Papers Containing Tag(s): 'Affordable Care Act'
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Viewing papers 1 through 10 of 13
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Working PaperRegional Trends in Hospitals in the United States
August 2026
Working Paper Number:
CES-26-51
Regional disparities in healthcare access and health outcomes are well-documented in the United States. Rural localities face worse health outcomes and greater challenges to accessing care than urban localities, particularly in the South. This study examines national and regional trends in hospital establishments (openings and closings), employment, size (employees per establishment), and regional concentration over three decades. We document an era of declining hospital counts and increasing employment within the industry, highlighting how the trends have differed across regions and rurality. Finally, we consider how these trends relate to the current policy environment in the United States.View Full Paper PDF
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Working PaperThe Impact of Expanding Public Health Insurance on Safety Net Program Participation: Evidence From the ACA Medicaid Expansion
May 2026
Working Paper Number:
CES-26-32
We examine spillover effects from the ACA Medicaid expansion to public programs providing cash and food assistance. We consider program participation in contiguous county pairs crossing state borders, where one state took up the Medicaid expansion and the other did not, allowing us to better control for local economic trends that could affect program participation. We find that the Medicaid expansion increased participation in food assistance and one of the cash programs, with impacts mainly due to participation conditional on eligibility, rather than from labor supply responses. Our results demonstrate the potential for spillovers across safety net programs.View Full Paper PDF
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Working PaperGeographic Disparities in Alzheimer's Disease and Related Dementia Mortality in the US: Comparing Impacts of Place of Birth and Place of Residence
January 2025
Working Paper Number:
CES-25-11
Objective: Building on the hypothesis that early-life exposures might influence the onset of Alzheimer's Disease and Related Dementia (ADRD), this study delves into geographic variations in ADRD mortality in the US. By considering both state of residence and state of birth, we aim to discern the comparative significance of these geospatial factors. Methods: We conducted a secondary data analysis of the National Longitudinal Mortality Study (NLMS), that has 3.5 million records from 1973-2011 and over 0.5 million deaths. We focused on individuals born in or before 1930, tracked in NLMS cohorts from 1979-2000. Employing multi-level logistic regression, with individuals nested within states of residence and/or states of birth, we assessed the role of geographical factors in ADRD mortality variation. Results: We found that both state of birth and state of residence account for a modest portion of ADRD mortality variation. Specifically, state of residence explains 1.19% of the total variation in ADRD mortality, whereas state of birth explains only 0.6%. When combined, both state of residence and state of birth account for only 1.05% of the variation, suggesting state of residence could matter more in ADRD mortality outcomes. Conclusion: Findings of this study suggest that state of residence explains more variation in ADRD mortality than state of birth. These results indicate that factors in later life may present more impactful intervention points for curbing ADRD mortality. While early-life environmental exposures remain relevant, their role as primary determinants of ADRD in later life appears to be less pronounced in this study.View Full Paper PDF
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Working PaperHow Do Health Insurance Costs Affect Firm Labor Composition and Technology Investment?
September 2023
Working Paper Number:
CES-23-47
Employer-sponsored health insurance is a significant component of labor costs. We examine the causal effect of health insurance premiums on firms' employment, both in terms of quantity and composition, and their technology investment decisions. To address endogeneity concerns, we instrument for insurance premiums using idiosyncratic variation in insurers' recent losses, which is plausibly exogenous to their customers who are employers. Using Census microdata, we show that following an increase in premiums, firms reduce employment. Relative to higher-income coworkers, lower-income workers see a larger increase in their likelihood of being separated from their jobs and becoming unemployed. Firms also invest more in information technology, potentially to substitute labor.View Full Paper PDF
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Working PaperWho Values Human Capitalists' Human Capital? Healthcare Spending and Physician Earnings
July 2020
Working Paper Number:
CES-20-23
Is government guiding the invisible hand at the top of the labor market? We study this question among physicians, the most common occupation among the top one percent of income earners, and whose billings comprise one-fifth of healthcare spending. We use a novel linkage of population-wide tax records with the administrative registry of all physicians in the U.S. to study the characteristics of these high earnings, and the influence of government payments in particular. We find a major role for government on the margin, with half of direct changes to government reimbursement rates flowing directly into physicians' incomes. These policies move physicians' relative and absolute incomes more than any reasonable changes to marginal tax rates. At the same time, the overall level of physician earnings can largely be explained by labor market fundamentals of long work and training hours. Competing occupations also pay well and provide a natural lower bound for physician earnings. We conclude that government plays a major role in determining the value of physicians' human capital, but it is unrealistic to use this power to reduce healthcare spending substantially.View Full Paper PDF
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Working PaperLabor Market Effects of the Affordable Care Act: Evidence from a Tax Notch
July 2017
Working Paper Number:
carra-2017-07
