Low-income Childless Adults Research Articles

Impacts of the Affordable Care Act Medicaid Expansion in California

We examined the impact of the Affordable Care Act (ACA) on healthcare coverage, access, health status, and affordability, as well as disparities in these outcomes by race/ethnicity among low-income Californians. We used nationally representative survey data from the Behavioral Risk Factor Surveillance Survey 2011-2019 and a difference-in-differences approach that compared California with nonexpansion states. We examined the impact of Medicaid expansion on health insurance coverage, having a usual source of care, self-reported health status, frequent (≥14) unhealthy days in the past month (physical, mental, and both), and foregone care due to cost. The sample population included low-income Californians (<100% of the federal poverty guidelines) aged 19-64 and low-income childless adults. Low-income adults, childless adults, and white childless adults in California saw post-ACA gains in six of seven outcomes, including a 7.7 percentage point increase in having a usual source of care for all low-income adults (CI: 0.051 to 0.104). Childless adult people of color (POC) reported significant improvements in three measures, with a 6.6 percentage point increase in having a usual source of care (CI: 0.013 to 0.120). All of the groups we examined had coverage gains, ranging from 3.9 percentage points for all low-income adults (CI: 0.013 0.066) to 8.4 percentage points for white childless adults (CI: 0.025 to 0.143). Additionally, all groups reported improved mental health, including an 8.2 percentage point decrease in frequent mental distress for childless adults (CI: -0.120 to -0.044). These findings indicate that the ACA coverage expansion benefitted the targeted population of low-income Californians. Additionally, the disparity between white and non-white Californians decreased for the unadjusted mean rate of having a usual source of care. However, unadjusted means showed that white low-income adults remained more likely to have health insurance coverage and a usual source of care compared with POC in both California and nonexpansion states.

The Impact of the Affordable Care Act on Dental Care: An Integrative Literature Review.

The goal of the Patient Protection and Affordable Care Act (ACA) is to increase access to health insurance and decrease health care cost while improving health care quality. With more articles examining the relationship between one of the ACA provisions and dental health outcomes, we systematically reviewed the effect of the ACA on dental care coverage and access to dental services. We searched literature using the National Library of Medicine’s Medline (PubMed) and Thomson Reuters’ Web of Science between January 2010 and November 2020. We identified 33 articles related to dental coverage, and access/utilization of dental care services. This systematic review of studies showed that the ACA resulted in gains in dental coverage for adults and children, whereas results were mixed with dental care access. Overall, we found that the policy led to a decrease in cost barriers, an increase in private dental coverage for young adults, and increased dental care use among low-income childless adults. The implementation of the ACA was not directly associated with dental insurance coverage among people in the U.S. However, results suggest positive spillover effects of the ACA on dental care coverage and utilization by people in the national level dataset.

The Effect of Affordable Care Act Medicaid Expansions on Household Composition

Prior research has shown improvements in low-income individuals' financial well-being as a consequence of the Affordable Care Act's Medicaid expansion. Given the connection between financial well-being and housing, we investigate the extent to which the provision of Medicaid to previously ineligible, low-income childless adults affects their household composition. Using a staggered adoption difference-in-differences design on an urban sample of individuals with less than a high school degree, we find that 26 to 39 year olds experience a significant 4.2% decline in the number of individuals living in the household, which is due to living with fewer extended family members. At the same time, 26 to 39 year olds experience a relatively smaller decline in the number of rooms (1.8%), leading to a 3.1% reduction in the level of household crowding, as measured by persons per bedroom. These reductions in household crowding are strongest for Hispanic individuals and those living in areas with above-median housing costs. In comparison, there are no significant impacts on household composition for 40 to 64 year olds as a consequence of the policy.

The Impact of the Medicaid Expansion on Telemental Health Utilization in Four Midwestern States.

