How Did the Affordable Care Act Affect Risky Health Behaviors?

Abstract

The Affordable Care Act (ACA) expanded insurance coverage in the USA through Medicaid expansions, insurance marketplaces, subsidies, and mandates in 2014. Insurance coverage at such a large scale may affect individuals' risky health behaviors such as smoking, excessive drinking, overeating, not exercising, and illicit substance use. Those effects are not easy to predict, and they may be positive or negative. On one hand, as more people have access to health care, they may improve their health behaviors with advice from medical professionals, educational materials, tobacco cessation treatments, and healthy behavior incentive programs provided by Medicaid. On the other hand, this increase in access can also lead to moral hazard where reduced costs of health care through insurance can make individuals choose less healthy behaviors. In this study, I asked whether the ACA changed risky health behaviors. I used a difference-in-difference-in-differences regression model where time, state Medicaid expansion status, and local area pre-ACA uninsured rate together constituted my identification strategy. In all my models, I controlled for a large set of individual-level and area-specific variables. I did not find any statistically significant negative effects on risky health behaviors that would have supported the existence of moral hazard that dominates other effects. On the other hand, I found significant improvements in smoking and excessive drinking in 2017 and 2018. These results are robust to using only the subsamples of poor childless adults and the newly insured. Early effects of the ACA's insurance coverage expansions did not lead to any significant changes in risky health behaviors except for improvements in smoking and excessive drinking in 2017 and 2018. Further research is needed for the later years as more individuals became aware of these benefits.