PoliticsandEconomics:HowPoliticalPolarizationImpactstheAffordableCareAct

Clarence“Boomer”Kelley

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TableofContents

Intro 3

Background 3

LiteratureReview 15

Methods 23

Data 24

Discussion 26

Appendix 28

Sources 32

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Intro

WiththepassageofthePatientProtectionandAffordableCareAct(PPACA),healthcarereformhas

becomeanincreasinglydivisivepoliticaltopicbetweentheRepublicanandDemocratparties.Formy

paperIwantedtofindoutifthePPACAhasimpactedtheuninsuredratesincebeingpastandto

measurethevariationofMedicaidexpansionbetweenthestates.

Inmyanalysisofthesetwoquestions,Iconcludethatitisinconclusivetodeterminetheeffectofthe

PPACAontheuninsuredrateasitwassignificantinsomemodelsbutnotinothers.Thedecisionto

expandMedicaidwaslargelybasedonpoliticalfactorswithsomeinfluenceofeconomicfactorssuchas

taxrevenues.

Background

IntheU.S.,healthcareisinlargepartfundedthroughhealthinsurance.Healthinsurancecanbe

obtainedmultiplewaysbutthethreeprimarymeansthatimpactthemostpeopleare:Employer-

SponsoredInsurance(ESI),MedicareandMedicaid(Thompson).In2000,theuninsuredratewas14%of

theU.S.populationwhileESIwas64.1%.MedicareandMedicaidcovered13.4%and10.3%respectively

(HealthInsurance).Duringthenext10years,theU.S.wentthroughtwoeconomicrecessions,aterrorist

attackandavarietyofothereconomicandpoliticalchanges.Withthesechanges,thehealthinsurance

coveragebegantochange,ESIdroppeddownto55.3%,Medicareincreasedto14.6%andMedicaid

changedto15.8%.Theoverallimpactincreasedtheuninsuredratefrom14%to16.3%oftheU.S.

population(Table).Thisincreaseinuninsured,alongwithrisinghealthcarecosts,sparkedmanydebates

regardinghealthcarereformbetweentheDemocratandRepublicanparties.

Intryingtoimplementanykindofhealthreform,therearethreespecificareasthatanypolicymust

address:access,costandquality.Healthcarepoliciesneedtobeabletoprovideawaytoincreasethe

numberofpeoplewithaccesstohealthcare;asof2010,therewere48.1millionAmericanswithout

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accesstohealthinsurancecoverage.Successfulpolicesalsoneedtobeabletoreducetheamountof

moneyspentonhealthcareastheU.S.isthehighestpercapitaspenderonhealthcare.Thequalityof

careisthethirdpillarofproblemsneededtobeaddressedinordertosuccessfullybringabouthealth

reform.Currently,healthcarewithintheU.S.islaggingbehindmanyotherindustrializednationsinthe

world(Burrill).

Asof2009,theUnitedStateswasspending17.6%ofitsgrossdomesticproduct(GDP)onhealthcare

services.Whilerisinghealthcarecostsareacommonproblemforallcountriesaroundtheworld,the

U.S.isspendingthelargestamountofmoneyonhealthcareasapercentageofGDP.Between1960and

2009,theannualpercapitaspendingonhealthcarecontinuallyincreasedby4.7%,goingfrom$809to

$7,375in49years(Chernew).Despiteleadingtheworldinspendingonhealthcare,thequalityofhealth

careissimilarorworsethanmanyindustrializedwesternandeasternnations(Peters).Accordingtothe

WorldHealthOrganization(WHO),theU.S.wasrankednumber37outof191countriesforoverall

healthcareperformance(World).Withthesechangesintheuninsuredrateandrisingtrendsofhealth

carespending,PresidentBarackObamapassedalandmarklegislationtitledthePatientProtectionand

AffordableCareActin2010.

Historyofhealthpolicy

In1965,PresidentLyndonB.JohnsonwasabletogetbothMedicareandMedicaidpassedandsigned

intolaw.Sincethen,manyotherpresidentsinbothmajorpoliticalpartieshavetriedandfailedtopass

anyhealthcarelegislationotherthanminoramendmentsorchangestoexistingpolicy.However,that

trendchangedin2010whenPresidentObamawasabletosignthePPACAintolaw.AsPresidentObama

wasgearinguptopasshishealthcarereform,hehadtoovercomeanumberofpoliticalchallenges

facinghim.Thefirstchallengedealtwithkeepinghisownpartyunitedontheissue;atthistime,the

Democratshadasupermajorityof60senatorsandamajorityofhousemembers.Thesemajorities,

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however,rangedfromstaunchliberalstosomewhatconservativeinnaturethatrequiredthecombined

effortsofMajorityLeaderHarryReidandHouseSpeakerNancyPelositokeepthemtogether

(Oberlander).

PresidentObamathenhadtoworryaboutpoliticalforcesoutsideofWashingtonD.C.intheformof

healthcareinterestgroupssuchastheAmericanMedicalAssociation,insurancecompaniesandmany

more.InlearningfromthefailedattemptbyPresidentBillClintonintheearly90’s,PresidentObama

wenttotheseorganizationsearlyontogettheminvolvedwithcreatingthelegislation.Whilehewasnot

abletogeteveryorganizationonboardwithhisplans,hewasabletowinoverenoughorganizationsfor

longenoughtogetthelegislationsigned(Oberlander).

H.R.3590wasintroducedbyRepresentativeCharlesRangel(D-NY)September17,2009totheHouseof

Representatives.TheprocessofthePPACAthroughcongresswasalonganddifficultprocessthat

ultimatelywaspassedstrictlyalongpartylines.ThefinalvoteforpassageintheSenatewas60

Democrats-39Republicans.TheHousewassimilarinthatitpassedalongpartylinesbuttherewasa

numberofDemocratswhodidvoteagainstthepassage.Thevotecountcameoutas219-212with219

Democratsvotingyes,173Republicansvotingnoand39Democratsvotingagainstfinalpassageaswell

(Informed).

WiththepassageofthePPACA,manydifferentaspectsofhealthcareandhealthinsurancebeganto

change.Thesechangeseitherbegantohappenimmediatelyorwerescheduledtobegintotakeplacein

thefutureallthewayuptotheyear2020.Thesechangesrangedfromrequirementsforindividualsto

havesomeformofhealthinsurancetostatesbeingrequiredtoexpandMedicaidto133%ofthefederal

povertylevel(FPL).Despitebeingpassedintolawalongstraightpartylines,thereweresomeprovisions

thatevenRepublicansliked.Theseprovisionsincludedthatabilityforchildrentostayontheirparents’

insuranceuntiltheage26ornotallowinginsurancecompaniestodenycarebasedonpre-existing

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conditions.Lesspopularreformscenteredaroundtaxincreasesorpenaltypaymentsforindividualswho

didnothavehealthinsurance(Focus—summary).

SupremeCourt

AfterthePPACAwassignedintolaw,manycourtcaseswerebroughtagainstit.Onecourtcasefrom

Florida,NationalFederationofIndependentBusinessv.Sebelius,eventuallymadeitbeforetheUnited

StatesSupremeCourt.Duetothecomplexityofthebill,onlysectionswereconsideredinthehearing.

TwoofthesesectionsweretheindividualmandateandMedicaidexpansion.Therulingofthecourt

upheldtheindividualmandatebutstruckdowntherequirementthateverystateexpandMedicaidto

133%FPL.ThisrulinggavestatestheoptiontochooseiftheywantedtoexpandMedicaidtothePPACA

requirementsornot(Perkins).

TheargumentforstrikingdowntheMedicaidexpansionrequirementwasthatitwasconsidered

coercivetothestatesfromtheFederalGovernmentandviolatedthePennhurstrulethatfederal

conditionsbeclearandunderstandable.WhenMedicaidwasfirstpassedin1965,statescould

voluntarilyopt-inoroutoftheprogram.Overtime,all50stateseventuallyoptedinandagreedto

providehealthinsurancetoneedyfamilieswithchildrenandtothepooranddisabled.Theconditionsat

thetimeweresuchthatstatescoulddecidewhatpovertylevelmetthedefinitionofpoorandneedy

families.UnderthePPACA,however,Medicaidwastobeexpandedfrominsurancetothepoorand

needyordisabledfamilies,toprovidinginsuranceforthoseinpoverty.TheSupremeCourtruledthat

thisexpansiontoMedicaidwasthesameasimplementingabrandnewprogramandthatunderthe

PennhurstrulestatesthatoriginallyoptedintoMedicaidcouldnothavereasonablyforeseenthisnew

program(Perkins)(Rosenbaum).

