The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions

Abstract

The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA-facilitated state-level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference-in-differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self-assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low-income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self-assessed health.

Early Effects of the Affordable Care Act on Health Care Access, Risky Health Behaviors, and Self-Assessed Health

“…11 Broadly speaking, our finding that the Medicaid expansion increased access along some but not all dimensions is consistent with the results from the DD studies by Sommers et al (2015) and Simon et al (2017).…”

“…Our small and insignificant estimates contrast the large, early improvements in these same self-assessed health outcomes seen after the Massachusetts health care reform (Courtemanche and Zapata, 2014;Van der Wees et al, 2013) and randomized Oregon Medicaid experiment (Finkelstein et al, 2012). However, our null results for the Medicaid expansion are consistent with the lack of clear improvements in self-assessed health found by the DD studies in the ACA Medicaid expansion literature Abramowitz, 2016;Simon et al, 2017).…”

“…However, since the magnitude of the estimated effect on checkups is meaningfully large despite its statistical insignificance, we are reluctant to strongly push this explanation. 12 The only noteworthy differences for specific access outcomes are that we find evidence of an effect on cost being a barrier to care but not having a primary care doctor, whereas the reverse is true for Sommers et al (2015) and Simon et al (2017). In our view, the difference in results for cost being a barrier to care is not a major discrepancy, as Sommers et al (2015) and Simon et al (2017) find the same signs and magnitudes that are only slightly smaller than ours -their estimates just do not quite reach statistical significance.…”

The Affordable Care Act and Ambulance Response Times

“…In the United States alone, these interventions include Medicaid (Currie and Gruber, 1996a;Dafny and Gruber, 2005;Baicker et al, 2013;Finkelstein et al, 2012;Taubman et al, 2014;Tello-Trillo, 2016), Medicare (Lichtenberg, 2002;Card et al, 2008), the Massachusetts universal coverage initiative (Miller, 2012a;Kolstad and Kowalski, 2012;Van der Wees et al, 2013), the 2010 expansion of coverage to young adults under the ACA (Sommers et al, 2013;Antwi et al, 2015;Barbaresco et al, 2015) and the various ACA provisions that took effect in 2014 Courtemanche et al, 2017b;Simon et al, 2017;Miller and Wherry 2017). …”

“…The private insurance portion of the ACA seems to have improved access to care, but the evidence with regard to its effect on self-assessed health is decidedly mixed Courtemanche et al, 2017b). Several studies have found that the Medicaid expansion under the ACA led to modest access gains for patients, but had no discernable effect on self-assessed health Courtemanche et al, 2017b;Simon et al, 2017).…”