Funding Opportunity: The Social, Economic, and Political Effects of the Affordable Care Act

Submission Deadlines: See upcoming deadlines

The Affordable Care Act (ACA) of 2010 represents the most significant reform of the U.S. health care system in decades. It was enacted to increase access to health insurance, enhance the quality of care and moderate the growth in costs. The law, and recent and proposed changes to the law, are likely to have had far reaching social, economic and political effects beyond their direct effects on health insurance markets and health outcomes. This initiative support social science research on the social, economic and political effects of the ACA.

RSF is especially interested in funding analyses that address the extent to which the ACA has affected outcomes such as financial security and family economic wellbeing, labor supply and demand, family and children’s outcomes, and participation in other social safety net programs. We are also interested in analyses of the political effects of the implementation of the law, including changes in views about government, support for future government policy changes, or the impact on policy development outside of health care.

We do not fund research on the effects of the ACA on health care delivery or health outcomes (e.g., barriers to implementation, changes in the quality of care and health status, or trends in enrollment, access, and affordability) because these issues are priorities for other funders. To date, the following studies have been funded under this initiative: https://www.russellsage.org/findings-aca-special-initiative. Examples of the kinds of topics and questions that are of interest include, but are not limited to, the following:

Financial Security and Family Economic Wellbeing

The ACA transfers considerable resources to low and moderate income families by subsidizing health insurance and expanding access to Medicaid. These policies increase total resources for targeted households and reduce their exposure to the financial risks associated with high medical bills. To what extent has the coverage expansion reduced this risk and improved material wellbeing among low and moderate-income families? To what extent has reduced spending on medical care freed up financial resources for other purposes, such as greater investments in child care or education or retirement savings?

Labor Market Outcomes

Given the association between health insurance and employment, the ACA may have had significant effects on both labor supply and labor demand. To what extent has the increased availability of affordable insurance alleviated “job-lock”? To what extent has it affected early retirement or voluntary part-time work, self-employment or entrepreneurship? To what extent has it affected the employment or higher education choices of young adults? To what extent has the availability of insurance affected the use of family leave for childbirth or to care for sick family members?

On the demand side of the labor market, larger firms are subject to penalties if they do not provide affordable coverage to employees working more than 30 hours per week. To what extent have firms shifted low-wage workers to part-time schedules to avoid the penalties? To what extent have workers who gained employer-sponsored insurance paid for this coverage through reduced wages or total compensation? To what extent have employers responded to the mandate, for example, by choosing insurance plans with greater employee cost-sharing?

Public Program Participation

The ACA’s Medicaid eligibility expansion extended coverage to low-income adults who were previously ineligible. Publicity about the law also increased coverage among people who were already eligible for Medicaid, but had not previously enrolled. To what extent has increased Medicaid enrollment contributed to increased enrollment for other means-tested programs such as the Supplemental Nutrition Assistance Program or the Earned Income Tax Credit? To what extent has the increased availability of Medicaid and subsidized health insurance affected enrollment in Social Security Disability (SSDI) or Supplemental Security Income (SSI)?

States are now being encouraged to submit waiver proposals that impose work requirements as a condition of Medicaid enrollment. To what exent do work-tests affect enrollment (especially of child-less adults who were not eligible for Medicaid before the ACA) and the social and economic wellbeing of those who are Medicaid eligible? Where work or work-related activities are required, what happens when recipients search for work, but cannot find an employer who will hire them? This may be especially relevant for Medicaid recipients with a substance abuse disorder or a criminal record. Some waiver proposals would allow states to impose more cost sharing or lock-out periods in Medicaid. To what extent migh these proposed changes affect participation in Medicaid and recipient financial security?

Family and Children’s Outcomes

Research suggests that gains in coverage for parents translate into gains in coverage and access to care for children which, in turn, might improve adult outcomes. To the extent that coverage expansions have improved the social and economic wellbeing of families, have they also affected the long-run outcomes of the children? For example, to what extent does parental Medicaid participation affect high school completion, college enrollment and other outcomes (e.g., fertility, earnings) as their children transition to adulthood?  

Immigrant Outcomes

The ACA will expand the coverage options for some, but not all, immigrant groups. Undocumented immigrants will not be allowed to enroll in Medicaid, nor will they be eligible to purchase coverage through the health insurance exchanges. Thus, most of the unauthorized foreign-born will likely remain uninsured. In addition, adult legalized permanent residents currently face a five-year waiting period to qualify for most public benefits, including health insurance coverage. What does this mean for the goals of immigrant integration? What are short- and long-term costs of excluding those whose legal status is not regularized from access to health care? How will differential enrollment policies affect social and economic outcomes for mixed-status families? Will differential enrollment policies affect immigrants understanding of, and attitudes towards, the new law?

Effects on Politics, Political Culture, and Public Policy

The U.S. has a long history of channeling public support through private sector mechanisms and the tax code. Measures of public opinion show that, when asked abstract questions, Americans oppose “big government” and any infringement on “individual liberties.” What explains the initial wide-spread disaffection with the ACA and the more recent increases in support for the law? How are attitudes changing as ACA implementation continues? To what extent have personal experiences with the ACA affected support for the law, views of government generally, and attitudes about future reform efforts? How do proposed changes to the law at the federal and state level –particularly those that roll back various provisions—affect engagement, mobilization, participation and attitudes towards the law?

The ACA requires all health insurance plans to cover minimum essential benefits. How are public attitudes towards Medicaid and the ACA interacting with political movements or politics? How are people whose incomes are higher than the income eligibility limit for premium tax credit subsidies judging their options for health insurance? 

Important for Applicants Proposing Causal Analyses

Difference-in-Differences estimation (DD) has become a standard method for estimating causal relationships in program and policy evaluation research. The appeal stems in part from the ease of its implementation. However, Difference-in-Differences is not without drawbacks. Research involving the use of DD techniques should address the limitations of DD estimates in the context of the Affordable Care Act. The applicant(s) should conduct the appropriate diagnostics and discuss strategies to correct for potential biases. A partial list of relevant references follows.

  • Abadie, Alberto. 2005. “Semiparametric Difference-in-Difference Estimators.” Review of Economic Studies, 72 (1) (January): 1-19.
  • Athey, Susan and Guido W. Imbens. 2006. "Identification and Inference in Nonlinear Difference-in-Differences Models." Econometrica, 74 (2): 431-97.
  • Bertrand, Marianne, Esther Duflo and Sendhil Mullainathan. 2004. “How Much Should We Trust Differences-In-Differences Estimates?” Quarterly Journal of Economics, 119 (1): 249-75.
  • Daw, Jamie R. and Laura A. Hatfield. Forthcoming 2018. “Matching and Regression-to-the-Mean in Difference-in-Differences Analysis.” Health Services Research.
  • Imbens, Guido W. and Jeffrey M. Wooldridge. 2009. Recent developments in the econometrics of program evaluation. Journal of Economic Literature, 47 (1): 5-86.
  • Dimick, Justin B. and Andrew M. Ryan. 2014. “Methods for Evaluating Changes in Health Care Policy: The Difference-in-Differences Approach.” Journal of the American Medical Association, 312(22): 2401-2
  • Rokicki, Slawa, Jessica Cohen, Günther Fink, Joshua A. Salomon, and Marybeth Landrum. 2018. Inference with Difference-in Differences with a Small Number of Groups. Medical Care, 56 (1): 97-105
  • Ryan, Andrew M., James F. Burgess and Justin B. Dimick. Why We Should Not Be Indifferent to Specification Choices for Difference-in-Differences. Health Services Research, 50 (4): 1211-35.

 

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