Support for Pre-Existing

Kevin Lewis

November 02, 2020

Policy Effects, Partisanship, and Elections: How Medicaid Expansion Affected Public Opinion Toward the Affordable Care Act
Michael Sances & Joshua Clinton
Journal of Politics, forthcoming


The Affordable Care Act (ACA) is one of the most consequential policies enacted in recent decades, but its political divisiveness and complexity call into question whether its effects can change public opinion. Using the varied implementation of one of the ACA’s key provisions – the expansion of Medicaid – and nearly 300,000 survey responses analyzed using a difference-in-differences design, we find the expansion of Medicaid makes respondents 1.5 percentage points more positive toward the ACA, and 2.2 points less likely to support repealing the ACA. Effects do not vary meaningfully by partisanship, are strongest for those most likely to be directly impacted, and are stronger after the 2016 election increased the chances of repeal. In addition to highlighting the ability of partisan policies to change public opinion when credibly threatened, we demonstrate how to estimate changes in model-based group opinion without bias.

Work Requirements and Perceived Deservingness of Medicaid
Jennifer Wu
American Politics Research, forthcoming


Does an individual’s effort to acquire employer-sponsored health insurance through employment affect whether they are deserving of health insurance? Much of the current literature that examines the deservingness of federally-funded health insurance focuses on an individual’s responsibility in becoming ill. However, logic from the welfare literature would suggest the willingness to work for one’s welfare, or reciprocity, is an important determinant of deservingness. The relevance of employment-seeking in Medicaid deservingness comes at a crucial time given recent attempts by state governments to implement work requirements as a part of Medicaid eligibility. Using a series of survey experiments, I compare the importance of responsibility versus reciprocity and find that responsibility, what one does to become ill, is the primary driver of judgments of deservingness. What one does to earn their Medicaid by working plays a negligible role in driving attitudes. These findings have implications for how we understand the determinants of support for Medicaid policy.

COVID-19 Has Increased Medicaid Enrollment, But Short-Term Enrollment Changes Are Unrelated To Job Losses
Chris Frenier, Sayeh Nikpay & Ezra Golberstein
Health Affairs, October 2020, Pages 1822-1831


The recent coronavirus disease 2019 (COVID-19) global pandemic has resulted in unprecedented job losses in the United States, disrupting health insurance coverage for millions of people. Several models have predicted large increases in Medicaid enrollment among those who have lost jobs, yet the number of Americans who have gained coverage since the pandemic began is unknown. We compiled Medicaid enrollment reports covering the period from March 1 through June 1, 2020, for twenty-six states. We found that in these twenty-six states, Medicaid covered more than 1.7 million additional Americans in roughly a three-month period. Relative changes in Medicaid enrollment differed significantly across states, although enrollment growth was not systemically related to job losses. Our results point to the important effects of state policy differences in the response to COVID-19.

The Aggregate and Local Economic Effects of Government Financed Health Care
Bill Dupor & Rodrigo Guerrero
Economic Inquiry, forthcoming


Government‐financed health care expenditures, through Medicare and Medicaid, have grown from roughly 0% to over 7.6% of national personal income over the past 50 years. This paper investigates the stimulative effects of Medicare spending. Using an annual, state‐level panel, we regress state income growth on own‐state spending and spending in other states, instrumented by unanticipated shocks to aggregate Medicare spending, to estimate local and spillover effects. In our benchmark specification, the own‐spending multiplier equals 1.3 and the spillover multiplier equals 0.4. The total Medicare spending multiplier (i.e., local plus spillover) is approximately 1.7.

Making Them Pay? Patient Ability to Pay and Care Disparities in Emergency Medical Services
Timothy Gubler, Haibo Liu & Alexandru Roman
BYU Working Paper, August 2020


We investigate how patient ability to pay through insurance influences the equity of care given by Emergency Medical Service (EMS) crews following 9-1-1 calls. EMS agencies are often underfunded and rely on self-generated revenues to carry out their health mission. Revenues depend on insurance reimbursement rates that typically decrease in the following order: private insurance, Medicare, and Medicaid. Reimbursement rate differences provide strong organizational-level incentives to treat patients differently based on ability to pay, but it is unclear if such differences might impact individual-level behaviors in the absence of direct incentives. Using data from 31 states reported to the US National Emergency Medical Services Information System, we find that both private insurance and Medicare patients receive more procedures (4.6% and 1.5%) and have longer transport times (5.1% and 3.9%) than Medicaid patients. These differences reduce with call urgency but increase on busy days. Differences manifest across all agency types but particularly in larger agencies and agencies with fewer private insurance calls in the recent past. While EMS crews do not benefit directly from patient payments, our results suggest they do respond to indirect organization-level incentives when making care decisions.

Improved survival for individuals with common chronic conditions in the Medicare population
Benjamin Cohen et al.
Health Economics, forthcoming


It is well established that the United States lags behind peer nations in life expectancy, but it is less established that there is heterogeneity in life expectancy trends. We compared mortality trends from 2004 to 2014 for the United States with 17 high‐income countries for persons under and over 65. The United States ranked last in survival gains for the young but ranked near the middle for persons over 65, the group with universal access to public insurance. To explore the over‐65 mortality trend, we estimated Cox proportional hazards models for individuals soon after entering Medicare. These were estimated separately by race and sex, controlling for 26 chronic conditions and condition‐specific time trends. The separate regressions enabled survival comparisons for the 2004 and 2014 cohorts by race and sex, conditional on baseline health. We predicted 5‐year survival for all combinations of diabetes, hyperlipidemia, hypertension, and ischemic heart disease (IHD). All 16 combinations of these conditions showed survival gains, with diabetes as a key driver. Notably, survival improved and racial disparities narrowed for individuals with diabetes, hypertension, and IHD. White females, black females, white males, and black males gained 3.61, 3.90, 3.57, and 5.89 percentage points in 5‐year survival, respectively.

