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The Patient Protection and Affordable Care Act (ACA) was designed to increase access to affordable health coverage by reforming the individual health insurance market and expanding eligibility for Medicaid, the insurance program targeted towards low-income individuals. Since its passage, however, the ACA has been plagued by criticisms that it has produced significant premium hikes. Moreover, many states chose not to expand their Medicaid programs. I examine whether there is a relationship between Medicaid expansion decisions and insurance premiums in the individual market. Because Medicaid expansions remove lower income individuals from individual insurance markets - and since these individuals tend to have poorer health outcomes - premiums in the private insurance market could be lower in expansion states where the private market is priced for a healthier risk pool. My results indicate that this may not be the case: I find that there is a positive and statistically significant relationship between Medicaid expansion and premiums, although this relationship is small in magnitude. I also find, however, that the relationship is the opposite for states that retained some measure of control over the administration of their marketplaces. This finding makes a novel contribution to the literature by demonstrating how state-level policy decisions can impact the success of national legislation. My study also illustrates the need for additional research into the impact of Medicaid expansions on premiums, as studies conducted to date have found contradicting results.
The Affordable Care Act is one of the most debated and dividing pieces of legislation in recent memory. One of the main elements of the ACA is the optional expansion of Medicaid eligibility to 138 % of the federal poverty line. The current debate has focused on the direct effects of the newly covered vs. the accounting cost of doing so, but there are also important other spillover effects to consider. In states that refused the Medicaid expansion, there exists a coverage gap that the private market will, at least partially, pick up. This gap, and the portion picked up, are not random and systematically exhibit higher expected costs. This raises prices for everyone taking part in the health insurance exchanges in states that refused the expansion. Our contribution is three-fold. We first confirm the interaction between the individual market and Medicaid expansion. We find that refusing the Medicaid expansion increases average monthly premiums by $22.94, an increase of 7.6 %. Our second and third contributions are more novel. We use a sharp discontinuity in the subsidy rates and find the premium increase is due to asymmetric information arising from the cost sharing reduction subsidies. We also provide a clean estimation of -0.34 for the price elasticity of healthcare in a pseudo-random experimental setting. Finally, we are able to separate the asymmetric information effect into adverse selection and moral hazard and find the moral hazard effect dominates.
A Shared Destiny is the fourth in a series of six reports on the problems of uninsurance in the United States. This report examines how the quality, quantity, and scope of community health services can be adversely affected by having a large or growing uninsured population. It explores the overlapping financial and organizational basis of health services delivery to uninsured and insured populations, the effects of community uninsurance on access to health care locally, and the potential spillover effects on a community's economy and the health of its citizens. The committee believes it is both mistaken and dangerous to assume that the persistence of a sizable uninsured population in the United States harms only those who are uninsured.
Brookings Papers on Economic Activity (BPEA) provides academic and business economists, government officials, and members of the financial and business communities with timely research on current economic issues. Contents: All Medicaid Expansions Are Not Created Equal: The Geography and Targeting of the Affordable Care Act Craig Garthwaite, John Graves, Tal Gross, Zeynal Karaca, Victoria Marone, and Matthew J. Notowidigdo Policies and Payoffs to Addressing America’s College Graduation Deficit Christopher Avery, Jessica Howell, Matea Pender, and Bruce Sacerdote The Optimal Inflation Target and the Natural Rate of Interest Philippe Andrade, Jordi Galí, Hervé Le Bihan, and Julien Matheron Inflation Dynamics: Dead, Dormant, or Determined Abroad? Kristen J. Forbes Macri’s Macro: The Elusive Road to Stability and Growth Federico Sturzenegger Progressive Wealth Taxation Emmanuel Saez and Gabriel Zucman
The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. This report analyzes health care utilizations as they relate to impairment severity and SSA's definition of disability. Health Care Utilization as a Proxy in Disability Determination identifies types of utilizations that might be good proxies for "listing-level" severity; that is, what represents an impairment, or combination of impairments, that are severe enough to prevent a person from doing any gainful activity, regardless of age, education, or work experience.
Some groups participate in politics more than others. Why? And does it matter for policy outcomes? In this richly detailed and fluidly written book, Andrea Campbell argues that democratic participation and public policy powerfully reinforce each other. Through a case study of senior citizens in the United States and their political activity around Social Security, she shows how highly participatory groups get their policy preferences fulfilled, and how public policy itself helps create political inequality. Using a wealth of unique survey and historical data, Campbell shows how the development of Social Security helped transform seniors from the most beleaguered to the most politically active age group. Thus empowered, seniors actively defend their programs from proposed threats, shaping policy outcomes. The participatory effects are strongest for low-income seniors, who are most dependent on Social Security. The program thus reduces political inequality within the senior population--a laudable effect--while increasing inequality between seniors and younger citizens. A brief look across policies shows that program effects are not always positive. Welfare recipients are even less participatory than their modest socioeconomic backgrounds would imply, because of the demeaning and disenfranchising process of proving eligibility. Campbell concludes that program design profoundly shapes the nature of democratic citizenship. And proposed policies--such as Social Security privatization--must be evaluated for both their economic and political effects, because the very quality of democratic government is influenced by the kinds of policies it chooses.
In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.
This monograph presents a brief overview of the literature on the difference-in-difference estimation strategy and discusses major issues mainly using a treatment effect perspective that allows more general considerations than the classical regression formulation that still dominates the applied work.
Few United States government programs are as controversial as those designed to aid the poor. From tax credits to medical assistance, aid to needy families is surrounded by debate—on what benefits should be offered, what forms they should take, and how they should be administered. The past few decades, in fact, have seen this debate lead to broad transformations of aid programs themselves, with Aid to Families with Dependent Children replaced by Temporary Assistance to Needy Families, the Earned Income Tax Credit growing from a minor program to one of the most important for low-income families, and Medicaid greatly expanding its eligibility. This volume provides a remarkable overview of how such programs actually work, offering an impressive wealth of information on the nation's nine largest "means-tested" programs—that is, those in which some test of income forms the basis for participation. For each program, contributors describe origins and goals, summarize policy histories and current rules, and discuss the recipient's characteristics as well as the different types of benefits they receive. Each chapter then provides an overview of scholarly research on each program, bringing together the results of the field's most rigorous statistical examinations. The result is a fascinating portrayal of the evolution and current state of means-tested programs, one that charts a number of shifts in emphasis—the decline of cash assistance, for instance, and the increasing emphasis on work. This exemplary portrait of the nation's safety net will be an invaluable reference for anyone interested in American social policy.