Using Discontinuous Eligibility Rules to Identify the Effects of the Federal Medicaid Expansions on Low Income Children

Despite intensive scrutiny, the effects of Medicaid expansions on the health insurance status of low-income children remain controversial. We re-examine the effects of the two largest federally-mandated expansions which offered Medicaid coverage to low-income children in specific age ranges and birth cohorts. We use a regression discontinuity approach, comparing Medicaid enrollment, private insurance coverage, and overall insurance coverage on either side of the age limits of the laws. We conclude that the modest impacts of the expansions on health insurance coverage arose because of very low takeup rates of the newly available coverage, rather than from crowd-out of private insurance coverage.

Using Discontinuous Eligibility Rules to Identify the Effects of the Federal Medicaid Expansions on Low Income Children

This paper exploits the discrete nature of the eligibility criteria for two major federal expansions of Medicaid to measure the effects on Medicaid coverage, overall health insurance coverage, and the probability of visiting a doctor. The '100 percent' expansion, effective in 1991, extended Medicaid eligibility to children born after September 30, 1983 in families below the poverty line. We estimate that this law led to about a 10 percentage point rise in Medicaid coverage for children born just after the cutoff date, and a similar or slightly smaller rise in overall health insurance. It also increased the fraction of children in the newly eligible group with a doctor visit in the previous year. The '133 percent' expansion, effective in 1990, extended Medicaid to children under 6 in families with incomes below 133 percent of the poverty line. This law had relatively small effects on Medicaid coverage for children near the eligibility limits, and little or no effect on health insurance coverage.

The Effect of Medicaid Expansions for Low-Income Children on Medicaid Participation and Private Insurance Coverage : Evidence from the SIPP

We examine Medicaid enrollment and private coverage loss following expansions of Medicaid eligibility. We attempt to replicate Cutler and GruberÂ’s (1996) results using the Survey of Income and Program Participation, and find smaller rates of take-up and little evidence of crowding out. We find that some of the difference in results can be attributed to different samples and recall periods in the data sets used. Extending the previous literature, we find that take-up is slightly increased if a childÂ’s siblings are eligible and with time spent eligible. Focusing on children whose eligibility status changes during the sample, we estimate smaller take-up effects. We find little evidence of crowding out in any of our extensions.

Stemming the Tide? The Effect of Expanding Medicaid Eligibility on Health Insurance

Despite considerable research, there is little consensus about the impact of Medicaid eligibility expansions for low-income children. In this paper, I reexamine the expansions' impact on Medicaid take-up and private insurance "crowd-out." Focusing on the most influential estimates of the expansions' impact, I show that while many of the critiques leveled at these estimates have little effect on their magnitude, accounting for age-specific trends in coverage produces estimates similar to others in the literature. Estimating the impact of later expansions using additional years of data, I find low rates of take-up and no evidence of crowding out.Migration, Educational Attainment, Rural China

Did Expanding Medicaid Affect Welfare Participation?

Using data from the 1988-1996 Current Population Surveys (CPS), we re-examine the evidence presented in Yelowitz (1995) showing that expansions in Medicaid eligibility for children were associated with increased labor force participation and reduced participation in Aid to Families with Dependent Children (AFDC) among single mothers. We find that Yelowitz's results were the result of two factors. First, he imposed a strong restriction on the parameter estimates that is not predicted by theory and is rejected in the CPS data. Second, he used only one of the two income tests that families must pass to be eligible for AFDC, resulting in higher imputed AFDC breakeven income levels for larger families. Once these problems are addressed, the Medicaid income limits have no significant effect on AFDC participation. The AFDC income limits, however, are significantly related to welfare and labor force participation in both his original sample and the entire 1988-1996 sample.

The Effect of Medicaid Expansions for Low-Income Children on Medicaid Participation and Insurance Coverage: Evidence from the SIPP

Increased availability of public health insurance for children has led to two potentially contradictory concerns for public policy: that expanded availability of public insurance may lead families to decline private insurance and that additional public coverage may not reach many uninsured children. We examine these two concerns using data from the 1987-1993 Surveys of Income and Program Participation. Using static models we find that the expansions resulted in increased Medicaid coverage, although the estimates of take-up are smaller than estimates from previous research. We find little evidence of a negative relationship of any significant magnitude between eligibility for Medicaid and private coverage. We also find that children who have been eligible for Medicaid longer are more likely to be enrolled in Medicaid but no more likely to have lost private coverage. Including individual fixed effects reduces the magnitude of the estimated take-up effect, while the fixed effects estimates for the private insurance regression become negative and marginally statistically significant in some specifications. Simple dynamic models of insurance choice show that insurance choice is quite persistent. The estimated long run impact of eligibility in the dynamic models is larger than the estimate from the static models, while the immediate impact of expanded Medicaid eligibility from the dynamic models is smaller than the estimated effect from the static models.

