TAXPAYER WILLINGNESS TO PAY FOR HEALTH INSURANCE REFORM: A CONTINGENT VALUATION ANALYSIS

A key criterion for evaluating policies to expand health insurance coverage is weighing the costs of such policies against the willingness of the public to pay for coverage expansions. We use new panel survey data from New York State to estimate residents' willingness to pay (WTP) to expand public insurance coverage. Using a nonparametric double‐bounded contingent valuation (CV) approach, we specifically ask residents about their WTP to reduce the rate of uninsurance in the state. Our results imply an aggregate lower‐bound WTP of over $2,800 per year to cover one person. We also analyze heterogeneity in WTP by sub‐group and changes in individual WTP over time between 2008 and 2010. We find that a large majority of residents are willing to pay additional taxes to reduce the number of uninsured in the state, and that average WTP remained remarkably stable despite the economic downturn and the politically polarized discussions surrounding the Affordable Care Act. Decomposing the changes in individual WTP, we find that economic factors related to the recession, including changes in income and employment status, cannot explain changes in individual WTP, whereas individual changes in political opinions about health insurance reform between 2008 and 2010 are strongly correlated with changes in WTP. (JEL H20, H42, H51, H75, I13)     

THE AFFORDABLE CARE ACT AND COLLEGE ENROLLMENT DECISIONS

We investigate the effect of the expansion of the federal dependent coverage mandate for young adults under the Affordable Care Act (ACA) on college enrollment decisions of young Americans. The expansion removes the requirement that young individuals need to be enrolled as full‐time students in order to remain on their parents' health insurance past the age of 18 and expands the coverage mandate to age 26 irrespective of student status. This changes the incentives for the full‐time college enrollment decisions of young individuals. We use panel data from the Survey of Income and Program Participation (SIPP) for the years 2003–2013 and estimate that the dependent coverage expansion under the ACA decreases the probability to enroll as full‐time student by 3 percentage points using a difference‐in‐differences framework. Furthermore, we find that part‐time college enrollment is unaffected by the new policy. The results are robust to changes in the model specification and become stronger when we increase the sample overlap between treatment and control groups using trimming based on propensity scores. (JEL C35, I23, I10, I18)     

ENHANCED CITIZENSHIP VERIFICATION AND CHILDREN'S MEDICAID COVERAGE

This article examines a potential unintended consequence of the mandated Medicaid citizenship verification requirements of the 2005 Deficit Reduction Act (DRA). We investigate whether or not these new rules led to an increase in the Medicaid exit rate among enrollees using state administrative data from Georgia. We do this by comparing the exit rate for children enrolled in Medicaid whose first coverage recertification occurs just after implementation of the DRA (which we refer to as a “high impact” first recertification) with those whose first recertification occurs just prior (which we refer to as a “low impact” first recertification). Our analysis suggests that children in the high‐impact first recertification group were about 2 percentage points more likely to exit Medicaid than those in the low‐impact group. Furthermore, these additional exits occurred in racial and ethnic groups more likely to be citizens than noncitizens and prereform estimates suggest that there were very few (roughly 0.10%) noncitizen Medicaid enrollees to begin with. Taken together, our results suggest that the DRA‐enhanced citizenship verification rules led to an increase in Medicaid disenrollment, and thus a reduction in coverage, among citizens. (JEL I18, I38, J13)     

TO “VAPE” OR SMOKE? EXPERIMENTAL EVIDENCE ON ADULT SMOKERS

A growing share of the U.S. population uses e‐cigarettes but the optimal regulation of these controversial products remains an open question. We conduct a discrete choice experiment to investigate how adult tobacco cigarette smokers' demand for e‐cigarettes and tobacco cigarettes varies by four attributes: (1) whether e‐cigarettes are considered healthier than tobacco cigarettes, (2) the effectiveness of e‐cigarettes as a cessation device, (3) bans on use in public places, and (4) price. We find that adult smokers' demand for e‐cigarettes is motivated more by health concerns than by the desire to avoid smoking bans or higher prices. (JEL C35, I12, I18)     

