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Supplemental material, INQ796361_Online_appendix_CLN for Effects of the Affordable Care Act on Health Care Access and Self-Assessed Health After 3 Years by Charles Courtemanche, James Marton, Benjamin Ukert, Aaron Yelowitz and Daniela Zapata in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

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.

The goal of the Affordable Care Act (ACA) was to achieve nearly universal health insurance coverage through a combination of mandates, subsidies, marketplaces, and Medicaid expansions, most of which took effect in 2014. We use data from the Behavioral Risk Factor Surveillance System to examine the impacts of the ACA on health care access, risky health behaviors, and self-assessed health after two years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from state participation in the Medicaid expansion and pre-ACA uninsured rates. Results suggest that the ACA led to sizeable improvements in access to health care in both Medicaid expansion and non-expansion states, with the gains being larger in expansion states along some dimensions. No statistically significant effects on risky behaviors or self-assessed health emerge for the full sample. However, we find some evidence that the ACA improved self-assessed health among older non-elderly adults, particularly in expansion states.

Restrictions imposed on property assessment practices by state legislation such as Proposition 13 in California and Proposition 2½ in Massachusetts can lead to significant divergences between the assessed and market values of property, particularly for households with long tenures. As properties are assessed at their market value when sold, this can lead to a significant divergence in the property tax payment for a current homeowner and a prospective purchaser of the property. This may lead to “lock-in”, decreased mobility, of homeowners reluctant to lose their tax advantage. Here using data on single family dwellings in Lexington, KY (Fayette County) we examine another practice leading to a systematic difference between assessed and market value of properties, the practice of assessing properties in individual neighborhoods on a four-year basis. In times of high housing appreciation, the difference in tax payments for houses last assessed two or three years earlier and their market values, the tax base for a new purchaser, can be significant and lead to a lock-in effect. Using administrative data from the Fayette County PVA we find evidence that housing sales are higher in the year before a neighborhood assessment suggesting that households adjust their mobility to capture the tax advantage associated with limited assessment.

In 2012, Connecticut became the first state to enact paid sick leave legislation. Using a difference-in-differences framework, we find the law had modest but negative effects on the labor market, particularly on the likelihood of working in the past week.

This paper estimates the impact of the introduction of Medicaid managed care (MMC) on the formal Medicaid participation of children. We employ a quasi-experimental approach exploiting the location-specific timing of MMC implementation in Kentucky. Using data from the March Current Population Survey from 1995-2003, our findings suggest that the introduction of MMC increases the likelihood of being uninsured and decreases formal Medicaid participation. This finding is consistent with an increase in “conditional coverage” – waiting until medical care is needed to sign up or re-enroll in Medicaid. These effects are concentrated among low-income children and absent for high-income children. We find no evidence of “crowd-in” – substituting private coverage for Medicaid. These results are robust to multiple placebo tests and imply the potential for less formal participation (i.e. more conditional coverage) among the ACA Medicaid expansion population (which is likely to be primarily covered under MMC) than is typically predicted.