The Impact of Public Health Insurance on Labor Market Transitions

An often-cited difficulty with moving low-income families out of welfare and into the labor force is the lack of health insurance in many low-wage jobs. Consequently, many low-income household heads may be reluctant to leave welfare and thereby lose health insurance coverage for their children. The expansions in the Medicaid program to cover low-income children and pregnant women who are not eligible for cash benefits may help alleviate the problem by allowing disadvantaged household heads to accept jobs which do not provide health insurance. We use a discrete time (monthly) hazard rate model and data from several panels of the Survey of Income and Program Participation to assess whether expansion of public health insurance to cover children of working parents contributes to increase transitions out of welfare and into employment and reduce transitions into welfare and out of employment. We model spells in progress and spells that start during the sample separately, which allows us to assess the effect on long-term welfare recipients. We find some evidence that expanded Medicaid eligibility for children leads single mothers to exit welfare more quickly; however the effects are not robust to the inclusion of year effects. In addition, the effect appears to be strongest and most consistent among long-term recipients (as proxied by recipients who begin the sample on welfare). We find less evidence of an effect of expanded Medicaid eligibility on transitions into welfare. A somewhat surprising finding is that higher AFDC income limits also appear to have little effect on the probability of such transitions.

The Measurement of Medicaid Coverage in the SIPP : Evidence from a Comparison of Matched Records

This paper studies the accuracy of reported Medicaid coverage in the Survey of Income and Program Participation (SIPP) using a unique data set formed by matching SIPP survey responses to administrative records from the State of California. Overall, we estimate that the SIPP underestimates Medicaid coverage in the California population by about 10 percent. The probability that a SIPP respondent who is covered by Medicaid in a given month correctly reports their coverage is around 85 percent. The corresponding probability for low-income children is higher – around 90 percent. Under-reporting by those who are actually in the Medicaid system is partially offset by over-reporting of coverage by people who are not. Some of these false positive responses are attributable to errors and missing data in the administrative system, rather than to problems in the SIPP. Taking account of these errors, the estimated false positive rate for the population as a whole is about 1.5 percent, and 4-5 percent for poor children.

The Measurement of Medicaid Coverage in the SIPP: Evidence from California, 1990-1996

This paper studies the accuracy of reported Medicaid coverage in the Survey of Income and Program Participation (SIPP) using a unique data set formed by matching SIPP survey responses to administrative records from the State of California. Overall, we estimate that the SIPP underestimates Medicaid coverage in the California population by about 10 percent. Among SIPP respondents who can be matched to administrative records, we estimate that the probability someone reports Medicaid coverage in a month when they are actually covered is around 85 percent. The corresponding probability for low-income children is even higher - at least 90 percent. These estimates suggest that the SIPP provides reasonably accurate coverage reports for those who are actually in the Medicaid system. On the other hand, our estimate of the false positive rate (the rate of reported coverage for those who are not covered in the administrative records) is relatively high: 2.5 percent for the sample as a whole, and up to 20 percent for poor children. Some of this is due to errors in the recording of Social Security numbers in the administrative system, rather than to problems in the SIPP.

The Impact of the ACA Medicaid Expansion on Disability Program Applications

The Affordable Care Act (ACA) expanded the availability of public health insurance, decreasing the relative benefit of participating in disability programs but also lowering the cost of exiting the labor market to apply for disability benefits. In this paper, we explore the impact of expanded access to Medicaid through the ACA on applications to the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs. Using the fact that the Supreme Court decision of June 2012 made the Medicaid expansion optional for the states, we compare changes in county-level SSI and SSDI caseloads in contiguous county pairs across a state border. We find no significant effects of the Medicaid expansion on applications or awards to either SSI or SSDI, and can reject economically meaningful impacts of Medicaid expansions on applications to disability programs