GOVERNMENT DEBT‐THRESHOLD CONTRACTS

Politicians tend to push the amount of public debt beyond socially desirable levels in order to increase their reelection chances. We develop a model that provides a new explanation for this behavior: office holders undertake debt‐financed public projects, but postpone the timing of part of the output to the next term. This makes it difficult to replace them. As a consequence, the office holders' reelection chances rise—as does public debt. As a potential remedy for this inefficiency, we allow candidates for public office to offer government debt‐threshold contracts. Such a contract contains an upper limit for government debt and the sanction that an office holder violating this limit cannot stand for reelection. We show that such competitively offered contracts contain low debt levels that limit debt financing and improve the citizens' welfare. When negative macroeconomic events occur, government debt‐threshold contracts may be violated, and the economy is stabilized. (JEL: D7, D82, H4)     

INTERGENERATIONAL EFFECTS OF WELFARE REFORM: ADOLESCENT DELINQUENT AND RISKY BEHAVIORS

This study investigates effects of welfare reform in the United States on the next generation. Most previous studies of effects of welfare reform on adolescents focused on high‐school dropout of girls or fertility; little is known about how welfare reform has affected other teenage behaviors or boys. We use a difference‐in‐difference‐in‐differences framework to identify gender‐specific effects of welfare reform on skipping school, fighting, damaging property, stealing, hurting others, smoking, alcohol, marijuana, and other illicit drugs. Welfare reform led to increases in delinquent behaviors of boys as well as increases in substance use of boys and girls, with substantially larger effects for boys. (JEL K42, I12, I31, I38)     

Sources of health insurance and characteristics of the uninsured: analysis of the March 2000 Current Population Survey

This Issue Brief provides summary data on the insured and uninsured populations in the nation and in each state. It discusses the characteristics most closely related to an individual's health insurance status. Based on EBRI estimates from the March 2000 Current Population Survey (CPS), it represents 1999 data--the most recent available. In 1999, for the first time since at least 1987, the percentage of Americans with health insurance increased: 82.5 percent of nonelderly Americans (under age 65) were covered by some form of health insurance, up from 81.6 percent in 1998. The percentage of nonelderly Americans without health insurance coverage declined from 18.4 percent in 1998 to 17.5 percent in 1999. The main reason for the decline in the number of uninsured Americans is the strong economy and low unemployment. Between 1998 and 1999, the percentage of nonelderly Americans covered by employment-based health insurance increased from 64.9 percent to 65.8 percent, continuing a longer-term trend that started between 1993 and 1994. In 1999, 34.1 million Americans received health insurance from public programs, and an additional 15.8 million purchased it directly from an insurer. Twenty-five million Americans participated in the Medicaid program, and 6.5 million received their health insurance through the Tricare and CHAMPVA programs and other government programs designed to provide coverage for retired military members and their families. Despite expansions in the State Children's Health Insurance Program (S-CHIP), public health insurance coverage did not increase overall between 1998 and 1999. The percentage of nonelderly Americans covered by Medicaid and other government-sponsored health insurance coverage did not change between 1998 and 1999, though some children benefited from expansions in government-funded programs. The percentage of children in families just above the poverty level without health insurance coverage declined dramatically, from 27.2 percent uninsured in 1998 to 19.7 percent uninsured in 1999. Some of the decline can be attributed to expansions in Medicaid and S-CHIP, but it appears that expansions in employment-based health insurance and individually purchased coverage had an even larger effect than expansion of S-CHIP. Even though the number and percentage of uninsured declined substantially between 1998 and 1999, more than 42 million Americans remain uninsured. As long as the economy is strong and unemployment is low, employment-based health insurance coverage will expand and the uninsured will decline gradually. If the economy continues to soften or comes close to a recession, the number of uninsured would easily and quickly start to increase again as unemployment rises. Should a severe downturn in the economy occur, causing the uninsured to represent 25 percent of the nonelderly population, 63 million Americans would be uninsured.     

CALIFORNIA'S EXPORTS AND THE 2004 OVERSEAS OFFICE CLOSURES

Estimating the impact of state import promotion programs on exports is difficult because of a simultaneity program. The 2003 California budget crisis provides a natural experiment allowing for an unbiased estimate. Due to the crisis, California closed all 12 overseas offices on 1 January 2004. Applying the differences‐in‐differences estimator to a sample of 44 countries over eight years yields an estimated 2%–3% increase in exports if the offices remained open. But this estimate is not statistically significant. Therefore, I find no statistical evidence that California's overseas offices increased exports. (JEL F13, H76, O24)     