Thesecondpointofstrikingdowntherequirementtoexpandwasthatitwasseenascoercivetothe

states.Inanattempttoprovideincentivesforthestatestoexpand,theDepartmentofHealthand

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HumanServices(HHS)notonlyofferedmorefundingforthestatestoexpand,theythreatenedtocutall

Medicaidfundingtostatesiftheydidnotexpand.Inthepast,theFederalGovernmenthasbeen

allowedtomakethreatslikethistocertainstatesforspecificfundingsources,butnevertothe

magnitudeoftheMedicaidmatchfunding.Forsomestates,thisfundingrangedbetween10-20%of

theirentirestatebudget.Becausethispotentiallossoffundingwassohighforanyandallstates,the

SupremeCourtruledthatthisthreatoflosingfundingwasunduecoercionandstruckdownHHS’ability

togothroughwiththethreat(Perkins).Duetothisruling,aproblemcalledthecoveragegapappeared.

Underthisproblem,individualswhomake100-133%FPLcanstillqualifyforinsurancesubsidiesthrough

theexchangesbutindividualsmakinglessthan100%FPLdonot.Ifastatechoosesnottoexpand

Medicaidfromthepre-PPACArequirement,individualsmayfindthemselvesmakingtoomuchmoneyto

qualifyforMedicaidbutnotenoughforthesubsidies(Rasmussen,Collins,DotyandGarber2013).

Thesecondfactorinthecourtcasewasregardingtheindividualmandate.Whenthecasewasbeing

argued,theSupremeCourtruledthattheindividualmandatewasoutsidethescopeofthecommerce

clausebutwasdeclaredconstitutionalundercongress’abilitytotax.Someoftheargumentsforand

againstthecommerceclauseincludedifcongresshadtheabilitytodeclareinactivitytobeactivityorif

thePPACAwasregulatingthehealthinsurancemarketorhealthcaremarket.TheSupremeCourt

decidedthattheabilitytoregulateinactivitywentbeyondtheabilityofcongress.Tohelpunderstand

this,themandatetobuycarinsurancewasused.Purchasingcarinsurancehasbecomesynonymous

withpurchasingacar,somuchsothattheonlywaytolegallygetaroundnotbuyingcarinsuranceisto

notpurchaseacar.However,thisprinciplecouldnotapplytohealthinsurancebecausethemandateto

buyhealthinsurancewouldbebasedonthefactthatthepersonisaliveandwillbeapartakerofthe

healthcaresystem(Rich).

Therulingthatthemandatewasconstitutionalundercongress’powertotaxcameasasurprisetomany

peoplebecauseuptothispoint,onlyoneofthemanylowerdistrictcourtdecisionsdiscussedandfound

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itqualifyingunderthattaxationpower.Inthefourthdistrictcourtcase,thejudgeruledthatthe

paymentfornothavinginsurancequalifiedasataxbecauseitaffectedonlythosewithincomeabove

thefilingthreshold,wasbasedonincomeandwassubjecttotheSecretaryoftheTreasury.The

SupremeCourtbaseditsrulingonthesesamecriteria.Wherethetwocourtsfounddisagreementwas

overtheanti-injunctionact(AIA)whichstatedthatcourtscouldnotruleinontaxes.Whilethefourth

districtcourtruledthatthemandatewasataxandthatitfellundertheAIA,theSupremeCourtruled

thatboththePPACAandAIAwerebothcreatedbycongressandthatcongresscouldineffectdecideifa

taxorpenaltyfitundertheAIA(Rich).

Implementation

IndividualMandate

TheindividualmandateisamandaterequiringAmericanCitizenstohavehealthinsurance.Forthose

individualsthatchoosenottohaveinsurance,thereisapenaltyimposedthatgraduallyincreasesfrom

yeartoyear.In2014,thepenaltyisthehigherof$95perpersonor1.0%oftaxableincome;in2015,itis

$325or2.0%taxableincome.Itthenincreasestothefinalamountof$695or2.5%taxableincome.This

penaltycanbechargeuptothreetimesperyeariftheindividualcontinuestochoosenottoobtain

healthinsurance.Anyincreasesinthepenaltyafter2016willreflectchangesinthecost-of-living

adjustments(Focus—Summary).

Aswithanyrequirement,thereareusuallysomeexceptionstotherulingandtheinsurancemandateis

nodifferent.UnderthePPACA,anindividualcanqualifyforanexemptionfromthefeeforfinancial,

politicalorreligiousreasons.Thesereasonscanincludereligiousaffiliationswithgroupsthatoppose

insuranceorbeingpartofanIndianhealthcareprovider;financialreasonscanincluderecent

bankruptcy,havinganincomeunderthetaxfilinglimitorbeingrequiredtopaymorethan8%ofyour

incomeforpremiums.Anotherexemptionwillspecificallyapplyformanypeopleinstatesthatdidnot

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expandMedicaidupto138%FPL.Theseexemptionswillbeforindividualswhocannotqualifyfor

MedicaidnorcantheyqualifyforpremiumassistanceduetoearningtoomuchforMedicaidbutnot

enoughforassistance(How).

Theindividualmandatealsoexpandstoregulatethatemployersaretoprovidehealthinsurancetoall

fulltimeemployeesorpayapenaltyaswell.Underthismandate,allemployersthathave50ormore

fulltimeemployeesarerequiredtoprovidehealthinsurancethatwillpayminimally60%ofallhealth

careexpensesandnotexceed9.5%oftheemployee’sincomeforallfulltimeemployees.Ifthe

employerdoesnotdothis,theyarethensubjecttoapenaltypaymentifatleastoneemployeeis

eligibleforataxcreditthroughtheexchange.Thispenaltywillbeassessedat$2,000perfulltime

employeesafterthefirst30employees.Employersthatdonothaveabove50fulltimeemployeesare

notsubjecttothepenalties(HealthReform2013;Wojcik2013).

TheindividualmandateisoneofthemostcriticalpartstothePPACAbecauseoftheverynatureof

insurance.Insuranceisawayforindividualsorbusinesstotransfertheriskoflossfromthemselvesto

anotherindividualorbusiness.Withhealthinsurance,anindividualorbusinesspurchasesapolicyfrom

ahealthinsurancecompanyinwhichtheindividualorbusinessagreestopaymonthlypremiumstothe

insurancecompanywiththepromisethatthecompanywillturnaroundandpaythemedicalexpenses

thattheinsuredindividualaccruesovertheyear.Innegotiatingthepolicycontract,insurance

companieswouldgatherinformationconcerningtheinsuredindividualsuchasage,healthhistory,

currentorprevioushealthtreatmentsandsoforth.Theywouldthenusethisinformationtodetermine

theriskfactorthattheindividualposedtothecompany.Thepremiumschargedwouldthenreflectthis

riskinthatthehighertherisk,thehigherthepremiumswerecharged.

Intermsoffinancialcosts,theelderlyposegreaterrisksduetoagethanyouth.AspartofthePPACA,

insurancecompanieswerenolongerallowedtodenyinsurancecoverageduetopre-existingconditions,

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norcouldtheydiscriminatebetweenracesandgendersduetopremiumscharged.Theonlyfactorthey

couldusetodefinepremiumswasageandsmoking.Duetothischange,insurancecompaniesfacedthe

riskofincreasedcostsduetoanincreaseinadverseselectioninwhichtheyinsuremorepeoplewith

highrisksthanlowrisksbecauseofanincreaseinelderlyorsickindividualswantinginsurance.The

individualmandateisawaytoremedythisproblembyensuringthatmoreyoungpeoplepurchase

insuranceasawaytobalancetheincreaseintheelderly.

