Medicaid, family spending, and the financial implications of crowd-out

Joint effects of Medicaid eligibility and fees on recession-linked declines in healthcare access and health status

Whether Medicaid can function as a safety net to offset health risks created by health insurance coverage losses due to job loss is conditional on (1) the eligibility guidelines shaping the pathway for households to access the program for temporary relief, and (2) Medicaid reimbursement policies affecting the value of the program for both the newly and previously enrolled. We find states with more expansive eligibility guidelines lowered the healthcare access and health risk of coverage loss associated with rising unemployment during the 2007-2009 Great Recession. Rises in cost-related barriers to care associated with unemployment were smallest in states with expansive eligibility guidelines and higher Medicaid-to-Medicare fee ratios. Similarly, states whose Medicaid programs had expansive eligibility guidelines and higher fees saw the smallest recession-linked declines in self-reported good health. Medicaid can work to stabilize access to health care during periods of joblessness. Our findings yield important insights into the alignment of at least two Medicaid policies (i.e., eligibility and payment) shaping Medicaid's viability as a safety net.

Research trends in contemporary health economics: a scientometric analysis on collective content of specialty journals

INTRODUCTION

Health economics is a thriving sub-discipline of economics. Applied health economics research is considered essential in the health care sector and is used extensively by public policy makers. For scholars, it is important to understand the history and status of health economics-when it emerged, the rate of research output, trending topics, and its temporal evolution-to ensure clarity and direction when formulating research questions.

METHODS

Nearly 13,000 articles were analysed, which were found in the collective publications of the ten most specialised health economic journals. We explored this literature using patterns of term co-occurrence and document co-citation.

RESULTS

The research output in this field is growing exponentially. Five main research divisions were identified: (i) macroeconomic evaluation, (ii) microeconomic evaluation, (iii) measurement and valuation of outcomes, (iv) monitoring mechanisms (evaluation), and (v) guidance and appraisal. Document co-citation analysis revealed eighteen major research streams and identified variation in the magnitude of activities in each of the streams. A recent emergence of research activities in health economics was seen in the Medicaid Expansion stream. Established research streams that continue to show high levels of activity include Child Health, Health-related Quality of Life (HRQoL) and Cost-effectiveness. Conversely, Patient Preference, Health Care Expenditure and Economic Evaluation are now past their peak of activity in specialised health economic journals. Analysis also identified several streams that emerged in the past but are no longer active.

CONCLUSIONS

Health economics is a growing field, yet there is minimal evidence of creation of new research trends. Over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%), but most of the top scholarly collaborations remain between six countries only.

The effects of pregnancy-related Medicaid expansions on maternal, infant, and child health

Prior research has examined how late 1980s pregnancy-related Medicaid eligibility expansions influenced outcomes around the time of birth and, more recently, adult outcomes. We offer a close examination of early childhood effects to better understand the mechanism(s) underlying the improved longer-term outcomes. The restricted-access National Maternal and Infant Health Survey allows us to explore the effects of these expansions on maternal and child outcomes near the time of birth as well as three years post-birth. Our evidence suggests earlier connection with prenatal care and possible modest improvements in birthweight and gestational age. In our follow-up data, we also identify evidence of persistent effects as measured by child developmental scores. However, the most consistent finding is our strong evidence of reduced levels of maternal depression-both during the child's infancy and three years later. We conclude that the alleviation of maternal stress is one likely mechanism for the longer-term improvements in later-life outcomes identified in studies of children exposed to Medicaid in-utero and in early infancy.

Difference-in-differences for categorical outcomes

OBJECTIVE

To discuss and develop difference-in-difference estimators for categorical outcomes and apply them to estimate the effect of the Affordable Care Act's Medicaid expansion on insurance coverage.

DATA SOURCES

Secondary analysis of Survey on Income and Program Participation (SIPP) data on health insurance coverage types before (Jan 2013) and after (Dec 2015) Medicaid expansion in 39 US states (19 expansion and 20 non-expansion).

STUDY DESIGN

We develop difference-in-difference methods for repeated measures (panel data) of categorical outcomes. We discuss scale dependence of DID assumptions for marginal and transition effect estimates, and specify a new target estimand: the difference between outcome category transitions under treatment versus no treatment. We establish causal assumptions about transitions that are sufficient to identify this and a marginal target estimand. We contrast the marginal estimands identified by the transition approach versus an additive assumption only about marginal evolution. We apply both the marginal and transition approaches to estimate the effects of Medicaid expansion on health insurance coverage types (employer-sponsored; other private, non-group; public; and uninsured).

DATA EXTRACTION

We analyze 16,027 individual survey responses from people aged 18 to 62 years in the 2014 SIPP panel.

PRINCIPAL FINDINGS

We show that the two identifying assumptions are equivalent (on the scale of the marginals) if either the baseline marginal distributions are identical or the marginals are constant in both grousp. Applying our transitions approach to the SIPP data, we estimate a differencial increase in transitions from uninsured to public coverage and differential decreases in transitions from uninsured to private, non-group coverage and in remaining uninsured.

CONCLUSIONS

By comparing the assumption that marginals are evolving in parallel to an assumption about transitions across outcome values, we illustrate the scale-dependence of difference-in-differences. Our application shows that studying transitions can illuminate nuances obscured by changes in the marginals.

Adult Medicaid benefit generosity and receipt of recommended health services among low-income children: The spillover effects of Medicaid adult dental coverage expansions

Low-income children are less likely to receive recommended health services than their high-income counterparts. This paper examines whether the design of parental Medicaid benefit packages could serve as a mechanism for reducing income-based disparities in unmet health care needs, considering dental benefits as a case study. Leveraging state-level changes to adult dental benefits over time, I find that coverage is associated with increases of 14 and 5 percentage points, respectively, in the likelihood of a recent dental visit among parents and children directly exposed to the policy. Child effects appear to be concentrated among younger children under age 12.

Young Adults' Selection and Use of Dependent Coverage under the Affordable Care Act

The dependent coverage expansion under the Affordable Care Act (ACA) required health insurance policies that cover dependents to offer coverage for policyholder' children up to age 26. It has been well documented that the provision successfully reduced the uninsured rate among the young adults. However, less is known about whether dependent coverage crowded out other insurance types and whether young adults used dependent coverage as a fill-in-the-gap short-term option. Using data from the Survey of Income and Program Participation 2008 Panel, the paper assesses dependent coverage uptake and duration before and after the ACA provision among young adults aged 19-26 versus those aged 27-30. Regressions for additional coverage outcomes were also performed to estimate the crowd-out rate. It was found that the ACA provision had a significant positive impact on dependent coverage uptake and duration. The estimated crowd-out rate ranges from 27 to 42%, depending on the definition. Most dependent coverage enrollees used the coverage for 1 or 2 years. Differences in dependent coverage uptake and duration remained among racial groups. Less healthy individuals were also less likely to make use of dependent coverage.