PRICES,INFLATION, AND SMOKING ONSET: THE CASE OF ARGENTINA

This article examines the effect of tobacco prices on the decision to start smoking in Argentina. Argentina is an interesting case to explore given its high smoking rates, its recent experience with periods of very high and hyperinflation, and the mixed evidence of the effect of prices on smoking onset, particularly in low‐ and middle‐income countries. We used data from four cycles of two large national surveys conducted between 2005 and 2011 and discrete‐time hazard models. We found that tobacco prices had a statistically significant and fairly large impact on the hazard of smoking onset, and these findings were robust to alternative specifications. We also found that prices had little effect on the hazards of smoking onset during periods of hyper‐ and very high inflation, which provide some support for the notion that prices lose their informational role in such periods. Governments need to be cognizant that their most important policy tool to reduce tobacco use—taxes that increase real tobacco prices—is likely no longer effective during these times. (JEL C41, H20, I12, I18)     

THE IMPACT OF PERCEIVED BACKGROUND RISK ON BEHAVIORAL HEALTH: EVIDENCE FROM HURRICANE KATRINA

I explore the hypothesis that Hurricane Katrina in August 2005 raised perceived background risks, which had spillover effects on behavioral health outcomes of mental health and substance use. I estimate the effect that Katrina had in the nondamaged storm surge region, in time intervals leading up to and after the hurricane, compared to areas impervious to hurricanes. I find causal evidence that Katrina increased poor mental health days by 18.8% for the first month after Katrina, and increased smoking among lifetime smokers until 2007. Effects were larger in counties with disproportionate risk to storm surge and for low‐educated individuals. (JEL D81, I12, Q54)     

A qualitative study of smoking cessation experiences and perceptions among homeless young adults

Up to 70% of homeless youth smoke, but there is little information available on their smoking cessation experiences and perceptions to guide cessation intervention efforts. This study examined reasons for quitting smoking, previous experiences quitting smoking, and preferences for smoking cessation programs among homeless young adults. Four focus groups (N?=?27) were conducted in centers serving homeless 18–25 year olds in Los Angeles. Sessions were audio recorded, transcribed, and analyzed by a systematic procedure for qualitative analysis to identify key themes on the topics of interest. The short-term health-related consequences of smoking and high cost of cigarettes were the main reasons participants indicated for quitting or wanting to quit. In terms of barriers to quitting, exposure to peers who smoke and smoking to cope with the daily stressors of homelessness were the two most salient themes. Suggested features of a smoking cessation program for homeless youth included having a group-based component to provide support, offering incentives to attend, and using “scare tactics” as a tool to increase motivation to quit. To increase acceptability and uptake, smoking cessation programs for homeless youth need to focus on the short-term consequences of smoking and harness of the power of peer influences.     

The importance of employer sponsorship in the long-term care insurance market

Medicare and Medicaid are major sources of long-term care payments and thus will bear much of the burden from the growth in long-term care service use. The large future demand for long-term care services is of great concern among policymakers due to its expense and the use of public program dollars. It is argued that the individual purchase of long-term care insurance can help alleviate the increasing financial pressure on public programs responsible for the majority of longterm care financing. However, consumers have shown little interest in insuring against the high costs of long-term care. This analysis examines the effect of several factors on the decision to purchase a long-term care insurance policy: knowledge and attitudes of long-term care insurance and the long-term care financing system, the perceived risk for longterm care, financial planning behavior, and the availability of long-term care insurance. The interim results indicate the factor most likely to affect the decision to purchase long-term care insurance is access to employer-sponsored long-term care insurance. This suggests tht the availability of affordable and high quality coverage is more important than demand-side factors such as awareness of long-term care insurance and a perceived greater risk for long-term care.     

THE EFFECT OF INSURANCE COVERAGE ON PREVENTIVE CARE

Despite the growth in health insurance products that differentially cover preventive care and nonpreventive care, little is known about how preventive care utilization responds to targeted changes in coverage. Using administrative data from a large company, this paper examines the implementation of an insurance benefit design which differentially increased the price of nonpreventive care while decreasing the price of prevention. Leveraging a difference‐in‐differences research strategy, we find that preventive care utilization did not increase and even declined due to the differential price change. This evidence indicates a meaningful negative cross‐price effect, suggesting that nonpreventive care and preventive care are complements. (JEL I13, I11)     

The Cost of Instability: The Effects of Family,Work, and Welfare Change on Low‐Income Women’s Health Insurance Status