Introduction: Low-income populations experience many barriers to accessing affordable, high-quality mental health services. One promising approach to improving access to care may be utilizing telemedicine in combination with expanding state Medicaid programs to cover low-income childless adults. This combination has the potential to reduce the prevalence of untreated mental illness; improve low-income populations' health and well-being; and save individuals', health care centers', and federal and state governments' money. Materials and Methods: A secondary data analysis on state Medicaid claims data was performed to calculate the percent difference in telemental health claims from 2014 through 2017 between two Medicaid expansion and two nonexpansion states in the Midwest. The percent change in claims during this time period within each of the four states was also calculated. Lastly, the difference between Medicaid telemental health utilization and other types of Medicaid telemedicine utilization was examined. Results: The Medicaid expansion states (Iowa and Minnesota) had 54% more telemental health claims per 10,000 state population than nonexpansion states (Nebraska and Wisconsin) from 2014 through 2017. During this time period, Iowa, Minnesota, and Nebraska experienced 481%, 329%, and 12% increases in Medicaid telemental health claims, respectively, and Wisconsin experienced a 10% decrease. Discussion and Conclusions: Medicaid telemental health utilization has been increasing since 2014 in the two Medicaid expansion states, especially in Iowa, while utilization has remained relatively constant in the two Medicaid nonexpansion states. This has implications for informing Medicaid policies, particularly with regard to Medicaid expansion and telemedicine reimbursement.

Health insurance and self-assessed health: New evidence from Affordable Care Act repeal fear.

Self-assessed health is one of the most commonly used health measures by economists. However, changes in self-assessed health are not always accompanied by changes in physical health as measured by clinical outcomes. This study provides suggestive evidence that this discrepancy arises because self-assessed health is significantly influenced by psychological factors. Specifically, when the perceived risk of Affordable Care Act (ACA) repeal increased, as documented by Google Trends data, self-assessed health declined among low-income childless adults living in states that expanded Medicaid under the ACA.

The Effect of Reduced Drug Copayments on Adherence to Oral Diabetes Medications Among Childless Adults in Wisconsin Medicaid.

Medication adherence is an indicator of the quality of drug use, which is associated with better health outcomes and reduced health care expenditures. Drug cost sharing can be a barrier to adherence, especially for low-income individuals with chronic conditions. Most of the existing studies in a Medicaid population have evaluated the effects of increasing drug copayments, but few studies have evaluated the effects of reducing drug copayments on medication adherence. Medicaid coverage for low-income childless adults in Wisconsin was expanded on April 1, 2014, which included reductions in drug copayments and monthly caps on out-of-pocket spending. To evaluate changes in adherence to oral diabetes medications using proportion of days covered (PDC) among Medicaid childless adults with type 2 diabetes after the 2014 Medicaid drug copayment reduction. A difference-in-differences design was used to compare the changes in medication adherence between childless adults (treatment group) and parents/caretakers (control group). Wisconsin Medicaid's administrative enrollment records, pharmacy claims, and medical claims data were analyzed. Medication adherence was evaluated for 4 commonly used oral diabetes drug classes (i.e., biguanides, sulfonylureas, dipeptidyl peptidase-IV inhibitors, and thiazolidinediones) by adapting the medication adherence quality measures endorsed by the Pharmacy Quality Alliance. The PDC for all diabetes drugs was calculated among patients who filled ≥ 2 prescriptions for any of the 4 drug classes. PDC for each drug class was also measured among patients who had ≥ 2 drug fills for each drug class. The proportion of adherent patients was evaluated using a threshold of PDC ≥ 0.80. Average PDC for all diabetes drugs was 0.87 in the childless adults at baseline and significantly increased by 0.02 (P = 0.025) relative to the parents/caretakers after the copayment reduction. The baseline proportion of adherent patients (PDC ≥ 0.80) among the childless adults was 76% and significantly increased by 6.2 percentage points (P = 0.003) relative to the control group. The odds of adherence to oral antidiabetic drugs increased by 47%, resulting in the proportion of adherent patients in the childless adults group reaching almost 80% after the coverage expansion. In the per class analyses, a significant effect was found for biguanides; the proportion of adherent patients increased by 5.5 percentage points in childless adults compared with the control group (P = 0.022). This program evaluation found that a reduction of drug copayments in Wisconsin Medicaid improved the quality of medication use by increasing adherence to oral antidiabetic drugs among childless adults. This study was conducted as part of a larger study funded by the Wisconsin Department of Health Services. The authors are solely responsible for the content of this study. The authors report an evaluation contract with the Wisconsin Department of Health Services, unrelated to this study. An earlier version of this paper was presented at the AcademyHealth Annual Research Meeting; June 23-24, 2018; Seattle, WA.

Effect of the Affordable Care Act's Medicaid Expansions on Food Security, 2010-2016.