Justlikeanyothermarket,whenthepriceforhealthinsuranceincreases,thequantitydemanded

diminishesaswellasviceversa.Thepremiumsfortheyoungergenerationwouldnaturallyincreasein

ordertooffsetthedecreaseinpremiumschargedfortheelderlygeneration.Duetothischangein

premiums,themarketresultwouldbeanincreaseinthenumberofpoliciestoolderindividualsanda

decreaseintheyouth.Thiswouldthenfurtherincreasethecostsofpremiumsfurtherdrivingmoreand

moreyouthoutoftheinsurancemarketaltogether.Eventually,thecostsofprovidinghealthinsurance

atanaffordableratetotheelderlywouldbetoocostlyandcausethePPACAtoimplode.Theindividual

mandateiskeytomaintainingcostsdownbecauseitforcestheyoungergenerationstopurchase

insuranceatahigherthanmarketvaluecostinordertosubsidizethelowerthanmarketcostforthe

olderandsickergenerations(Otter).

MedicaidExpansion

Inordertoaccomplishthegoalofprovidinginsuranceaccesstopeoplefrom0-400%FPL,thePPACA

wasdividedintotwomainpartstoaccomplishthis.Premiumsubsidiesweretobeofferedtopeople

withincomesof133-400%FPLandMedicaidaccesswastobeexpandedtoalladults18-64from0-133%

FPL(Focus—Summary).However,duetotheModifiedAdjustedGrossIncome(MAGI)incomedisregard,

5%ofanindividual’sincomewillbedisregardedwhenbeingconsideredforMedicaidwhichmakesthe

upperincomelevelequalwith138%FPL(Mitchell).TohelpfundtheincreaseinnewlyeligibleMedicaid

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recipients,theFederalGovernmentimplementedaphaseoutfundingsourcetothestates.Fromthe

years2014-2016,theywouldpay100%ofthecostsassociatedwiththeincreaseinMedicaidrecipients.

After2016,thepercentagewoulddecreasealittleeveryyearbeginningin2017with95%,94%in2018,

93%in2019and90%in2020andbeyond(Focus—Summary).

UnderthePPACA,Medicaideligibilitywouldextendthepovertylevelforparentsandallowchildless

adultstoqualifyforMedicaid.Traditionally,thispopulationofchildlessadultshasneverbeenableto

qualifyforMedicaidormostgovernmentassistanceprogramsunlesstheyhavesomesortofdisabilityor

othercircumstance(Kaiser).ManyofthedebatesconcerningMedicaidexpansionrevolvearoundthis

groupofchildlessadultsandwhetherornottheyshouldbeincludedinMedicaideligibility.

WiththewaythePPACAwaswritten,peoplefrom0-400%FPLweregoingtohaveaccesstohealth

insurance;however,becauseoftheSupremeCourtdecisionregardingthePPACA,thiscontinuousscale

from0-400wasbroken.StatesnowhadtheoptiontochoosetoexpandMedicaidtowhateverlevels

theywantedortonotexpandatall.Thiscreatedaproblemcalledthecoveragegapproblem.This

coveragegapexistedinstatesthatchosenottoexpandMedicaideligibilityto138%.Rather,theychose

tokeeptheeligibilityatwhateverstateleveltheypreviouslyhadresultinginanincomegapwhere

people’sincomesweretoohighforMedicaidbuttoolowtoqualifyforthepremiumassistancethrough

theFederalGovernment.ThisdecisiontoexpandMedicaidisasmuchapoliticaldebateasitisan

economicdiscussion.

Theoptimalresultforincreasingaccesstohealthinsurancewouldhavebeenifallstateshadaccepted

thefederalrequirementofexpandingMedicaidto138%.CarterC.PriceandChristineEibnerwrotean

articleintheHealthAffairsjournalinwhichtheydidastudyoftheoutcomesifallthestatesdidthefull

Medicaidexpansion.Intheirstudy,PriceandEibnerfoundthatifallstatesfullyexpandedMedicaid,the

numberofMedicaidenrolleeswouldincreasefrom46.7millionto62.9million.However,accordingto

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theiropt-outscenarioinwhichtheyestimatedthat14stateswouldnotexpand,those62.9million

enrolleeswoulddropto58.5millionMedicaidrecipients.Thefinancialimpactofthose14statesnot

expandingwoulddecreasethefederalMedicaidcostsandreducetheestimatedsavingstostatesby

about$1billion(Price&Eibner).

InsuranceExchanges

ThesecondpartofthePPACAthatwasdesignedtoincreaseaccesstohealthinsuranceisthroughan

insuranceexchangemarket.Thegoaloftheexchangewastoprovideanonlinemarketwhere

consumerscouldlogontothewebsitefortheirareaandthencomparepricesandbenefitstofindthe

insuranceplanthatbestfitthem.Toaccomplishthis,eachstatewasrequiredtosetupastatebased

exchangewebsitethatofferedatleasttwodifferentqualifiedhealthplanoptionsfortheresidentsto

compare.Theseinsuranceplanoptionswererequiredtomeetthefederalstandardofbenefitstobe

consideredaqualifiedhealthplan.Thesehealthexchangesweretobedividedintotwogroups:an

exchangeforindividualsandanexchangeforsmallbusiness(Focus—Summary).

Aspartoftheexchangesystems,stateswereallowedtodecideiftheywantedtoofferastatebased

exchangesystemorallowtheFederalGovernmenttooperatetheexchangesystem.Underthese

exchangesites,anindividualcouldlogonandshopforinsuranceplanstoenrollinbasedongeography

oftheindividual.InOctober1,2013,theFederalGovernment’swebsite,“healthcare.gov,”waslaunched

toallowcitizenstocreateprofilesandenrollininsuranceplans.Unfortunately,thereweremany

problemswiththewebsitethatresultedinitcrashingwithinhoursofitbeingonlineduetosomany

users.Ittookthegovernmentalmosttwomonthstoworkoutallthedetailsresultinginthewebsite

malfunction.

Therearefourdifferentplanlevelsthatanyonecanpurchasewiththeoptionofacatastrophicplanfor

thosethatmeettherequirements.Thefourplans,ortiers,arecalledbronze,silver,goldandplatinum.

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Thedifferencebetweenthesefivelevelsistheamounthealthcarecoststheinsurancecompanywillpay

andtheamounttheindividualwillpay.Catastrophicplanspaytheleastamountofhealthcarecostsas

theyaretoinsureagainstcatastrophichealthcareemergencies;theseplansareofferedonlytothose

whoareunder30orqualifyforahardshipexemption.Thebronzeplanspayona60:40levelinwhich

thecompanypays60%ofthecostsandtheconsumerpaysabout40%.Theseplansusuallyhavelower

monthlypremiumstooffsetthehigherdeductiblepaymentsthattheinsuredmustsatisfy.Silverplans

moveuptoa70:30,Goldplansare80:20andPlatinumplanspayona90:10scale.Astheplansincrease

inbenefitsandpayment,theinsured’smonthlypremiumwillincreasewithit(Focus—Summary).

Asawaytohelpwiththecosts,thePPACAhasafewdifferentcostsavingoptionstohelpindividuals

affordcoverage.Twosuchwaysarethroughpremiumcreditsandout-of-pocketsavings.TheAdvance

PremiumTaxCreditisavailabletoindividualsandfamilieswithincomesfrom100-400%FPLwhodonot

haveemployercoverageorqualifyforpublicinsurance.Thistaxcreditisapplieddirectlytothepremium

paymentsforallhealthplanssoldonthroughtheinsurancemarketplace.Thistaxcreditcanbetakenin

oneofthreedifferentways.ThefirstwayisthatanindividualcandesignatethattheywanttheFederal

Governmenttopayallthedifferenceofpremiumsdirectlytothecompanythatthehealthplaniswith.

Alltheindividualhastodoisthenpaywhattheyowetothecompanyeachmonthandthegovernment

paystherest.Thesecondoptionisthattheindividualcandesignatethegovernmenttopayonlypartof

themonthlypaymenteachmonththatrequirestheinsuredtopaymorethantheirdesignatedamount.