The number of uninsured Americans has risen substantially over the last decade. Despite the availability of Medicaid, low‐income women are at particularly elevated risk of having no or inadequate health insurance. How does continuity of work, family, and welfare affect low‐income women’s health insurance status? A multinomial logistic regression analysis of 1,662 low‐income women from the Welfare, Children, and Families: A Three‐City Study provides evidence of the consequences of life changes on access to health insurance from 1999–2005. The results show that compared to those with stable welfare, work, and family attachments, new full‐time employment actually increases low‐income women’s risk of being uninsured as does being underemployed, on welfare, or single for extended periods of time. These findings illustrate how health‐care reform must adequately address the complexity of low‐income women’s lives—including the ways labor market, state, and family factors interact to create barriers to health insurance—in order to improve access to care under the current U.S. health insurance model.     

THE EFFECTS OF SINGLE MOTHERS' WELFARE USE AND EMPLOYMENT DECISIONS ON CHILDREN'S COGNITIVE DEVELOPMENT

We examine the effects of single mothers' welfare use and employment decisions on children's short‐run cognitive development, as measured by their preschool standardized math test scores. We control for three mechanisms through which these decisions might affect children's outcomes: direct monetary benefits, parental time invested in the child, and nonpecuniary benefits from in‐kind transfer programs such as Medicaid. We employ a correction function approach and control for state‐fixed effects to address the endogenous nature of welfare participation and employment decisions. Our estimates suggest that although each additional quarter of either mother's employment or welfare use results in only a small increase in a child's standardized math test score, the total effects after several quarters are sizable. We allow mothers' decisions to have varying effects on attainment by children's observed innate ability and by the intensity of welfare use and employment. A child who has the mean level of observed innate ability with a mother who simultaneously worked and used welfare in all 20 quarters after childbirth experiences an 8.25 standardized‐point increase in standardized scores. The positive impact is more pronounced for the more disadvantaged children, who tend to be born to mothers with low Armed Forces Qualification Test scores, or have lower birth weights. We also examine the effects using timing of employment and welfare use, as well as children's maturity and gender. (JEL I3, J13, J22)     

EFFECTS OF WELFARE REFORM ON ILLICIT DRUG USE OF ADULT WOMEN

Exploiting changes in welfare policy across states and over time and comparing relevant population subgroups within an econometric difference‐in‐differences framework, we estimate the effects of welfare reform on adult women's illicit drug use from 1992 to 2002, the period during which welfare reform unfolded in the United States. The analyses are based on all available and appropriate national data sets, each offering unique strengths and measuring a different drug‐related outcome. We investigate self‐reported illicit drug use (from the National Household Surveys on Drug Abuse and National Surveys on Drug Use and Health), drug‐related prison admissions (from the National Corrections Reporting Program), drug‐related arrests (from Federal Bureau of Investigation Uniform Crime Reports), and drug‐related emergency department episodes (from the Drug Abuse Warning Network). We find robust evidence that welfare reform led to a 10%–21% decline in illicit drug use among women at risk of relying on welfare, as well as associated declines in drug‐related arrests (6%–7%), drug‐related hospital emergency department episodes (7%–11%), and possibly drug‐related prison admissions (11%–19%). The findings indicate that an appropriately designed welfare system with sufficient job opportunities for those who are able to work can result in both increases in employment and decreases in drug use. (JEL I38, K42, J21)     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

DO HIGHER TOBACCO TAXES REDUCE ADULT SMOKING? NEW EVIDENCE OF THE EFFECT OF RECENT CIGARETTE TAX INCREASES ON ADULT SMOKING

There is a general consensus among policymakers that raising tobacco taxes reduces cigarette consumption. However, evidence that tobacco taxes reduce adult smoking is relatively sparse. In this paper, we extend the literature in two ways: using data from the Current Population Survey Tobacco Use Supplements we focus on recent, large tax changes, which provide the best opportunity to empirically observe a response in cigarette consumption, and employ a novel paired difference‐in‐differences technique to estimate the association between tax increases and cigarette consumption. Estimates indicate that, for adults, the association between cigarette taxes and either smoking participation or smoking intensity is negative, small, and not usually statistically significant. Our evidence suggests that increases in cigarette taxes are associated with small decreases in cigarette consumption and that it will take sizable tax increases, on the order of 100%, to decrease smoking by as much as 5%. (JEL I18, I12)