Objectives. To examine whether the expansion of Medicaid under the Affordable Care Act (ACA) decreased the prevalence of severe food insecurity.Methods. With data on adult respondents to the Food Security Supplement to the Current Population Survey in US states for the years 2010 to 2013 and 2015 to 2016, I used a difference-in-difference design to compare trends in very low food security (VLFS) among low-income childless adults in states that did and did not expand Medicaid in 2014 under the ACA.Results. Among low-income, nonelderly childless adults, VLFS rose from 17.4% before ACA to 17.5% after ACA in nonexpansion states, and fell from 17.6% to 15.9% in expansion states. In difference-in-difference analysis, Medicaid expansion was associated with a significant adjusted 2.2-percentage-point decline in rates of VLFS, equivalent to a 12.5% relative reduction.Conclusions. The improvement in food security after the ACA's health insurance expansion suggests that health insurance provision has spillover effects that reduce other dimensions of poverty.Public Health Implications. Providing free or low-cost health insurance coverage may free up household funds, reducing food insecurity and improving this important social determinant of health.

Low-Income Childless Adults' Access To Antidiabetic Drugs In Wisconsin Medicaid After Coverage Expansion.

Medicaid coverage was expanded for childless adults in Wisconsin through an amended Section 1115 demonstration waiver on April 1, 2014. Coverage for prescription drugs was expanded via copayment reductions and a drug formulary expansion. We analyzed administrative drug claims data to evaluate changes in the use of and out-of-pocket spending on antidiabetic drugs among childless adults who experienced the drug coverage expansion. Compared to parents or caretakers, who were not affected by the expansion, childless adults experienced a significant increase of 4percent in the use of antidiabetic drugs-driven mainly by an increase in the population using the drugs, rather than by more intense use. The expanded drug coverage also reduced the burden of out-of-pocket spending for childless adults by 70percent. Our findings demonstrate that expanding prescription drug benefits led to increased access to antidiabetic drugs for childless adults in Wisconsin Medicaid.

Health Status and Access to Care among Maine’s Low-Income Childless Adults: Implications for State Medicaid Expansion

Health Status and Access to Care among Maine’s Low-Income Childless Adults: Implications for State Medicaid Expansion

The Effect of the Affordable Care Act Medicaid Expansion on Disparities in Access to Care and Health Status.

Before the Affordable Care Act Medicaid expansion, nonelderly childless adults were not generally eligible for Medicaid regardless of their income, and Hispanics had much higher uninsured rates than other racial/ethnic subgroups. We estimated difference-in-differences models on Behavioral Risk Factor Surveillance data (2011-2016) to estimate the impacts of Medicaid expansion on racial/ethnic disparities in insurance coverage, access to care, and health status in this vulnerable subpopulation. Uninsured rates among all poor childless adults declined by roughly 9 percentage points more in states that expanded Medicaid. While expansion also had favorable impacts on most access and health outcomes among Whites in expansion states, there were relatively few such impacts among Blacks and Hispanics. Through 2016, Affordable Care Act Medicaid expansion was more effective in improving access and health outcomes among White low-income childless adults than mitigating racial/ethnic disparities.

Medicaid expansions and labor supply among low-income childless adults: evidence from 2000 to 2013.

Medicaid expansions to low-income childless adults could have unintended effects on labor supply. Using 2000-2013 current population survey data, we exploit changes in adult Medicaid eligibility across states to estimate its effect on labor supply for three samples of adults most likely to be affected by changes in Medicaid eligibility: those with less than a high school degree, a high school degree only, and income less than 300% of the federal poverty line. Medicaid eligibility was associated with a reduction in labor supply for low-income women with a high school degree. In our preferred estimations, these women were about 7 percentage points less likely to be employed than similar women in states without expanded Medicaid. Only a modest reduction was observed for weekly hours worked and then only for women with less than a high school degree and who were hourly employees (about 3h), leading us to conclude that the effect is largely driven by those who leave the workforce. Older low-income women with a high school degree had the strongest negative response to changes in Medicaid eligibility. They were 17 percentage points less likely to be employed in states that had expanded Medicaid, possibly since these women are motivated to leave employment because they lack access to employer-sponsored insurance and have health needs that can be addressed with Medicaid coverage. Men's employment appeared largely unaffected by changes in Medicaid eligibility.

Third Year of Survey Data Shows Continuing Benefits of Medicaid Expansions for Low-Income Childless Adults in the U.S.

