How Did the ACA Affect Health Insurance Coverage in Kentucky?

The major components of the Affordable Care Act (ACA) were implemented in 2014, including the rollout of the Health Insurance Marketplace, Medicaid expansions, and the individual mandate. Kentucky stands out as one of the few southern states to expand Medicaid, and earlier work has demonstrated that Kentucky experienced some of the largest gains in health insurance coverage. The goal of the current study is to further explore the sources that individuals used to gain coverage in Kentucky using a large, publicly available dataset, the American Community Survey (ACS). Several findings emerge. First, overall health insurance coverage increased by 5.7 percentage points, from 85.1 percent to 90.8 percent, from 2013 to 2014. Roughly 269,000 individuals in Kentucky gained coverage, the overwhelming majority (85%) of whom were adults aged 19–64 (229,000 individuals). Gains were extremely modest for both children and the elderly. Among adults, roughly 80 percent of the gains were from Medicaid coverage, with most of the rest coming from individual coverage. Using income reported by the ACS respondents, approximately 38 percent of new adult Medicaid recipients had incomes exceeding the Medicaid eligibility threshold (roughly $33,000 for a family of four). This translates into 73,000 ineligible, new Medicaid participants. Almost all ineligible, new participants would appear to qualify for private, nongroup coverage with subsidies through the premium tax credit. A variety of sensitivity checks suggest at least 36,000 ineligible, new participants on Medicaid due to the expansions, including more than 13,000 with incomes exceeding 250 percent of the FPL. Possible explanations are explored and ineligible participants are characterized

Health Insurance and Less Skilled Workers

We begin this research with the belief that low and declining levels of private-employer sponsored health insurance were a continuing problem, especially among less skilled workers. Our analysis, however, paints a more complex picture. Using data from the March CPS, the SIP, and CPS benefits surveys, we find that while many less skilled workers remain uncovered, the decline in private employer-sponsored health insurance coverage has slowed recently and may even have reversed. Neither crowdout nor a deterioration in the quality of jobs available to the less skilled seems likely to fully explain these time-series trends in health insurance coverage. A simple explanation that has been largely overlooked is that rising health care costs have driven much of the reduction in private insurance coverage, but it is more difficult to test this hypothesis given the available data.

Public Health Insurance and Private Savings

Recent theoretical work suggests that means and asset-tested social insurance programs can explain the low savings of lower income households in the U.S. We assess the validity of this hypothesis by investigating the effect of Medicaid, the health insurance program for low income women and children, on savings behavior. We do so using data on asset holdings from the Survey of Income and Program Participation, and on consumption from the Consumer Expenditure Survey, matched to information on the eligibility of each household for Medicaid. Exogenous variation in Medicaid eligibility is provided by the dramatic expansion of this program over the 1984-1993 period. We document that Medicaid eligibility has a sizeable and significant negative effect on wealth holdings; we estimate that in 1993 the Medicaid program lowered wealth holdings by 17.7% among the eligible population. We confirm this finding by showing a strong positive association between Medicaid eligibility and consumption expenditures; in 1993, the program raised consumption expenditures among eligibles by 5.2%. We also exploit the fact that asset testing was phased out by the Medicaid program over this period to document that these Medicaid effects are much stronger in the presence of an asset test, confirming the importance of asset testing for household savings decisions.

Competition and market structure in local real estate markets

The persistence of the standard six percent real estate sales commission across markets and over time calls into question the competitiveness of the residential real estate brokerage industry. While there is anecdotal evidence that some local real estate markets are fairly concentrated, no systematic study of market structures has been conducted. We have collected primary data on the number and market shares of real estate brokers in a variety of small, medium, and large real estate markets across the U.S. for 2007 and 2009. In addition to these cross sectional data, we have also collected longitudinal data on the size distribution of firms for Louisville, KY for a nine-year period. In our cross-sectional analysis of medium and large markets, we find no evidence that market concentration might create problems for competition. We do find that small markets on average have higher HHI’s than medium and large markets. The longitudinal analysis reveals that many small brokers are in and out of the market, selling a house or two one year and selling zero houses the next year.HHI; real estate brokerage competition; Herfindahl-Hirschman Index

Health Insurance Generosity and Conditional Coverage: Evidence from Medicaid and Managed Care in Kentucky