Attheendoftheyear,theinsuredwillthenreceiveataxrefundthatisequaltotheextraamountthey

hadhadtopaythroughouttheyear.Thethirdoptionisthattheindividualcandesignatethattheywant

topaythefullamountofmonthlypremiumsandreceiveallthereimbursementswhentheydotheir

taxesthenextyear(Will).

Thesepremiumreimbursementsarebasedonaslidingscalethatisdependentuponanindividual’s

income.Individualsupto400%FPLwillgetaloweramountofpremiumassistancethanthosewhoare

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at100%FPL.Theassistanceamountsarebasedonapercentageoftheindividual’sincomeinthatthe

FederalGovernmentdefinesthemaximumamounttheindividualcanpayforpremiumsandthenwill

paytheremainder.Forindividualswithanincomeof100-133%FPL,theirmaximumpremiumpayment

isequalto2%oftheirincome.Individualsbetween133-150%FPLwillpay3-4%oftheirincomewhilean

incomeof150-200%FPLwillincreasefrom4-6.3%oftheirincome.Incomesfrom200-250%FPLwillpay

6.3-8.05%ofincomeinpremiums,250-300%FPLwillpay8.05-9.5%oftheirincome.Lastly,individuals

withincomesof300-400%FPLwillpay9.5%oftheirincomeinpremiums.Anyonewithincomesabove

400%FPLarenoteligibleforpremiumassistance(Focus—Summary).

ThesecondoptionisthroughCostSharingReductionsavailabletothosewithanincomeupto250%FPL.

Theseoptionsareavailableonlyforsilverlevelplansofferedthroughtheinsurancemarketplace.The

premiumassistanceismodeledoninsuranceplanswithanactuarialvalue,theportiontheinsurance

companywillpay,of70%.UndertheCostSharingReductionoptionavailabletothosebetween100-

250%FPL,itisequivalentofhavingahigheractuarialvalueforthesameinsurance.Individualswith

incomesof100-150%FPLwillhaveanactuarialvalueof94%,150-200%FPLwillhave87%actuarial

valueand200-250%FPLwillhave73%actuarial.ThisoccursbecausetheFederalGovernmentwillpay

partoftheirout-of-pocketexpensessuchasco-paysanddeductibles,makingitsothattheinsurance

companywillpayagreaterportionofthecostsascomparedtoanotherplan(Focus—Explaining).

Inadditiontopayingforoutofpocketcostsandpremiums,thePPACAalsosetsamaximumout-of-

pocketlimitforcostsharingonessentialbenefits.Thesemaximumsvarybyincomerangeandarebased

ontheout-of-pocketlimitsofaHealthSavingsAccount(HSA)qualifiedhealthplanthatis$5,950for

singlecoverageand$11,900forfamily.Theselimitsaretwo-thirdstheHSAamountforincomelevels

100-200%FPL,one-halftheHSAamountfor200-300%FPLandone-thirdtheHSAamountforincomes

300-400%FPL(Focus—Explaining).

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InaninterviewwithKathleenSebelius,secretaryfortheDepartmentofHealthandHumanServices,

Sebeliusstatedthatthegoalwastoenroll7millionpeopleinhealthinsuranceplansduringthe

enrollmentperiodthatstartedOctober1,2013,andendedMarch31,2014(Haberkorn).Atfirst,itdid

notseemthattheywouldhitthisgoalbutatthelastminute,theywereabletoget7.041millionpeople

toenrollinaninsuranceplan(Carey).

LiteratureReview

OnetopiccurrentlyunderdebateistheoverallimpactontheuninsuredpopulationwithintheU.S.This

debateisdividedintotwodifferentareasofinsuranceincrease,throughtheexchangesandMedicaid

expansion.Whenhealthcarereformwasbeingaddressedin2008,thetwomaintopicsofdiscussion

wereaboutrisinghealthcarecostsandthenumberofuninsuredindividualsintheU.S.In2009,the

uninsuredrateforAmericawasaround16.1%oftheU.S.populationwhichisabout48.9million

Americans(US2011).In2013,thatnumberdroppedto13.4%orabout41.9millionAmericans(US

2014).AccordingtotheCongressionalBudgetOffice’s(CBO)originalestimates,thePPACAwould

increasethenumberofinsuredAmericansby18millionwhichwouldleavetheuninsuredpopulationat

27million.However,duetotheSupremeCourt’sdecisionthatmadeMedicaidexpansionoptional,the

CBOrevisedtheirestimatestopredictthatthenumberofAmericansinsuredbythePPACAwould

decreaseby3million(Tanner).Thisamountof3millionwasalsoestimatedbytheRANDCorporationin

astudydonetoestimatetheimpactsofcertainstatesoptingoutoftheMedicaidexpansion(Priceand

Eibner).InastudydonebytheLewinGroup,theyestimatedthatthenumberofuninsuredwouldbe

closerto20millionintotal.Additionally,theyestimatedthattheindividualmandateonlyimpacted

about8millionpeopleinthatwithoutthemandate,thenumberofuninsuredAmericanswouldbe

around28million.ThisestimateismoreconservativethantheCBOestimatesofanincreaseby16

millioninthenumberofuninsuredAmericans(SheilsandHaught2011).Thefullsetofresearch

hypothesesare:

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PPACAHypothesis:ThePPACAwillresultinadecreaseintheuninsuredrate.

TaxHypothesis:Stateswithahigherper-capitataxwillseeanincreaseintheuninsuredrate.

PremiumsHypothesis:Stateswithhigherpremiumsforhealthcarecoveragewillseeanincreaseintheuninsuredrate.

IncomeHypothesis:Stateswithahigherper-capitaincomewillseeadecreaseintheuninsuredrate.

PoliticalIdeologyHypothesis:ConservativestateswillbelesslikelytoexpandMedicaidto138%FPL.

PovertyHypothesis:Stateswithahighpercentageofpeopleunder135%FPLwillbemorelikelytoexpandMedicaidto138%FPL.

SpendingHypothesis:Statesthatspend100%orlessoftheirgeneralfundrevenuewillbelesslikelytoexpandMedicaid.

RaceHypothesis:StateswithahigherpercentageofaCaucasianpopulationwillbelesslikelytoexpandMedicaidto138%FPL.

Sixstates,Washington,Oregon,Tennessee,Hawaii,MassachusettsandMaine,passedstatemanaged

healthplanswiththeplantoextendhealthcoveragetoallcitizensofthestate.Somecommonalities

amongtheseplanswerecommunityratings,capsonpremiumpricesandguaranteesofinsurability.

Communityratingsstatedthatinsurancepremiumswerenottobechargedonanindividualbasisbuton

ageographicallocation.Pricecapswereanattempttocontrolthepriceschargedbynotallowing

insurancecompaniestochargeoveracertainprice.Guaranteesofinsurabilitymeantthatanyone,

regardlessofpre-existingconditionsorcurrenthealthstatus,couldpurchasehealthinsuranceatany

timeoftheirlives.Insteadofimprovingthequalityofhealthcare,allofthestatessawadecreasein

healthcarequalitythateventuallyleadtomanyofthereformsbeingrepealed.Whattheselawmakers

eitherdidn’tunderstandorjustsimplyignoredwasbasiceconomics.Byimposingcapsonpremium

prices,insurancecompanieswereunabletochargepricestoappropriatelypayforthehealthbenefits.

Thecommunityratingsnotonlypreventedtheinsurancecompaniestochargeappropriateprices,but

alsocontributedtoincreasingthenumberofpeopleuninsured.Thisisbecauseitforcedthosethatare

healthytopayhigherpricesthantheynormallywouldwhereasthosethatweresickwouldpaylower

premiumsthantheynormallywould.Insurancecompaniessawanincreasednumberofsickpeople

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buyingpoliciesandanincreasingnumberofhealthypeopledroppinginsurance.Thisaffectwas

compoundedbytheguaranteeofinsurabilitybecauseitallowedpeopletolegallydroptheircoverage

whentheywerehealthyandthenbuypoliciesduringtimesofcrisisorsickness(Stark).

Anotherfinancialtopicunderdebateistheimpactoninsurancepremiumsforindividualsandfamilies.