The Affordable Care Act (ACA) of 2010 incentivized states to expand eligibility for their Medicaid programs. Many did so in 2014, and there has been great interest in understanding the effects of these expansions on access to health care, health care utilization, and population health. To estimate the longer-term (three-year) impact of Medicaid expansions on insurance coverage, access to care, preventive care, self-assessed health, and risky health behaviors. A difference-in-differences model, exploiting variation across states and over time in Medicaid expansion, was estimated using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 2010-2016. Low-income childless adults aged 19-64years in the BRFSS. Outcomes included insurance coverage, access to care, several forms of preventive care (e.g., routine checkups, flu shots, HIV tests, dental visits, and cancer screening), risky health behaviors (e.g., smoking, alcohol abuse, obesity), and self-assessed health. The previously documented benefits of Medicaid expansions on insurance coverage, access to care, preventive care, and self-assessed health have persisted 3years after expansion. There was no detectable effect on risky health behaviors. The Affordable Care Act was motivated in part by a desire to increase health insurance coverage, improve access to care, and increase use of preventive care. The Medicaid expansions facilitated by the ACA are helping to achieve those objectives, and the benefits have persisted 3years after expansion.

Public Health Insurance Take-Up and Labor Supply: Evidence from State Expansions in Coverage to Childless Adults in the Early 2000s

This paper considers the effects of public health insurance expansions for low-income childless adults in the early 2000s in a causal framework, prior to passage of the 2010 Affordable Care Act. Using the 1998 through 2007 March Current Population Surveys, my estimates suggest the expansions increased low-educated childless women's public health insurance coverage by 1.6 to 2.5 percentage points, but the results do not provide evidence of a change in public health insurance coverage for low-educated childless men. I do not find any statistically significant negative effects on the labor supply of low-educated childless men or women, despite an increase in take-up for women. While the estimates are imprecise, confidence intervals rule out the possibility of large negative labor supply effects. These results are also supported by event study analyses.

Medicaid Expansion Under the Affordable Care Act and Insurance Coverage in Rural and Urban Areas.

To analyze the differential rural-urban impacts of the Affordable Care Act Medicaid expansion on low-income childless adults' health insurance coverage. Using data from the American Community Survey years 2011-2015, we conducted a difference-in-differences regression analysis to test for changes in the probability of low-income childless adults having insurance in states that expanded Medicaid versus states that did not expand, in rural versus urban areas. Analyses employed survey weights, adjusted for covariates, and included a set of falsification tests as well as sensitivity analyses. Medicaid expansion under the Affordable Care Act increased the probability of Medicaid coverage for targeted populations in rural and urban areas, with a significantly greater increase in rural areas (P < .05), but some of these gains were offset by reductions in individual purchased insurance among rural populations (P < .01). Falsification tests showed that the insurance increases were specific to low-income childless adults, as expected, and were largely insignificant for other populations. The Medicaid expansion increased the probability of having "any insurance" for the pooled urban and rural low-income populations, and it specifically increased Medicaid coverage more in rural versus urban populations. There was some evidence that the expansion was accompanied by some shifting from individual purchased insurance to Medicaid in rural areas, and there is a need for future work to understand the implications of this shift on expenditures, access to care and utilization.

The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions.

The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA-facilitated state-level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference-in-differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self-assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low-income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self-assessed health.

Health Insurance and Labor Supply: Evidence from the Affordable Care Act Early Medicaid Expansion in Connecticut

This paper examines how health insurance affects labor supply by exploiting a quasi-experimental change in health insurance provision under the Affordable Care Act (ACA) early Medicaid expansion in Connecticut implemented in 2010. Applying an instrumental variables approach to a difference-in-differences-in-differences strategy, I find remarkable labor supply impacts of the ACA early Medicaid expansion in Connecticut. I show evidence that Connecticut's Medicaid expansion increased Medicaid coverage for low-income childless adults by 5.9 percentage points, and as a result reduced the employment rate by 3.8 to 4.5 percentage points among those low-income childless adults.

The effects of expanding public insurance to rural low-income childless adults.

