (2017). The long-term health effects of early life Medicaid coverage. Journal of Human Resources, 54(3), 785–824

    Article  Google Scholar 

  • Miller, S., & Wherry, L. R. (2017). Health and access to care during the first 2 years of the ACA Medicaid expansions. New England Journal of Medicine, 376(10), 947–956

    Article  Google Scholar 

  • Miller, S., & Wherry, L. R. (2019). Four years later: Insurance coverage and access to care continue to diverge between ACA Medicaid expansion and non-expansion states. AEA Papers and Proceedings, 109, 327–333. https://doi.org/10.1257/pandp.20191046

    Article  Google Scholar 

  • Rosenbaum, S., & Westmoreland, T. M. (2012). The Supreme Court’s surprising decision on the Medicaid expansion: How will the federal government and states proceed? Health Affairs, 31(8), 1663–1672

    Article  Google Scholar 

  • Shartzer, A., Long, S. K., & Anderson, N. (2016). Access to care and affordability have improved following Affordable Care Act implementation; problems remain. Health Affairs (Millwood)., 35(1), 161–168

    Article  Google Scholar 

  • Simon, K., Soni, A., & Cawley, J. (2017). The impact of health insurance on preventive care and health behaviors: Evidence from the first two years of the ACA Medicaid expansions. Journal of Policy Analysis and Management, 36(2), 390–417

    Article  Google Scholar 

  • Siu, A. L. (2015). Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 163(8), 622–634

    Article  Google Scholar 

  • Sommers, B. D., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2016). Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Internal Medicine, 176(10), 1501–1509

    Article  Google Scholar 

  • Sommers, B. D., Gunja, M. Z., Finegold, K., & Musco, T. (2015). Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA, 314(4), 366–374

    Article  CAS  Google Scholar 

  • Sommers, B. D., Musco, T., Finegold, K., Gunja, M. Z., Burke, A., & McDowell, A. M. (2014). Health reform and changes in health insurance coverage in 2014. New England Journal of Medicine, 371(9), 867–874

    Article  CAS  Google Scholar 

  • Soni, A. (2020). The effects of public health insurance on health behaviors: Evidence from the fifth year of Medicaid expansion. Health Economics, 29(12), 1586–1605

    Article  Google Scholar 

  • Torres, H., Poorman, E., Tadepalli, U., Schoettler, C., Fung, C. H., Mushero, N., & McCormick, D. (2017). Coverage and access for Americans with chronic disease under the Affordable Care Act: A quasi-experimental study. Annals of Internal Medicine, 166(7), 472–479

    Article  Google Scholar 

  • US Department of Health and Human Services. Healthy People 2020. Leading Health Indicators. Washington, DC: DHHS; updated April 18 2013. Available from http://www.healthypeople.gov/2020/LHI/default.aspx. Accessed May 29 2017.

  • Wherry, L. R., & Miller, S. (2016). Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: A quasi-experimental study. Annals of Internal Medicine, 164(12), 795–803

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Economics and Business, The Colin Powell School at City College of New York, The Graduate Center, City University of New York, 160 Convent Avenue, New York, 10031, USA

    Prabal K. De

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The findings and conclusions in this paper are those of the author and do not necessarily represent the views of the Research Data Center, the National Center for Health Statistics, or the Centers for Disease Control and Prevention. I am grateful to Nataliya Kravets at the Center for Disease Control and Shirley H Liu at the Census Bureau for helping me access the restricted state variable. All remaining errors are mine. This research was partially funded by a grant from PSC-CUNY welfare fund.

Appendix

Appendix

See Table 5.

Table 5 Medicaid Expansion as part of ACA
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De, P.K. Impacts of insurance expansion on health cost, health access, and health behaviors: evidence from the medicaid expansion in the US. Int J Health Econ Manag. 21, 495–510 (2021). https://doi.org/10.1007/s10754-021-09306-5

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  • DOI: https://doi.org/10.1007/s10754-021-09306-5

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