Tounderstandtheimpactsonhealthinsurancepremiums,itisimportanttounderstandthatpremiums

aredeterminedbyhealthinsurancecompaniesthroughtheirunderwritingphase.Underwriters

determineifapplicantsareapprovedandhowmuchhe/shewillpayinpremiumsbasedontheoverall

healthandtheriskfactortheyimpose(Botkin).Currently,whileinsurancepremiumshavecontinuedto

rise,theyhaverisenataslowerratethantheyhaveinthepast.ProponentsofthePPACAattributethis

tothePPACAwhileopponentsattributethistotheeconomicrecessionwhereeverythingsloweddown.

Manypeoplepredictthathealthinsurancepremiumswillincreasesimplyduetothechangesassociated

withthePPACA.Thesechangesincludegroupratings,whichbasespremiumsonascalerangebasedon

thecommunitytheindividuallivesinratherthantheindividual’shealth,andprohibitingcoverage

denialsbasedonpreexistingconditions.Despitethisincreaseininsurancepremiums,noteveryonewill

experiencetheincreaseinthesameway(Tanner).

Forexample,individualsthatfallwithin100-400%oftheFPLwillbeeligibletoreceivesubsidiesfromthe

FederalGovernmenttohelpoffsettheincreaseincosts.However,thosethatareonthelowerendof

subsidiesorreceivenosubsidieswilllikelyseeanincreaseinoutpremiumcoststhataregreaterthan

theirsubsidies.Withtherisingpremiums,itisimportanttonotethatduetothePPACA’sgrouprating,

mostoftheincreaseinpremiumswillbeseenbytheyoungerandhealthierpopulationwhiletheelderly

willpotentiallyseetheirpremiumsremainthesameordecrease(Tanner).Thischangeinpremiumprice

betweentheyoungerandoldergenerationscontributestothespiralingpremiumtheory.Thistheory

statesthatasthepremiumsfortheyoungerandhealthierinsuredscontinuetorise,moreandmorewill

decidetodroptheircoverage.Thislossleadstoadisproportionateamountofyoungandhealthy

18

individualsnotintheriskpoolascomparedtoolderandsickerindividualswhoareintheriskpool.This

resultsinpremiumscontinuingtorisecausingagreaterdecreaseintheyoungandhealthyinsureds.

Despitethistheory,however,researchershavebeenunabletoproveittobetrue—evenincasesof

largepremiumincreases(SheilsandHaught2011).

Atfirstglance,Gruberseemstoarguethatinsurancepremiumswillincrease10-13%morethanthey

wouldhavewithoutthePPACA.However,theCBOestimatesthatthisincreaseisdependentonthe

typesofpoliciespurchasedfornon-grouppolicies.Thepredictionsarebaseduponthreedifferent

categories,thehealthmixtureofinsuredindividuals,enhancedcompetitionandincreasedgenerosityof

policies.AccordingtotheCBOestimates,thefirsttwocategorieswillactuallyresultinpremiums

decreasing;whereasthethirdcategory,plangenerosity,cancounteractthedecreasesandresultinan

overallincrease.Duetothisfactorbeingincontroloftheindividualpurchasinginsurance,itisquite

possibleforthisestimatetovaryinactualresultsdependingonthelevelofpoliciesthatconsumers

purchase.Forgrouppolicies,theCBOestimateslittletonochangeinpremiumincreaseswhichis

consistentwiththeresultsfromMassachusetts(Gruber).

Onegroupthatincursthemostcostinregardstohealthinsuranceistheelderly.Adverseselectionisan

insurancetermusedtodescribeanindividualwithahighrateofrisk.Insurancecompanieswillavoid

adverseselectionwheneverpossibleinordertolimitcosts.Tocontrolforadverseselection,every

applicantundergoesareviewprocesstodeterminetheriskofthatindividualorgroup.Theelderlyhave

ahigherdenialratebecausetheyareathigherriskforincurringlargemedicalexpenses.Inorderto

providehealthcoveragefortheelderly,theMedicare-Medicaidactwassignedintolaw.Medicaidisa

governmentrunprogramdesignedtoprovidehealthcoveragetotheindigentelderly,theblindand

permanentlydisabled.Itisadministeredbythestatesunderfederalguidelines.AsthecostsofMedicaid

increased,congressbegantolimittheeligibilityrequirementsinanattempttocontainthecosts(Cohn).

19

OnemajorgoalofthePPACAistolowertheuninsuredrate.Accordingtotheanalysisdoneby

RichardsonandYilmazer(2013),stateswithmoregenerousMedicaideligibilityruleswillseeasmaller

increaseinMedicaidparticipantsandindividualsenrollinginthesubsidizedexchanges.Inaddition,

statesthathavehigherpercentageofESIwillseelowerenrollmentsintosubsidizedexchanges

(RichardsonandYilmazer2013).WhilethePPACAwasapplieduniformlythroughoutthecountry,each

stateislikelytoexperiencedifferentresults.StatesthathadgenerousMedicaideligibilityrequirements

beforeexpandingwilllikelyseeasmalltomodestgrowthinMedicaidparticipantsunlesstheyhavea

highlevelofpovertyinwhichcasetheywillseealargegrowthinMedicaid(RichardsonandYilmazer

2013).

DuringthedebatetopassthePPACAandsinceitsconception,manygroupshaveattemptedtoweighin

onthedebatebycompletingtheirowntypeofmodelingontheimpactofthePPACA.Usingmicro-

simulationmodelsmanyorganizationsestimatedthenumberofpeoplewhowouldgainhealth

insuranceunderthePPACA(e.g.,seeRobyetal.2013).TheCBOestimatedthatunderthePPACA32

millionpeoplewouldgainhealthinsuranceby2019,theUrbanInstitutepredicted27.8millionwould

gaincoverage,andtheLewinGroupestimated30.7millionwouldgaincoverage(Robyetal.2013).In

additiontonationalstudies,manygroupshavebuiltmodelstoexplainchangesinstate-levelhealth

insurancecoverageresultingfromthePPACA(Robyetal.2013).Robyetal.(2013)testedtwomodelsof

thePPACA:thefirstbeingageneralimpactoftheoverallPPACAandthesecondtotesttheimpactof

themandate.Inthegeneralmodel,theyfoundadecreaseinthenumberofuninsuredindividualsby

30.73%(5,791,000to4,011,000).Inadditiontoanetincreaseinthenumberofinsuredindividuals,they

alsofoundthatthenetnumberofESIdecreasedwhilethenumberofMedicaidparticipantsincreased.

InRobyetal.’s(2013)secondmodel,theytestedtheimpactofthePPACAwithoutthemandatefor

coverage.Inthismodel,thenumberofuninsuredindividualsstilldropped,butby53%lessthanthe

whenthemandateisinclude.Thisreductioninthenumberofinsuredindividualscamefrompeoplenot

20

enrollingineithersubsidizedinsuranceortheindividualmarket(Robyetal.2013).Thisdifference

causedbythemandateissimilartoothernationalstudiesaswell.TheCBOestimatedareductionof

50%,JonathonGruberestimatedatleast50%,andtheLewingroupestimated25.3%.However,these

reductionswouldonlycomefromtheinsuranceexchangesorindividualmarketasthemandatewould

notimpactthenumberofMedicaidparticipants(Robyetal2013;SheilsandHaught2011).

AccordingtoamorerecentstudyconductedbyUrbanInstitute(2012),Medicaidwouldincreaseby

about5.6millionpeopleincontrastto21.2millionifallstatesexpandedMedicaid.Inadditiontothese

changestotheuninsured,theUrbanInstitutealsocalculatedthechangeinMedicaidandGeneralFund

expendituresperstate.Overall,theU.S.wouldseea$10billiondecrease(0.1%)instateGeneralFund

expenditures.Thiscostsavingscomesfromtheestimatedsavingsinuncompensatedcarethatwould

counteracttheincreaseinMedicaidexpendituresaspartofthestate’sbudget(Holahanetal.2012).

Thisfinancialanalysis,however,overstatesandunderstatesnetcostsandgains,respectively,becauseit

onlyusesgeneralizeddatacollectedforall50states(Holahanetal.2012;Robyetal.2013).Other

financialvariables,suchasnon-Medicaidhealthcarespending,taxesandeconomicactivity,could

increasethenetcostsorsavings(Holahanetal.2012).