The Effects of the Affordable Care Act on the Near-Elderly: Evidence for Health Insurance Coverage and Labor Market Outcomes
Mark Duggan, Gopi Shah Goda & Gina Li
NBER Working Paper, October 2020


The Affordable Care Act (ACA) not only changed the landscape of health insurance coverage in the United States, but also affected the relationship between working decisions and health insurance. In this paper, we estimate the impact of the ACA on the near-elderly (ages 60-64) in the five years after the implementation of its key provisions in early 2014. We exploit variation across geographic areas in the pre-existing level of uninsurance and use 65-69 year olds, whose insurance coverage was unaffected by the ACA, as a within-region control group. Our findings indicate that the ACA increased health insurance coverage among the near elderly by approximately 4.5 percentage points and reduced their labor force participation rate by approximately 0.6 percentage points.

Do the uninsured demand less care? Evidence from Maryland’s hospitals
Amanda Cook
International Journal of Health Economics and Management, September 2020, Pages 251–276


Uninsured individuals receive fewer healthcare services for at least three reasons: responsibility for the entire bill, higher prices, and potential provider reductions for concern of nonpayment. I isolate reductions when uninsured patients are solely financially responsible by capitalizing on Maryland’s highly regulated health care system. Prices are set by the state, are uniform across all patients, and hospitals are compensated for free care and bad debt. I use a unique feature of the data, multiple readmissions for patients who gain or lose insurance between visits, to isolate the reductions in quantity demanded when individuals are faced with paying the full price without an insurance contribution. A Blinder–Oaxaca decomposition estimates uninsured individuals receive 6% fewer services after accounting for differences in patient, illness, and hospital characteristics than when these same individuals are insured.

Biomarkers, disability and health care demand
Apostolos Davillas & Stephen Pudney
Economics & Human Biology, forthcoming


Using longitudinal data from a representative UK panel, we focus on a group of apparently healthy individuals with no history of disability or major chronic health condition at baseline. A latent variable structural equation model is used to analyse the predictive role of latent baseline biological health, indicated by a rich set of biomarkers, and other personal characteristics, in determining the individual’s disability state and health service utilisation five years later. We find that baseline biological health affects future health service utilisation very strongly, via progression to functional disability channel. We also find systematic income gradients in future disability risks, with those of higher income experiencing a lower progress to disability. Our model reveals that observed pro-rich inequity in health care utilisation, is driven by the fact that higher-income people tend to make greater use of health care treatment, for any given biological health and disability status; this is despite the lower average need for treatment shown by the negative association of income with both baseline ill biological health and disability progression risk. Factor loadings for latent baseline health show that a broader set of blood-based biomarkers, rather than the current focus mainly on blood pressure, cholesterol and adiposity, may need to be considered for public health screening programs.

The Effects of Medicare Payment Changes on Nursing Home Staffing
Daifeng He, Peter McHenry & Jennifer Mellor
American Journal of Health Economics, Fall 2020, Pages 411-443


In light of persistent shortcomings in nursing home care quality and evidence that lower nurse staffing levels could be harmful to residents, we examine whether staffing levels are affected by changes in Medicare reimbursement rates. We exploit a 2006 change in Medicare’s methodology for adjusting provider payments for geographic differences in costs, a change that generated plausibly exogenous variation in nursing facility reimbursement rates. Our method compares facilities with higher and lower shares of Medicare resident days, which were differentially exposed to the payment changes we examine. Using panel data on US nursing homes from 2003 through 2009, we find that higher Medicare payments increased nurse staffing hours per resident day. Additional results suggest that changes in Medicare payments did not affect other measures of quality.

Electronic Trace Data and Legal Outcomes: The Effect of Electronic Medical Records on Malpractice Claim Resolution Time
Sam Ransbotham, Eric Overby & Michael Jernigan
Management Science, forthcoming


Information systems generate copious trace data about what individuals do and when they do it. Trace data may affect the resolution of lawsuits by, for example, changing the time needed for legal discovery. Trace data might speed resolution by clarifying what events happened when, or they might slow resolution by generating volumes of new and potentially irrelevant data that must be analyzed. To investigate this, we analyze the effect of electronic medical records (EMRs) on malpractice claim resolution time. Use of EMRs within hospitals at the time of the alleged malpractice is associated with a four-month (12%) reduction in resolution time. Because unresolved malpractice claims impose substantial costs on the entire healthcare system, our finding that EMRs are associated with faster resolution has broad welfare implications. Furthermore, as we increasingly digitize society, the ramifications of trace data on legal outcomes matter beyond the medical context.

The effect of Affordable Care Act Medicaid expansion on hospital revenue
Ali Moghtaderi et al.
Health Economics, forthcoming


Prior research has found that in states which expanded Medicaid under the Affordable Care Act, hospital Medicaid revenue rose sharply, and uncompensated care costs fell sharply, relative to hospitals in nonexpansion states. This suggests that Medicaid expansion may have been a boon for hospital revenue. We conduct a difference‐in‐differences analysis covering the first four expansion years (2014–2017) and confirm prior results for Medicaid revenue and uncompensated care cost, over this longer period. However, we find that hospitals in expansion states showed no significant relative gains in either total patient revenue or operating margins. Instead, the relative rise in Medicaid revenue was offset by relative declines in commercial insurance revenue. In subsample analyses, we find higher revenue and margins for rural hospitals in expansion states, little change for small urban hospitals, and a revenue decline for large urban 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
Melissa McInerney, Jennifer Mellor & Lindsay Sabik
Journal of Policy Analysis and Management, forthcoming


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.


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