This study measures the change in health care use after enrollment into a new public insurance program for low-income childless adults. The data sources include claims from a large integrated health system in rural Wisconsin and Medicaid enrollment files, January 2007-September 2012. We employ a regression discontinuity design to measure the causal effect of public insurance enrollment on counts of outpatient, emergency department, and inpatient events for 2years following enrollment for a sample of previously uninsured low-income adults in rural Wisconsin. Public insurance enrollment led to substantial increases in outpatient visits including preventive visits, but not mental health visits. Public insurance enrollment also led to increases in inpatient stays, but the study is inconclusive on whether it led to an increase in ED visits. Public insurance expansions to childless adults have the potential to impact the use of health care. The large increase in Medicaid coverage and reduction in rates of uninsurance anticipated to result from the Affordable Care Act should increase the use of inpatient and outpatient services, but they will have an uncertain impact on the use of ED among rural populations.

New Evidence On The Affordable Care Act: Coverage Impacts Of Early Medicaid Expansions

The Affordable Care Act expands Medicaid in 2014 to millions of low-income adults in states that choose to participate in the expansion. Since 2010 California, Connecticut, Minnesota, and Washington, D.C., have taken advantage of the law's option to expand coverage earlier to a portion of low-income childless adults. We present new data on these expansions. Using administrative records, we documented that the ramp-up of enrollment was gradual and linear over time in California, Connecticut, and D.C. Enrollment continued to increase steadily for nearly three years in the two states with the earliest expansions. Using survey data on the two earliest expansions, we found strong evidence of increased Medicaid coverage in Connecticut (4.9 percentage points; $$p ) and positive but weaker evidence of increased coverage in D.C. (3.7 percentage points; $$p=\mathbf{\boldsymbol{0.08}}$$). Medicaid enrollment rates were highest among people with health-related limitations. We found evidence of some crowd-out of private coverage in Connecticut (30-40percent of the increase in Medicaid coverage), particularly for healthier and younger adults, and a positive spillover effect on Medicaid enrollment among previously eligible parents.

Health Reform and the US Virgin Islands

There are 4.1 million residents living in the US territories, which is more than the combined population of many US states, yet the territories and their citizens are often overlooked from a policy perspective, because most individual territories are relatively small, geographically isolated, and have been treated differently than the states historically. This tendency to fall beneath the radar is clear in the realm of health policy, especially in the area of insurance coverage. This article provides an initial assessment of the potential impact of health reform on the US Virgin Islands (USVI) and, in light of this assessment, considers how the results of a USVI household survey conducted in 2003 and 2009 might be used as a baseline for future monitoring of the impact of national reform. A study by the Virgin Island's Bureau of Economic Research, Office of the Governor, and the University of Minnesota, was conducted in 2003 and 2009. The Virgin Islands Health Insurance telephone Surveys were random digit dial landline telephone surveys of households in the USVI. A stratified sample was drawn to produce precise estimates of insurance coverage for the USVI as a whole and for the 3 islands separately. Almost one-third of the residents (28.7%) in the Virgin Islands were uninsured in 2009. This rate is twice the US average (15.4%) and significantly higher than the uninsured rate of 24.1% when a similar survey was last conducted the Virgin Islands in 2003. The Patient Protection and Affordable Care Act of 2010 provides special funding to the territories through a mix of increased Medicaid caps for each territory and the provision of premium subsidies through newly established health insurance exchanges to low-income populations. However, the Affordable Care Act's Medicaid expansions to newly eligible adults--primarily adults without children--are limited to current eligibility levels in the territories, which is $5,500 in annual income for adult coverage in the USVI. Within these abbreviated parameters, the Medicaid expansion can go so far only toward mitigating uninsurance among the lowest income groups in the territories. With certain low-income childless adults overlooked, the Affordable Care Act does not fully address the high need for affordable health insurance coverage in the territories.

Wisconsin Experience Indicates That Expanding Public Insurance To Low-Income Childless Adults Has Health Care Impacts

As states consider expanding Medicaid to low-income childless adults under the Affordable Care Act, their decisions will depend, in part, on how such coverage may affect the use of medical care. In 2009 Wisconsin created a new public insurance program for low-income uninsured childless adults. We analyzed administrative claims data spanning 2008 and 2009 using a case-crossover study design on a population of 9,619 Wisconsin residents with very low incomes who were automatically enrolled in this program in January 2009. In the twelve months following enrollment in public insurance, outpatient visits for the study population increased 29 percent, and emergency department visits increased 46 percent. Inpatient hospitalizations declined 59 percent, and preventable hospitalizations fell 48 percent. These results demonstrate that public insurance coverage expansions to childless adults have the potential to improve health and reduce costs by increasing access to outpatient care and reducing hospitalizations.