ToestimatetheimpactsofthePPACA,KolstadandKowalski(2012)measuredthechangeininsurance

statusinMassachusettsbyanalyzinghospitaldischargedata.Intheiranalysis,theycomparedthe

overallimpactsinMassachusettsusingthecurrentpopulationsurvey(CPS)dataandtheNational

InpatientSample(NIS)datafromtheHealthcareCostandUtilizationProjecttoexaminethecoverageof

hospitalizedpatientsaroundtheU.S.incomparison.Inrunningadifference-in-differencemodel,the

authorsfoundthattheoveralluninsuredpercentageofthepopulationdecreasedinboththeCPSand

NISdatamodel.IntheNISdata,Medicaidwasfoundtohaveincreasedwhilecrowdingouttheprivate

insurancepercentage.However,usingtheCPSdataresultedinanincreaseinboththeMedicaid

participantsandemployersponsoredinsurancewithasmallcrowdingoutofprivatenon-employment

21

basedinsurance(Kolstand&Kowalski2012).Usingalogisticdifference-in-differencemodel,Sonier,

BoudreauxandBlewett(2013)showedthatMassachusettssawastatisticallysignificantgrowthin

Medicaidparticipationthatwasdifferentfromacontrolgroupofeasternstates.Whilethiscanbeused

topredictsimilarresultstooccurfromthePPACA,itisimportanttorealizethatstateswillvary

regardinggenerosityofMedicaideligibilitywhichwillimpacthowmuchgrowthmayormaynotoccurin

otherstates(Sonier,BoudreauxandBlewett2013).

Currently,20%ofBlacksandAsiansand30%ofLatinosareconsidereduninsuredandmanystudieshave

shownthatthereisasignificantcoveragedifferencebetweenblacksandwhitesandbetweennatives

andimmigrants(Filindra2012).StudieshavealsoshownthatAfricanAmericanssufferfrompoorer

healthsuchashigheradultandinfantmortalityrates,cancers,HIVandotherhealthproblemsthat

whites(FiscellaandWilliams2004).Inherstudy,AlexandraFilindra(2012)analyzedtheimmigrant

inclusivityofstateeligibilityrequirementsforTemporaryAssistanceforNeedyFamilies(TANF)and

Medicaid.ShefoundthatthepercentageoftheAfricanAmericanpopulationhadasignificantand

negativeeffectontheTANFinclusivitybutnosignificantimpactonMedicaid.Thepercentageofthe

populationinpovertyalsohadasignificantandnegativeimpactonTANFandMedicaidexceptwhen

politicalideologywasadded.Afteraccountingforpoliticalideology,povertynolongerhadasignificant

effectonMedicaidinclusivity.PoliticalideologyalsopositivelyimpactedbothTANFandMedicaidasthe

statebecomemoreliberal(Filindra2012).

Agrowingfieldofacademicliteraturecentersaroundtheconceptofpartisanpoliticsandhealthcare.In

additiontodifferencesbetweeneconomicandsocialpolicies,growingcontentionbetweenDemocrats

andRepublicanshasbeenshownasimpactinghealthcarepolicy.Intheirstudy,LingZhuandJennifer

Clark(2015)createdaGinivariablemeasuringinequalityregardinghealthcarecoveragebaseduponthe

relationshipbetweenincomedistributionandhealthcarecoverage.ZhuandClark(2015)discovered

22

thatthereisasignificantandnegativerelationshipbetweenastatehavingaDemocratsupermajority

andhealthcareinequality.Racialdiversitywasfoundtohaveapositiverelationshipwithhealthcare

inequalityhoweverthiseffectwasdiminishedastheDemocraticmajorityincreased(ZhuandClark

2015).

SimonHaederandDavidWeimer(2013)discoveredthatstatesthatjoinedthelawsuitagainstthe

PPACAwerelesslikelytoestablishastatebasedinsuranceexchange.Thestateisalsolesslikelyto

establishandinsuranceexchangeifthegovernorisRepublicanwhileaunifiedDemocraticlegislatureis

morelikelytoestablishaninsuranceexchange(HaederandWeimer2013).ElizabethRigby(2012)found

thatastatewasmorelikelytoresistthePPACAwhenthepublicopposedthePPACA,thecontrolling

partywasRepublicanorthelegislatureswerelessprofessionalized.BarrilleauxandRainey(2014)found

strongevidencestatingthatRepublicangovernorsweremorelikelytoopposetheideaofexpansion

regardlessifthelegislaturewascontrolledbyRepublicansorDemocrats.ARepublicancontrolled

legislaturealsohasanimpactbutnotasmuch.WhileaDemocratcontrolledlegislaturelowersthe

oppositionfromaRepublicangovernor,theopinionofthepeoplealsocanlowerit.Aspoliticalopinion

becomesmorefavorableforthePPACA,Republicangovernor’soppositiontowardsexpansion

decreases.IftheRepublicanlegislatureisdealingwithaRepublicangovernor,thenthegovernorismore

likelytoopposeexpansionbutthereisessentiallynoeffectifthegovernorisaDemocrat(Barrilleaux&

Rainey2014).

InRasmussenetal.(2013),researchersfoundthatthe26stateschoosingnottoexpandMedicaidhad

anuninsuredrateof42%ofpeoplewhopotentiallywouldfallinthecoveragegapascomparedto29%

inthestatesplanningtoexpand.Duetothevariabilityinjobsandincome29%ofthosewithincomes

between100-133%FPLand12%withincomesfrom133-249%FPLfoundthemselvesineconomic

23

situationswheretheyfellbelowthe100%threshold.Incontrast,30%withincomesbelowthe100%

thresholdreceivedandeconomicgainthatboostedthemabovethethresholdwheretheycouldqualify

forsubsidies(Rasmussenetal.2013).

Methods

Forthisstudy,Iamconductingtwodifferenttypesofmodelsinregardstotheuninsuredrateandthe

Medicaidexpansiondecision.Tomodeltheimpactsontheuninsuredrate,Iamrunningastatefixed-

effectsregressiononall50statesinordertoaccountforvariationsbetweenstatesusingtimeseries

datafrom2004-2014.

Iamusingasimplymultivariatelinearregressiononall50statesusing2014datatomodeltheMedicaid

expansionresultsasthiswasaonetimedecisionmadeindividuallybyeachstate.

TABLE1:VARIABLEDESCRIPTIONSANDSOURCESVARIABLE Description DataSourceIDEOLOGY Quantitativescorerangingfrom-100(perfectlyliberal)

to100(perfectlyconservative)baseduponvotingrecordsforU.S.SenatorsandCongressmen.

AmericansforDemocraticAction,AmericanConservativeUnion

RESISINDX Politicalrankingofresistanceranging0-3 Rigby,ElizabethVOTING Percentageofthevotingeligiblepopulationthatvoted

inthegeneralelectionsUnitedStatesElectionsProject,NonprofitVOTE,GeorgeWashingtonUniversity

COLLPOP Percentageofthestate’spopulation25andolderwithabachelor’sdegree

U.S.Census

HSPOP Percentageofthestate’spopulation25andolderwithahighschooldiploma

U.S.Census

PERCAPINC Statepercapitaincome BureauofEconomicAnalysis

PVRT100 Percentageofastate’spopulationthatisatorbelow100%FPL

U.S.Census

PVRT135 Percentageofastate’spopulationthatisatorbelow135%FPL

U.S.Census

GINI Giniscoreperstate America’sHealthRankings,U.S.Census

24

SINGPREM Averageannualcostforanemployee’shealthinsuranceforsinglecoverage

U.S.AgencyforHealthcareResearchandQuality

EMPINS Percentageofthestate’spopulationcoveredbyemployersponsoredhealthinsurance

U.S.Census

UNEMP Percentageofthestate’spopulationthatisunemployed

BureauofLaborStatistics

MEDINS Percentageofthestate’spopulationcoveredbyMedicaid

U.S.Census

GENSPEND Percentageofthestate’sgeneralfundthatisspent.Thisiscalculatedbydividingtheamountofexpendituresfromthegeneralfundbytheamountofrevenuesinthegeneralfund

NationalAssociationofStateBudgetOfficers

FEDSPEND Percentageofastate’sexpenditurethatcomesfromfederalfunds

NationalAssociationofStateBudgetOfficers

MEDSPEND Percentageofastate’sbudgetspentonMedicaid NationalAssociationofStateBudgetOfficers

PERCAPTAX Thisistheamountoftaxrevenuesperemployee.Thisiscalculatedbydividingthetotaltaxrevenuebytheamountoffull/parttimeemployees.