This paper estimates the impact of the introduction of Medicaid managed care (MMC) on the formal Medicaid participation of children. We employ a quasi-experimental approach exploiting the location-specific timing of MMC implementation in Kentucky. Using data from the March Current Population Survey from 1995-2003, our findings suggest that the introduction of MMC increases the likelihood of being uninsured and decreases formal Medicaid participation. This finding is consistent with an increase in “conditional coverage” – waiting until medical care is needed to sign up or re-enroll in Medicaid. These effects are concentrated among low-income children and absent for high-income children. We find no evidence of “crowd-in” – substituting private coverage for Medicaid. These results are robust to multiple placebo tests and imply the potential for less formal participation (i.e. more conditional coverage) among the ACA Medicaid expansion population (which is likely to be primarily covered under MMC) than is typically predicted

How Does Occupational Licensing Affect Entry into the Medical Field? An Examination of EMTs

The COVID-19 pandemic has led to temporary suspensions of many occupational licensing laws, especially for health care professionals, in an effort to manage surges in health care demand. The crisis highlights more general concerns about occupational licensing laws, yet convincing empirical evidence on the degree to which such laws have inhibited entry into health care professions is scarce because most studies must rely on cross-sectional variation to identify such effects. In this study, we indirectly examine how occupational licensing affects the choice to become an Emergency Medical Technician (EMT) by exploiting the demand-side shock from the Affordable Care Act (ACA). Although demand-side shocks should increase the likelihood of becoming an EMT relative to other similar non-medical professions, this effect should be moderated in states with higher barriers to entry. Using a large number of individuals from the American Community Survey (ACS) who work as either EMTs or in a similar non-medical field (protective services), we find suggestive evidence that while the demand-side shock from the ACA increased the likelihood of being an EMT, this effect was substantially moderated by more stringent occupational licensing laws. Although the effect for the full sample is marginally significant, the estimated effects are substantially larger for individuals under age 40, who are presumably more flexible in choosing a career path. Evaluated at the average number of days to complete EMT training and the pre-treatment uninsured rate, the implied effects for young individuals in the most careful specification suggests virtually complete offset; the ACA demand-side shock would increase entry by 18 percentage points, while occupational licensing restrictions reduce entry by a similar magnitude

Anticipated Property Tax Increases and the Timing of Home Sales: Evidence from Administrative Data

Restrictions imposed on property assessment practices by state legislation such as Proposition 13 in California and Proposition 2½ in Massachusetts can lead to significant divergences between the assessed and market values of property, particularly for households with long tenures. As properties are assessed at their market value when sold, this can lead to a significant divergence in the property tax payment for a current homeowner and a prospective purchaser of the property. This may lead to “lock-in”, decreased mobility, of homeowners reluctant to lose their tax advantage. Here using data on single family dwellings in Lexington, KY (Fayette County) we examine another practice leading to a systematic difference between assessed and market value of properties, the practice of assessing properties in individual neighborhoods on a four-year basis. In times of high housing appreciation, the difference in tax payments for houses last assessed two or three years earlier and their market values, the tax base for a new purchaser, can be significant and lead to a lock-in effect. Using administrative data from the Fayette County PVA we find evidence that housing sales are higher in the year before a neighborhood assessment suggesting that households adjust their mobility to capture the tax advantage associated with limited assessment

Targeting Intensive Job Assistance to Ex-Offenders by the Nature of Offense: Results from a Randomized Control Trial

As many as two-thirds of newly-released inmates will be arrested for a new offense within three years. This study evaluates the impact of job assistance on recidivism rates among ex-offenders. The job assistance program, run though the private company America Works, uses a network of employers to place clients. Ex-offenders were randomly assigned to intensive job assistance (treatment group) or the standard program (control group). The intensive program is meant to improve average work readiness for ex-offenders. It reduces the likelihood of subsequent arrest among non-violent ex-offenders, but has little effect on violent ex-offenders. The re-arrest rate for non-violent ex-offenders in the treatment group was 19 percentage points lower than those in the control group. The re-arrest rate for violent ex-offenders in the treatment group was indistinguishable from those in the control group. We estimate benefits from intensive job assistance from averted crimes and find that they outweigh the $5,000 up-front cost for non-violent ex-offenders