This paper examines the impacts of the Affordable Care Act (ACA) – which substantially increased insurance coverage through regulations, mandates, subsidies, and Medicaid expansions – on behaviors related to future health risks after three years. Using data from the Behavioral Risk Factor Surveillance System and an identification strategy that leverages variation in pre-ACA uninsured rates and state Medicaid expansion decisions, we show that the ACA increased preventive care utilization along several dimensions, but also increased risky drinking. These results are driven by the private portions of the law, as opposed to the Medicaid expansion. We also conduct subsample analyses by income and age.
Given the $3 trillion spent on health care in 2015 and the political contention surrounding insurance expansions, the impact of health insurance on health behaviors, medical utilization, and health outcomes continues to be of the upmost importance. How insurance influences investment in good health and risky behavior (ex ante moral hazard) has received much less attention than the effect of insurance on the out-of-pocket cost of care (ex post moral hazard). Since many risky health behaviors take decades to result in illness, these behaviors likely respond to expectations about future insurance but could be unaffected by current insurance status. I examine the effect of moral hazard in the context of risky sex, a health behavior that results in quick and economically meaningful consequences – fertility and sexually transmitted infections. I isolate the effect of ex ante moral hazard by exploiting a policy in the Affordable Care Act, the 2012 zero cost-sharing for prescription contraception mandate. Leveraging pre-policy insured rates as a measure of policy intensity, I use dose-response event studies that estimate both a time-varying treatment effect as well as a one-time jump in outcomes in the treatment year. I find evidence ex ante moral hazard from health insurance decreases prevention and increases STIs. I then exploit the 2010 dependent coverage mandate to determine the overall effect of health insurance. Based on this policy I find that the protective effect of insurance on STIs more than compensates for the reduction in prevention.
A study by the Fraser Institute titled The Effect of Wait Times on Mortality in Canada estimated that “increases in wait times for medically necessary care in Canada between 1993 and 2009 may have resulted in between 25,456 and 63,090 (with a middle value of 44,273) additional deaths among females.” Adjusting for the difference in populations (the US has about 9 times as many people), that middle value inflates to an estimated 400,000 additional deaths among females over a 16 year period. This translates to an estimated 25,000 additional female deaths each year if the American system were to suffer from increased mortality similar to that experienced in Canada due to increases in wait times.
Question Have patients with different types of health insurance benefitted equally from recent improvements in cancer survival?
Findings In this large population-based study, improvements in survival between January 1997 and December 2014 were limited to patients with private or Medicare insurance. Survival disparities for uninsured or other publicly insured patients with prostate, lung, or colorectal cancer increased significantly over time.
Meaning To mitigate these growing disparities, patients with cancer need access to health insurance that covers all the necessary elements of health care, from prevention and early detection to timely treatment according to clinical guidelines.
Recent research shows increasing inequality in mortality among middle‐aged and older adults. But this is only part of the story. Inequality in mortality among young people has fallen dramatically in the United States converging to almost Canadian rates. Increases in public health insurance for U.S. children, beginning in the late 1980s, are likely to have contributed.
Following introduction of the ACA guidelines, readmissions did go down, but mortality went up, according to a study published in November in JAMA Cardiology. “It’s possible that doctors may have made treatment decisions designed to avoid readmissions rather than to give patients the best possible care,” said UCLA’s Gregg Fonarow, the study’s senior author.
Featuring Bernard S. Black, Nicholas J. Chabraja Professor, Northwestern University, Pritzker School of Law; Megan McArdle, Columnist, Bloomberg View; Benjamin Sommers, Associate Professor of Health Policy and Economics, Harvard H.T. Chan School of Public Health; moderated by Michael F. Cannon, Director of Health Policy Studies, Cato Institute.
A key question in debates over whether states should implement Obamacare’s Medicaid expansion, and whether Congress should repeal Obamacare entirely, is whether government expansions of health insurance coverage improve health, and if so, how much. A new study by Bernard Black and colleagues finds that the uninsured “consume fewer healthcare services, but their health (while alive) does not deteriorate relative to the insured, and, in our central estimates, they do not die significantly faster than the insured.” Come hear Professor Black and leading scholars discuss one of the most important but least understood aspects of health reform.
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