Health insurance generosity and conditional coverage: Evidence from medicaid managed care in Kentucky

This article 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 to 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 Affordable Care Act‐Medicaid expansion population (which is likely to be primarily covered under MMC) than is typically predicted.     

U.S. States,the Medicaid Program,and Tax Smoothing

This paper tests the tax smoothing theory by focusing on its implication that a change in permanent government spending should result in an equal sized change in the tax rate. The effect of Medicaid, a state administered, federal and state funded medical insurance program for the poor, on state tax rates is investigated. The Medicaid program provides a natural experiment for this test as states are required to cover certain groups in order to receive federal matching money. Additionally, during the 1980s, a series of federal mandates greatly increased state Medicaid expenditures. Two stage least squares is used on a panel of U.S. states (1978-1994) to test whether changes in permanent state Medicaid expenditures resulted in equal sized tax rate changes. Tax smoothing as a positive theory of state government behavior is rejected. Additionally, it is found that this rejection cannot be attributed to the stringency of balanced budget rules.     

The Social Performance and Distributional Consequences of Contract Farming: An Equilibrium Analysis of the Arachide de Bouche Program in Senegal

This paper is an empirical analysis of the impact of a contract-farming program in Senegal. We examine the access of poorer community members to contracts and the effect of the program on the income of participants. The program performs very well on both counts: participants and nonparticipants are indistinguishable by wealth measures and farmers increase their income substantially by participating in the program. We attribute the former to the program's mobilization of local information through its use of village intermediaries, permitting the substitution of social collateral for physical collateral and making the program more accessible to the poor.     

Pregnancy outcomes for medicaid patients in mandatory managed care: The Pennsylvania HealthChoices program

A number of states have adopted mandatory managed care to provide health services to Medicaid patients, raising concerns that the care provided may be of lower quality than care provided under traditional fee‐for‐service arrangements. In this article, we study the effect of Pennsylvania's mandatory managed care program, HealthChoices, on health outcomes and the cost of care for pregnant Medicaid patients. Using difference‐in‐differences, we find evidence that the adoption of managed care resulted in fewer preventable complications, particularly for more severely ill mothers, but no general reduction in costs except in the highest decile of the cost distribution.     

Early Effects of the Affordable Care Act on Health Care Access,Risky Health Behaviors,and Self-Assessed Health

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 nonexpansion states, with the gains being larger in expansion states along some dimensions. However, we do not find clear effects on risky behaviors or self-assessed health.     

WIC Participation and Relative Quality of Household Food Purchases: Evidence from FoodAPS

We examine the effect of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on the quality of household food purchases using the National Household Food Acquisition and Purchase Survey (FoodAPS) and propensity score matching. A healthy purchasing index (HPI) is used to measure nutritional quality of household food purchases. WIC foods explain the improvement in quality of food purchases, not self‐selection of more nutrition‐conscious households into the program. The improvement in purchase quality was driven entirely by WIC participating households who redeemed WIC foods during the interview week. There was no significant difference between WIC participants who did not redeem WIC foods and eligible nonparticipants. In this sample, there is no evidence that lack of access to clinics has adverse effects on participation nor is there evidence that HPI depends on supermarket access. A supervised machine learning process supports our main conclusion on the importance of WIC foods.     

Households' participation in energy transition and sustained use of clean energy: Evidence from China's clean heating program

Household energy transition is a critical tool for air pollution mitigation and energy inequality reduction. The effectiveness of the transition largely relies on not only households' decision to participate but also their sustained use of clean energy after participation. However, the sustained use of clean energy has not yet received sufficient attention in policy making and in literature. This study examines China's Household Clean Heating program, which has switched millions of households' heating energy sources from coal to electricity and gas. We focus on both households' adoption and coal substitution behavior in the program. Based on the large-scale household survey conducted in rural areas of Northern China, we find that both high subsidies and compulsory measures effectively increased the household adoption rate; however, the latter did not guarantee sustained use of clean energy. We also find that In-person and repeated dissemination of program information had a better effect on involvement than passive announcements. Moreover, lower-income households were less likely to participate. Our findings suggest effective implementation approaches and supplementary measures to promote household energy transition, with fewer negative consequences for participants, particularly for the participants with lower income.     