TheNelsonA.RockefellerInstituteofGovernment

HEALTH ThisisaquantitativescoretakenfromAmerica’sHealthRankingabouttheoverallhealthstatusofeachstate

America’sHealthRankings

POPDENS Totalpopulation/totallandareaofeachstate U.S.CensusAGE Percentageofastate’spopulationthatisbetweenthe

agesof18-64U.S.Census

RACCAUC Percentageofastate’spopulationthatidentifiesonlyasCaucasian

U.S.Census

ACA AdummyvariablerepresentingwhentheACAwaspassed.0=beforeACA,1=ACA

PARTEXCH Thisisadummyvariablewhere1=partnershiphealthcareexchangebetweentheFederalandStategovernment,0=nopartnershipexchange

KaiserFamilyFoundation

Data

TABLE2:UNINSUREDMODEL Fullmodel Model1 Model2 Model3IDEOLOGY 0.001

(0.339)b0.001(0.685)

----- ----

COLLPOP -0.116(0.134)

---- ---- ----

HSPOP -0.167(0.068)

---- ---- ----

PERCAPINC 0.001(0.407)

0.001(0.455)

0.001(0.132)

0.001(0.14)

PVRT100 -0.031(.865)

---- ---- 0.06(0.232)

25

GINI -0.048(0.524)

-0.032(0.666)

---- -0.073(0.341)

SINGPREM -0.001(0.001)

-0.001***(0.001)

-0.001***(0.001)

-0.001***(0.001)

EMPINS -0.278***(0.001)

-0.26***(0.001)

-0.24***(0.001)

----

UNEMP 0.351***(0.001)

0.375***(0.001)

0.43***(0.001)

0.537***(0.001)

GENSPEND 0.006(0.267)

0.006(0.202)

---- ----

PERCAPTAX 0.001(0.216)

0.001(0.179)

0.001(0.122)

----

HEALTH 0.004(0.512)

---- ---- -0.001(0.926)

POPDENS -0.001***(0.001)

-0.001***(0.001)

-0.001***(0.001)

-0.001***(0.001)

RACCAUC -0.154***(0.001)

-0.161***(0.001)

-0.162***(0.001)

-0.188***(0.001)

AGE 0.178(0.296)

0.228(0.178)

---- 0.11(0.517)

ACA -0.005(0.051)

-0.007*(0.019)

-0.004(0.063)

-0.001(0.625)

CONSTANT 0.657***(0.001)

0.443***(0.001)

0.569***(0.001)

0.379**(0.004)

aP<.05*,P<.01**,P<.001***bp-valuesinparentheses

TABLE3:MEDICAIDEXPANSION Fullmodel Model1 Model2 Model3 Model4PARTEXCH 0.216a

(0.084)b0.317**(0.005)

0.304**(0.006)

0.288**(0.006)

0.278**(0.007)

RESISINDX -0.058(0.342)

---- -0.111*(0.021)

---- -0.137**(0.002)

IDEOLOGY -0.001(0.538)

-0.003(0.057)

---- -0.003**(0.004)

----

VOTING -0.045(0.954)

-0.051(0.932)

0.009(0.988)

---- ----

HSPOP -0.432(0.904)

---- ---- ---- ----

COLLPOP 0.579(0.735)

---- ---- ---- ----

PERCAPINC 0.001(0.113)

---- ---- ---- ----

PVRT135 2.263(0.316)

3.08*(0.026)

1.861(0.158)

3.152*(0.017)

1.516(0.206)

GINI -6.432 -4.015 -4.224 ---- ----

26

(0.143) (0.235) (0.192)MEDINS 1.756

(0.437)---- ---- ---- ----

UNEMP 9.262(0.111)

---- ---- ---- ----

EMPINS 3.042*(0.044)

2.491(0.06)

1.928(0.11)

3.227**(0.004)

2.535*(0.018)

FEDSPEND 0.29(0.752)

---- ---- ---- ----

GENSPEND -0.354(0.19)

-0.196(0.42)

-0.233(0.31)

-0.191(0.369)

-0.236(0.239)

PERCAPTAX 0.109*(0.018)

0.125***(0.001)

0.118**(0.002)

0.099**(0.002)

0.092**(0.004)

MEDSPEND 0.928(0.326)

1.102(0.171)

1.054(0.179)

---- ----

POPDENS -0.001(0.607)

0.001(0.413)

0.001(0.347)

---- ----

RACCAUC 0.536(0.15)

0.439(0.217)

0.454(0.192)

0.46(0.14)

0.485(0.113)

AGE -2.082(0.696)

4.635(0.256)

6.938(0.059)

2.734(0.453)

5.9(0.068)

CONSTANT 0.339(0.953)

-3.453(0.19)

-4.05(0.114)

-4.161(0.083)

-5.188(0.023)

ADJUSTEDR2 .635 .616 .634 .629 .644aP<.05*,P<.01**,P<.001***bp-valuesinparentheses

Discussion

Inrunningtheuninsuredmodel,IconcludethatthereislimitedevidencetosupportthePPACA

hypothesisasitisnotsignificantforallthemodels.Thereisnoevidencetosupportthetaxhypothesis

northeincomehypothesis.Surprisingly,thereisevidencetorejectthepremiumhypothesisasthe

evidencesuggeststhataspremiumsincreaseby$1,theuninsuredpopulationwilldecreaseby.001%.

InrunningtheMedicaidexpansionmodel,Iconcludethereislimitedevidencetosupporttheideology

hypothesisasitissignificantinsomemodelsbutnotall.Iconcludethereisevidencetosupportthe

povertyhypothesis.Itisinterestingtonotethatpovertyissignificantwhenideologyisinthemodelbut

27

whenideologyisreplacedwithresisindxvariablethenpovertyisnolongersignificant.Thereisno

evidencetosupportthespendinghypothesisnortheracehypothesis.

28

Figures

Figure2

Figure1

29

Figure3

30

AL

AK

AZ

AR

CA

CO

CTDE

FL

GA

HI

ID

IL

IN

IA

KS

KY

LA

MEMD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

NDOH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VT

VA

WAWV

WI

WY

AL

AK

AZ

ARCA

CO

CTDE

FLGA

HI

ID

IL

IN

IA

KS

KY

LA

ME

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

NDOH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VT

VA

WAWV

WI

WY

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Uninsured

StateUninsured2013-2014

2013

2014

Linear(2013)

Linear(2014)

31

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

2002 2004 2006 2008 2010 2012 2014 2016 2018

StateAverageUninsuredRate2004-2014

32

WorksCited

Litreview

1. Barrilleaux,C.,andRainey,C.(2014).“ThePoliticsofNeed:ExaminingGovernors’DecisionstoOpposethe‘Obamacare’MedicaidExpansion.”StatePolitics&PolicyQuarterly14(4)437-460.

2. Botkin,K.10FactorsThatAffectYourHealthInsurancePremiumCosts.MoneyCrashers.RetrievedNovember1,2014,fromhttp://www.moneycrashers.com/factors-health-insurance-premium-costs/

3. Brownlee,Shannon.Overtreatedwhytoomuchmedicineismakingussickerandpoorer.NewYork:BloomsburyUSA,2007.Print.

4. Burrill,Steve.“HealthCareIndustryConvergenceIt’saSmall(er)WorldAfterAll.”Deloitte.SenateBuilding,SaltLakeCity,UT.25Feb.2014.Speaker.

5. Carey,MaryAgnes.“AsInsuranceEnrollmentExceeds7M,ObamasaysHealthLaw‘HeretoStay’”.KaiserHealthNews.1Apr.2014.Web.7Apr.2014.

6. Chernew,MichaelE.,andJosephP.Newhouse.“HealthCareSpendingGrowth.”HandbookofHealthEconomics.Vol.2.Ed.MarkV.Pauly,ThomasG.McGuire,andPedroP.Barros.UnitedStatesofAmerica:NorthHolland,2012.Print.

