Association for Public Policy Analysis & Management

Panel: Medicaid Policy, Risky Health Behaviors, and Health Care Utilization

(Health Policy)

Differences in state Medicaid programs have been a source of policy variation exploited by researchers for many years via a “laboratory of the states” approach to identify the impact of changes in insurance coverage on risky health behaviors, health care utilization, and health outcomes. The state Medicaid expansions that occurred through the Affordable Care Act (ACA) contributed to this policy variation along several dimensions. First, not all states opted to expand their Medicaid program. Second, expansion states differed in their pre-ACA eligibility levels. Finally, in some cases, expansion states structured their Medicaid expansions differently. Our panel consists of four papers that exploit variation in state Medicaid policy to examine the impact of changes in insurance coverage on risky health behaviors, health care utilization, and health outcomes.

The first two papers in our panel focus on timely issues related to substance abuse. The first of these examines the extent to which expansions in insurance coverage (via Medicaid) reduced the rate of substance use disorder deaths and emergency room visits resulting from an over-dose. The second examines the impact of within-state variation in the use of prior authorization for opioids among managed care organizations that serve Medicaid enrollees on rates of abuse and overdose following initiation of opioid medication treatment.

The final two papers augment variation in coverage generated by state ACA Medicaid expansions with variation in coverage generated by other components of the ACA, such as the introduction of subsidized Marketplace plans, to examine the impact of insurance coverage on health care utilization. The first of these uses the Medical Expenditure Panel Survey (MEPS) to examine a wide range of different types of health care utilization. This allows for an investigation of substitution between different types and locations of services, such as transitions from using the emergency room for primary care to a doctor’s office. The MEPS also allows for an evaluation of changes in total spending, out-of-pocket (OOP) spending, and exposure to catastrophic OOP costs. The final paper analyzes how increases in insurance coverage affects the U.S. birth rate via an increase in access to prescription contraception for low-income women. Using data on all U.S. births between 2010 and 2015 from the Vitality Statistics database, preliminary results suggest that access to subsidized health insurance had a negative effect on the birth rate, and that reduction is greater for younger women.