Effect of Medicaid Expansion on Health Insurance for Low-Income Nursing Home Aides

A Cross-Sectional Study of Nurse Turnover in Residential Care Communities

We examine what facility characteristics are associated with nurse turnover in residential care communities (RCCs). This is a cross-sectional study using the 2018 National Study of Long-term Care Provider Public Use File. There were 3331 RCCs (unweighted n = 272) represented when examining registered nurse (RN) turnover and when examining aide turnover there was a weighted sample of 13,676 RCCs (unweighted n = 68). RN turnover was 72% (95% confidence interval (CI) 59%, 84%), 52% reported 100% turnover. Aide turnover was 48% (95% CI 43%, 53%); 11% reported 100% turnover. We examined ownership and facility type, job design, economic, and working environment factors related to turnover. Using multivariate linear regression, non-profit RCCs had 25 percentage points lower RN turnover (95% CI: -44.46, -4.31) and 9.7 percentage points lower aide turnover (95% CI: 18.8, -0.6) compared to for-profits. We find larger RCCs had lower aide turnover.

Effects of the Affordable Care Act Medicaid Expansions on the Employment and Work Hours of Nursing Assistants in Hospitals and Nursing Homes

We examine the effects of the Affordable Care Act Medicaid expansions on the employment and work hours of nursing assistants (NAs). We use the 2011-2019 American Community Survey data to identify NAs likely to be affected by Medicaid expansions (income up to 138% of the federal poverty level) in nursing homes and hospitals. Using classical difference-in-differences regressions, we find that Medicaid expansions have little effect on employment and work hours among NAs in the full sample. However, there is a 4.4 percentage-point increase in the probability of working part-time (<30 hours/week) for nursing home NAs (p < .05). We found no employment effects of Medicaid expansions for hospital NAs. Our study adds to the literature on the heterogeneous effects of Medicaid expansions on work effort across occupations and workplaces. The rise in part-time employment for nursing home NAs following Medicaid expansions suggests the need for improved benefits to encourage full-time employment.

Medicaid Expansions and Private Insurance 'Crowd-Out' (1999-2019)

Recent Medicaid expansions have rekindled the debate around private insurance "crowd-out". Prior research is limited by short-time horizons and state-specific analyses. Our study overcomes these limitations by evaluating twenty years of Medicaid expansions across the entire United States. We obtain data from the U.S. Census Bureau for all U.S. states and D.C. for private insurance coverage rates of adults 18-64, for years 1999-2019. After estimating a naïve, staggered Two-Way Fixed Effects Difference-in-Differences regression model, we implement four novel econometric methods to diagnose and overcome threats of bias from staggered designs. We also test for pre-treatment differential trends and heterogenous effects over time. Our findings suggest that Medicaid expansion was associated with a 1.5%-point decline in private insurance rates (p < 0.001). We also observe significant heterogeneity over time, with estimates peaking four years after expansion. The importance of a 1-2%-point crowd-out, we leave for future research and debate.

Can Medicaid be a Solution to the Problem? Underinsurance in Medicaid Expansion Versus Non-Expansion States

The positive effects of Medicaid expansions have been extensively documented in the literature. However, it is not clear whether the reform has had an equally meaningful effect with respect to underinsurance, which is the state of having health insurance yet lacking adequate coverage or facing substantial financial risks upon usage of services. Based on a quasi-experimental difference-in-differences approach, we analyzed the data from a nationally representative sample to estimate the effect of Medicaid expansion on the probability of underinsurance among the non-elderly low-income adult population of the U.S. We found no evidence of significant changes in the likelihood of underinsurance due to Medicaid expansion during the first 4 years after the ACA implementation. However, a supplementary analysis of the longer-term impact (2018-2019) suggests that there might be a time lag between Medicaid expansion and its effect on underinsurance. It is important to realize that expansion of coverage alone may not be sufficient to protect millions of Americans, particularly those with low incomes, from underinsurance. It is, therefore, crucial for policymakers to build legislative frameworks that protect individuals from excessive healthcare expenses and prevent treatment avoidance or delay.