7. Cohn,Jonathan.SicktheUntoldStoryofAmerica’sHealthCareCrisis-AndthePeopleWhoPaythePrice.NewYork,NY:HarperCollinsPublishers,2007.Print.

8. Filindra,A.(2012).“ImmigrantSocialPolicyintheAmericanStates:RacePoliticsandStateTANFandMedicaidEligibilityRulesforLegalPermanentResidents.”StatePolitics&PolicyQuarterly13(1),26-48.

9. Fiscella,K.andWilliams,D.(2004).“HealthDisparitiesBasedonSocioeconomicInequities:ImplicationsforUrbanHealthCare.”AcademicMedicine79(12),1139-1147.

10. FocusonHealthReform.“ExplainingHealthCareReform:QuestionsAboutHealthInsuranceSubsidies.”TheHenryJ.KaiserFamilyFoundation.July2012.Web.13Mar.2014.

11. FocusonHealthReform.“SummaryoftheAffordableCareAct.”TheHenryJ.KaiserFamilyFoundation.23Apr.2013.Web.7Nov.2014.

12. GruberJ.(2011).TheImpactsoftheAffordableCareAct:HowReasonablearetheProjections?NationalTaxJournal64(3),893-908.

13. Haberkorn,Jennifer.“KathleenSebelius:Exchangeenrollmentgoalis7millionbyendofMarch.”Politco.24June2013.Web.7Apr.2014.

14. Haeder,S.,andWeimer,D.(2013).“YouCan’tMakeMeDoIt:StateImplementationofInsuranceExchangesundertheAffordableCareAct.”PublicAdministrationReview75(S1),S34-S47.

15. HealthInsuranceDetailedTable:2000.(2001).U.S.CensusBureau,CurrentPopulationSurvey,March2000and2001[HTMLfile].Retrievedfromhttp://www.census.gov/hhes/www/hlthins/data/incpovhlth/2000/hi00t1.html

16. HealthReform.“EmployerResponsibilityUndertheAffordableCareAct.”TheHenryJ.KaiserFamilyFoundation.15July2013.Web.2Apr.2014.

17. Holahan,J.,Buettgens,M.,Carrol,C.,&Dorn,S.“TheCostandCoverageImplicationsoftheACAMedicaidExpansion:NationalandState-by-StateAnalysis.”TheUrbanInstitute.November2012.

18. “HowdoIqualifyforanexemptionfromthefeefornothavinghealthcoverage?”HealthCare.gov.U.S.CentersforMedicareandMedicaidServices.N.d.Web.2Apr.2014.

19. InformedAmericanComputersoftware.MicrosoftAppStore.n.p.2012.Web.10Apr.2014.

33

20. Kolstad,J.&Kowalski,A.(2012).“Theimpactofhealthcarereformonhospitalandpreventivecare:EvidencefromMassachusetts.”JournalofPublicEconomics96,909-929.

21. Mitchell,Alison&EvelyneP.Baumrucker.UnitedStates.CongressionalResearchService.Medicaid’sFederalMedicalAssistancePercentage(FMAP),FY2014.Washington:GPO,2013.Web.3Apr.2014.

22. Oberlander,Jonathan.(2010)“LongTimeComing:WhyHealthReformFinallyPassed.”HealthAffairs29:6,1112-1116.

23. Otter,Jack.“Whyeconomistslikethehealthinsurancemandate.”MoneyWatch.CBS,27Mar.2012.Web.2Apr.2014.

24. Perkins,Jane.“ImplicationsoftheSupremeCourt’sACAMedicaidDecision.”JournalofLaw,Medicine&Ethics41.(2013):77-79.AcademicSearchPremier.Web.11Apr.2014.

25. Peters,B.Guy.AmericanPublicPolicyPromise&Performance.8thed.UnitedStatesofAmerica:CQPress,2010.Print.

26. Price,C.C.andEibner,C.(2013).ForStatesThatOptOutOfMedicaidExpansion:3.6MillionFewerInsuredAnd$8.4BillionLessInFederalPayments.HealthAffairs32(6),1030-1036.

27. Rasmussen,P.,Collins,S.,Doty,M.,&Garber,T.(2013).“InStates’HandsHowtheDecisiontoExpandMedicaidWillAffecttheMostFinanciallyVulnerableAmericans.”TheCommonWealthFund1702(23).

28. Rich,RobertF.,EricCheung,&RobertLurvey.“ThePatientProtectionandAffordableCareActof2010:ImplementationChallengesintheContextofFederalism.”JournalOfHealthCareLaw&Policy16.1(2013):77-140.AcademicSearchPremier.Web.10Apr.2014.

29. Richardson,L.&Yilmazer,T.(2013).“UnderstandingtheImpactofHealthReformontheStates:ExpansionofCoveragethroughMedicaidandExchanges.”TheJournalofConsumerAffairs47(2),191-218.

30. Rigby,E.(2012).“StateResistancetoObamaCare.”TheForum10(2)31. Rosenbaum,Sara.“NationalFederationofIndependentBusinessv.SebeliusandtheMedicaid

Aftermath.”PublicAdministrationReview73.supplemental(2013).Web.10Apr.2014.32. Roby,D.,Watson,G.,Jacobs,K.,Graham-Squire,D.,Kinane,C.,Gans,D.,Needleman,J.&

Kominski,G.(2013).“ModelingtheImpactoftheAffordableCareActandtheIndividualMandateonCalifornians.”JournalofFamilyandEconomicIssues34:16-28.

33. Sheils,J.andHaught,R.(2011).WithouttheIndividualMandate,theAffordableCareActWouldStillCover23Million;PremiumsWouldRiseLessThanPredicted.HealthAffairs30(11),2177-2185.

34. Sonier,J.,Boudreaux,M.,andBlewett,L.(2013).“Medicaid‘Welcome-Mat’EffectOfAffordableCareActImplementationCouldBeSubstantial.”HealthAffairs32(7),1319-1325.

35. Stark,Roger,MD.“LessonsFromStateHealthReforms.”ReformingAmerica’sHealthCareSystemtheFlawedVisionofObamaCare.Ed.ScottW.Atlas,MD.Stanford:HooverInstitution,2010.99-122.Print.

36. TableHI05.HealthInsuranceCoverageStatusandTypeofCoveragebyStateandAgeforAllPeople:2010.(2011).U.S.CensusBureau,CurrentPopulationSurvey,2011AnnualSocialandEconomicSupplement[excelfile].Retrievedfromhttp://www.census.gov/hhes/www/cpstables/032011/health/toc.htm

37. Tanner,M.(2013).ThePatientProtectionandAffordableCareAct:ADissentingOpinion.JournalofFamilyandEconomicIssues34,3-15.

34

38. TheKaiserCommissiononMedicaidandtheUninsured.“MedicaidEligibilityforAdultsasofJanuary1,2014.”TheHenryJ.KaiserFamilyFoundation.Oct.2013.Web.23Feb.2014.

39. “TheWorldHealthReport2000HealthSystems:ImprovingPerformance.”TheWorldHealthOrganization.France:2000.Web.18Apr.2014.

40. Thompson,F.J.(2013).HealthReform,PolarizationandPublicAdministration.PublicAdministrationReview73(S1),S3-S12.

41. UnitedStatesCensusBureau.(2011).Income,Poverty,andHealthInsuranceCoverageintheUnitedStates:2010(DepartmentofCommercepublicationNo.P60-239).Washington,DC:U.S.GovernmentPrintingOffice.

42. UnitedStatesCensusBureau.(2014).HealthInsuranceCoverageintheUnitedStates:2013(DepartmentofCommercePublicationNo.P60-250).Washington,DC:U.S.GovernmentPrintingOffice.

43. “WillIqualifyforlowercostsonmonthlypremiums?”HealthCare.U.S.CentersforMedicare&MedicaidServices,N.d.Web.7Apr.2014.

44. Wojcik,S.(2013).“ImplementingthePatientProtectionandAffordableCareAct:TheTimeIsNow”BenefitsQuarterly2,30-33.