Enactment of the Patient Protection and Affordable Care Act (ACA) in 2010 marked the most important accomplishment in U.S. health care reform in decades. Not since Medicare and Medicaid were passed in 1965 have so many Americans been given access to insurance coverage for their health care. Though the goal of universal health care was not achieved, ACA brought coverage to millions of uninsured Americans and provided assurance to the already-insured that if they lost their insurance through job loss or job change, they could turn to an expanded Medicaid program or a government-subsidized insurance policy for affordable coverage.
But while ACA has had a major impact on the U.S. health care system, its promise has been limited by its design. Rather than replacing the U.S. system with a more effective, less costly, and politically sustainable model, lawmakers decided to build on top of an inefficient, expensive, and politically insecure, existing model. A health care system that rested on a shaky foundation now has to carry more weight and that makes for an unstable future. Indeed, we are already starting to see some unraveling of ACA. For ACA to achieve its goals in a durable fashion, it should be replaced by a health care program that provides the same kind of health care coverage for all Americans rather than relying on a system that mixes employer-based insurance with individually-purchased private insurance and government-provided coverage.
Is the opioid epidemic attributable to prescription painkillers being more accessible or to opioid substitutes being less accessible ? I find that the state-level decision to increase access to prescription painkillers by expanding Medicaid under the Affordable Care Act increased both opioid prescriptions and in opioid-related deaths. These results vary strongly by demography, being driven largely by deaths of white men without college degrees. A back of the envelope calculation suggests that, for an average county, Medicaid expansion caused approximately 2,800 more people to be insured per year, 175,000 more opioid units to be prescribed per year, and 4 additional opioid-related deaths per year. Overall, opioid accessibility shocks explain about 12,000 opioid deaths per year, or nearly a third of the overall death toll. I also find that the state-level decision to legalize recreational Marijuana (a substitute painkiller) reduced opioid- related deaths. Overall, these opioid-substitute accessibility shocks also explain about 12,000 opioid deaths per year. I conclude that policy-makers can achieve reductions in opioid mortality without restricting access to opioids.
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.