Health Reform and Retirement

The Evolution of Job Lock in the U.S.: Evidence from the Affordable Care Act

Since at least the early 1990s, economists have found substantial evidence of “job lock” in the United States: workers who get health insurance from their employer are less likely to switch jobs. Early work showed stronger job lock among groups that place a higher value on health insurance, whereas more recent work has focused on measuring the effect of specific policies on job lock. We combine these approaches by replicating some of the classic group comparisons (job switching among the more versus less healthy, and among those whose spouses do or do not have their own health insurance) over a much longer time period, using data from the Current Population Survey and the Medical Expenditure Panel Survey. This enables us to document the evolution of job lock over time, with a particular focus on how it changed when policies such as the Affordable Care Act (ACA) took effect. Estimates based on a difference-in-differences methodology indicate that job lock remains substantial, and that ACA has not significantly affected job mobility.

Changes in Health Care Access and Utilization for Low-SES Adults Aged 51-64 Years After Medicaid Expansion

OBJECTIVES

Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults aged 51-64 years has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults aged 51-64 years before and after the ACA Medicaid expansion.

METHODS

Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N = 2,088 noninstitutionalized low-education adults aged 51-64 years (n = 633 in Medicaid expansion states, n = 1,455 in nonexpansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, and private), access (usual source of care, difficulty finding a physician, foregone care, cost-related medication nonadherence, and out-of-pocket costs), utilization (outpatient visit and hospitalization), and health status.

RESULTS

Low-education adults aged 51-64 years had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in nonexpansion states, DID +7.4 pp, p = .001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in nonexpansion states, DID +10.4 pp, p = .003) in Medicaid expansion compared with nonexpansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in nonexpansion states (+3.6 pp in expansion states, +11.0 pp in nonexpansion states, DID -7.5 pp, p = .006). There were no other significant differences in access, utilization, or health trends between expansion and nonexpansion states.

DISCUSSION

After Medicaid expansion, low-education status adults aged 51-64 years were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.

Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study

BACKGROUND

Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy.

OBJECTIVE

To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities.

CONCLUSIONS

Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.

Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply

We examined the effect of the expansion of Medicaid eligibility under the Affordable Care Act on health insurance coverage and labor supply of low-educated and low-income adults. We found that the Medicaid expansions were associated with large increases in Medicaid coverage, for example, 50 percent among childless adults, and corresponding decreases in the proportion uninsured. There was relatively little change in private insurance coverage, although the expansions tended to decrease such coverage slightly. In terms of labor supply, estimates indicated that the Medicaid expansions had little effect on work effort despite the substantial changes in health insurance coverage. Most estimates suggested that the expansions increased work effort, although not significantly.