States that declined to raise their Medicaid income eligibility cutoffs to 138 percent of the federal poverty level (FPL) under the Affordable Care Act (ACA) created a "coverage gap'' between their existing, often much lower Medicaid eligibility cutoffs and the FPL, the lowest level of income at which the ACA provides refundable, advanceable "premium tax credits'' to subsidize the purchase of private insurance. Lacking access to any form of subsidized health insurance, residents of those states with income in that range face a strong incentive, in the form of a large, discrete increase in post-tax income (i.e. an upward notch) at the FPL, to increase their earnings and obtain the premium tax credit. We investigate the extent to which they respond to that incentive. Using the universe of tax returns, we document excess mass, or bunching, in the income distribution surrounding this notch. Consistent with Saez (2010), we find that bunching occurs only among filers with self-employment income. Specifically, filers without children and married filers with three or fewer children exhibit significant bunching. Analysis of tax data linked to labor supply measures from the American Community Survey, however, suggests that this bunching likely reflects a change in reported income rather than a change in true labor supply. We find no evidence that wage and salary workers adjust their labor supply in response to increased availability of directly purchased health insurance.View Full Paper PDF
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Working PaperPlanning Parenthood: The Affordable Care Act Young Adult Provision and Pathways to Fertility
January 2017
Working Paper Number:
CES-17-65
This paper investigates the effect of the Affordable Care Act young adult provision on fertility and related outcomes. The expected effect of the provision on fertility is not clear ex ante. By expanding insurance coverage to young adults, the provision may affect fertility directly through expanded options for obtaining contraceptives as well as through expanded options for obtaining pregnancy-, birth-, and infant-related care, and these may lead to decreased or increased fertility, respectively. In addition, the provision may also affect fertility indirectly through marriage or labor markets, and the direction and magnitude of these effects is difficult to determine. This paper considers the effect of the provision on fertility as well as the contributing channels by applying difference-in-differences-type methods using the 2008-2010 and 2012-2013 American Community Survey, 2006-2009 and 2012-2013 Centers for Disease Control and Prevention abortion surveillance data, and 2006-2010 and 2011-2013 National Survey of Family Growth. Results suggest that the provision is associated with decreases in the likelihood of having given birth and abortion rates and an increase in the likelihood of using long-term hormonal contraceptives.View Full Paper PDF
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Working PaperConsidering the Use of Stock and Flow Outcomes in Empirical Analyses: An Examination of Marriage Data
January 2017
Working Paper Number:
CES-17-64
This paper fills an important void assessing how the use of stock outcomes as compared to flow outcomes may yield disparate results in empirical analyses, despite often being used interchangeably. We compare analyses using a stock outcome, marital status, to those using a flow outcome, entry into marriage, from the same dataset, the American Community Survey. This paper considers two different questions and econometric approaches using these alternative measures: the effect of the Affordable Care Act young adult provision on marriage using a difference-indifferences approach and the relationship between aggregate unemployment rates and marriage rates using a simpler ordinary least squares regression approach. Results from both analyses show stock and flow data yield divergent results in terms of sign and significance. Additional analyses suggest prior-period temporary shocks and migration may contribute to this discrepancy. These results suggest using caution when conducting analyses using stock data as they may produce false negative results or spurious false positive results, which could in turn give rise to misleading policy implications.View Full Paper PDF
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Working PaperEstimating the Costs of Covering Dependents through Employer-Sponsored Plans
January 2017
Working Paper Number:
CES-17-48
Several health reform microsimulation models use synthetic firms to estimate how changes in federal and state policies will affect employers' offers of health insurance, as well as the price of health insurance for workers and firms. These models typically rely on distinct measures of the average costs of single and dependent coverage, for employees and employers, which do not capture the joint distribution of these costs. Since some firms pay a large share of the premium for single polices but a lower share for dependent coverage, or the reverse, simulation models that do not account for the joint distribution of premium costs may not be sufficient to answer certain policy questions. To address this issue, we developed a method to extract estimates of the joint distribution of employer and employee costs of health insurance coverage from the Medical Expenditure Panel Survey ' Insurance Component (MEPS-IC). This paper describes how these distributions were constructed and how they were incorporated into the Urban Institute's Health Insurance Policy Simulation Model (HIPSM). The estimates presented in this paper and those available in supplementary datasets may be useful for other simulation models that need to utilize information on the joint distribution of single and dependent employee premium contributions.View Full Paper PDF
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Working PaperEvaluating Race and Hispanic Origin Responses of Medicaid Participants Using Census Data
April 2015
Working Paper Number:
carra-2015-01
Health and health care disparities associated with race or Hispanic origin are complex and continue to challenge researchers and policy makers. With the intention of improving the measurement and monitoring of these disparities, provisions of the Patient Protection and Affordable Care Act (ACA) of 2010 require states to collect, report and analyze data on demographic characteristics of applicants and participants in Medicaid and other federally supported programs. By linking Medicaid records to 2010 Census, American Community Survey, and Census 2000, this new large-scale study examines and documents the extent to which pre-ACA Medicaid administrative records match self-reported race and Hispanic origin in Census data. Linked records allow comparisons between individuals with matching and non-matching race and Hispanic origin data across several demographic, socioeconomic and neighborhood characteristics, such as age, gender, language proficiency, education and Census tract variables. Identification of the groups most likely to have non-matching and missing race and Hispanic origin data in Medicaid relative to Census data can inform strategies to improve the quality of demographic data collected from Medicaid populations.View Full Paper PDF
