Income Shocks and Out-of-Pocket Health Care Spending: Implications for Single-Mother Families.

We examine how out-of-pocket health care spending by single-mother families responds to income losses. We use eleven two-year panels of the Medical Expenditure Panel Survey for the period 2004-2015 and apply the correlated random effects estimation approach. We categorize income in relation to the federal poverty line (FPL): poor or near-poor (less than 125% of the FPL); low income (125 to 199% of the FPL); middle income (200 to 399% of the FPL); and high income (400% of the FPL or more). Income losses among high-income single-mother families lead a decline in out-of-pocket spending toward office-based care and emergency room care of $119-$138 and $30-$60, respectively. Among middle-income single-mother families, income losses lead to a $30 decline in out-of-pocket spending toward family emergency room care and a $45-$91 decline in mother's out-of-pocket spending toward prescription medications. Further research should examine whether these declines compromise health status of single-mother family members.

The Impact of Increasing Community-Directed State Mental Health Agency Expenditures on Violent Crime.

Violent crime remains a prevalent threat to population health within the United States. States offer varying policy approaches to prevent violent crime and support behavioral health, such as community-based programs that include substance use disorder prevention and treatment. Using state mental health agency data, we construct a panel of U.S. states over nine years and apply an instrumental variables empirical model with state and time fixed effects to adjust for policy endogeneity, omitted variable bias, and time trends. We find that a 10% increase in community-directed state mental health agency expenditures yielded nearly a 4% reduction in violent crime rates. Larger magnitude reductions in violent crime rates were associated with the presence of gun control regulations and increases in the proportion of the population completing secondary education. Policymakers should consider the added benefit of violent crime reduction when considering budgetary allocations of community-directed state mental health agency expenditures.

HOW DO CHANGES IN INCOME, EMPLOYMENT AND HEALTH INSURANCE AFFECT FAMILY MENTAL HEALTH SPENDING?

Using eight two-year panels from the Medical Expenditure Panel Survey data for the period 2004 to 2012, we examine the effect of economic shocks on mental health spending by families with children. Estimating two-part expenditure models within the correlated random effects framework, we find that employment shocks have a greater impact on mental health spending than do income or health insurance shocks. Our estimates reveal that employment gains are associated with a lower likelihood of family mental health services utilization. By contrast employment losses are positively related to an increase in total family mental health. We do not detect a link between economic shocks and mental health spending on behalf of fathers.

Reform of the Individual Insurance Market in New Jersey: Lessons for the Affordable Care Act.

The individual health insurance market has played a small but important role in providing coverage to those without access to group insurance or public programs. With implementation of the Affordable Care Act (ACA), the individual market has attained a more prominent role. However, achieving accessible and affordable coverage in this market is a long-standing challenge, in large part due to the threat of adverse risk selection. New Jersey pursued comprehensive reforms beginning in the 1990s to achieve a stable, accessible, and affordable individual market. We review how adverse risk selection can pose a challenge to achieving such objectives in the individual health insurance market. We follow this discussion by describing the experience of New Jersey through three rounds of legislative reform and through the first year of the implementation of the ACA coverage provisions. While the New Jersey reforms did not require individuals to purchase coverage, its experiences with direct and indirect market subsidies and regulations guiding plan design, issuance, and rating have important implications for how the ACA may achieve its coverage goals in the absence of the controversial individual purchase mandate.

Early impact of the Affordable Care Act on health insurance coverage of young adults.

RESEARCH OBJECTIVE: To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent's private health plan. Nearly one-in-three young adults lacked coverage before the ACA. STUDY DESIGN, METHODS, AND DATA: Data from the Current Population Survey 2005-2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws. PRINCIPAL FINDINGS: This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law. CONCLUSIONS AND IMPLICATIONS: ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.

Expanding dependent coverage for young adults: lessons from state initiatives.

The Patient Protection and Affordable Care Act (ACA) requires that adults up to age twenty-six be permitted to enroll as dependents on their parents' health plans. This article examines the experiences of states that enacted dependent expansion laws. Drawing on public information from thirty-one enacting states and case studies of four diverse reform states, it derives lessons that are pertinent to the implementation of this ACA provision. Dependent coverage laws vary across the states, but most impose residency, marital status, and other restrictions. The federal Employee Retirement Income Security Act further limits the reach of state laws. Eligibility for expanded coverage under the ACA is much broader. Rules in some states requiring or allowing separate premiums for adult dependents may also discourage enrollment compared with rules in other states (and the ACA), where these costs must be factored into family premiums. Business opposition in some states led to more restrictive regulations, especially for how premiums are charged, which in turn raised greater implementation challenges. Case study states did not report substantial young adult dependent coverage take-up, but early enrollment experience under ACA appears to be more positive. Long-term questions remain about the implications of this policy for risk pooling and the distribution of premium costs.

The health insurance status of low-wage workers: the role of workplace composition and marital status.

Many of the provisions in the Affordable Care Act (ACA), such as tax credits and penalties for employers, vary by employer size and average wage level. Therefore, knowing the wage and firm size distribution of low-wage workers and how employer-sponsored insurance (ESI) characteristics vary by these dimensions is particularly important for understanding the extent to which low-wage workers and their employers may be affected by different provisions in the ACA. To inform this issue, the authors use data from the 2006 Medical Expenditure Panel Survey-Insurance Component to examine offers of coverage and cost-sharing requirements by the wage distribution and firm size dimensions of employers. They also draw on Medical Expenditure Panel Survey household-level data to describe the household circumstances of low-wage workers. The authors find that where low-wage workers are employed, who their colleagues are, and their spouses' wage levels are important factors in determining low-wage workers' access to coverage and the cost and generosity of such coverage.

How have state policies to expand dependent coverage affected the health insurance status of young adults?

RESEARCH OBJECTIVE: Nearly one in three adults of ages 19-29 lack health insurance, representing the highest uninsured rate of any age group. To help address this gap, 38 states have enacted laws requiring insurers to permit young adults to enroll as dependents on their parents' plans. This paper evaluates their impact on coverage for young adults. STUDY DESIGN/METHODS/DATA: This study uses data for individuals ages 19-29 from the Current Population Survey's Annual Demographic Supplement for calendar years 2000-2008. Linear probability models are used to obtain difference-in-differences estimates of the impact of dependent coverage expansions in 19 early-adopting states on young adults' insurance status. The models also address possible policy endogeneity due to the nonrandom enactment of expansion policies across states. PRINCIPAL FINDINGS: State young adult dependent coverage policies yielded small increases in dependent coverage ranging from 1.52 percentage points for all young adults to 3.84 percentage points for those ages 19-25 residing with parents. These increases were largely offset by declines in employer-sponsored insurance (ESI) in the young adults' own name. No significant impact on young adult uninsured rates was observed. CONCLUSIONS AND IMPLICATIONS: Adult dependent coverage expansions have had a relatively small impact on enrollment as an ESI dependent and appear to have the unintended consequence of reducing ESI policyholder coverage. This policy did not achieve a reduction in uninsured rates as policy makers had intended. Federal reform efforts to expand dependent coverage are likely to be more successful because reform will be accompanied by subsidies and enrollment mandates.