Resource allocation, equality of access and health

Based upon the experience of Tanzania, this paper relates resource allocation in the health sector to the output of health, by contrasting access to and utilization of available health services by urban and rural populations. The writer argues that increased health expenditures alone cannot yield an efficient health care return unless the additional expenditure is spread ‘thinly’, in keeping with the realities of population distribution, transport possibilities, and disease patterns in most poor countries. Detailed data are presented for recurrent and capital expenditures for health facilities at different levels, and the output of those institutions is considered in terms of the volume of services offered. Those services are then measured according to their utilization by urban and rural populations. Because referral systems are found to function only marginally, it is argued that further building of large hospitals is not justified in the present situation of most poor countries. Specifically, the writer describes the ways in which Tanzania is changing its inefficient and unjust health care system. The paper concludes that the major obstacles to change are not shortages of resources or technologic ignorance but social systems that do not place high value upon the health care needs of rural peasants. It is in this way that the professional and elitist interests of the few are often destructive of the needs of the many.     

Effects of food stamp program participation and other sociodemographic characteristics on food expenditure patterns of elderly minority households

An Engel-type regression model was used to examine the relationship between Food Stamp program participation, socioeconomic characteristics, and household food expenditures. Findings suggest that Food Stamp subsidies, money income levels, and housing subsidies have a strong relationship with household food expenditure patterns. Food Stamp subsidies were significantly more effective in enhancing food expenditures at the lower household income ranges. Food Stamp subsidies also interacted strongly with housing rental subsidies, feeding programs, and money income to improve the quantity and quality of food consumption. Findings suggest that multiple-program benefits are important policy instruments for providing an adequate economic safety net for the elderly poor.     

Assortative matching and commercial insurance participation: Evidence from the China Household Finance Survey

We investigated three assortative matching forms, positive assortative matching, women marrying up and men marrying up, and their effects on household commercial insurance participation, the number of family members with commercial insurance and household premium expenditures. Men marrying up has a significantly positive effect on the possibility of household commercial insurance participation and the number of family members having commercial insurance. The effect of men marrying up is larger in health insurance than in life insurance and annuity due to the salience of health risks. Finally, men marrying up interacts with the gender and risk attitude of the household financial decision-maker and may jointly affect household commercial insurance participation. Female decision-makers in marriages are more likely to purchase commercial insurance.     

Private Sector Participation in the Provision of Quality Drinking Water in Urban Areas of Ghana: What Do Households Want and Can Afford?

This study conducts a survey among households in three cities in Ghana on how water delivery should be managed. The contingent valuation method was used to estimate the willingness to pay for improved water delivery under private sector participation. Results indicate that most households will remain connected to their current water supplies if private sector is engaged to improve water delivery at higher monthly water bills. Given that the mean household monthly water bill of GH¢10.82, the results indicate that there is demand for water quality improvement, and private sector engagement is likely to provide these services. However, this policy measure marginalises the poor in terms of access to water. Therefore, private sector participation in water delivery may require a complementary programme to promote access to water.     

Food Stamp Program Participation of Refugees and Immigrants

The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) dramatically changed the availability of food stamps to immigrants, but not to refugees. However, refugee usage of food stamps in the post-reform era has declined more than usage of either other immigrants or native citizens. We investigate food stamp program participation of immigrants and refugees to ascertain if the resulting decline was an unintended effect of the reform or is due to some other phenomena. We use data from the Immigration and Naturalization Service to construct an instrument for refugees. We find that refugees are more likely than other immigrants to use food stamps. While PRWORA clearly reduced non-refugee immigrant food stamp participation, the post-reform era decline in refugee usage is fully attributable to a strong refugee response to changing labor market conditions. We also find that refugees' use of food stamps declines rapidly with time in the United States, unlike that of other immigrants.     

Structural determinants of government budget deficits in developing countries

The purpose of this study is to examine the possibility that certain structural factors make some developing countries more likely to incur government budget deficits than others. Empirical evidence is provided to support the hypotheses that developing countries are likely to have larger government budget deficits the lower their level of economic development, the greater the degree of government participation in the economy, and the less control exercised over government expenditures. Less convincing support is given for the hypothesis that revenue instability contributes to government budget deficits. An unexpected result of the study is that growth of government revenues is positively related to budget deficits, which leads the author to consider the possibility of a ‘Please effect’.     

Capacity Building for Post-Disaster Mental Health Since Katrina: The Role of Community Health Workers

The floods and devastation of Hurricanes Katrina and Rita contributed to socioeconomic instability and psychosocial trauma for the affected communities and populations, significantly for people of limited economic means and persons of color. Though more than 1/3 of the adult population from impacted areas experienced significant psychological distress, few people had access to or received appropriate health or mental health services in the months and years that followed. Community health workers (CHWs)—defined as lay community members whose backgrounds are similar to those for whom they provide such services as culturally relevant health education, individual- and community-level advocacy, and links to the health care system— may represent a particularly promising workforce strategy to increase access to quality mental health services and overcome racial and ethnic disparities in care. In this paper, we briefly review a post-disaster mental health training program for CHWs from the greater New Orleans area. We present preliminary evidence that CHWs remain engaged in addressing post-disaster concerns, and that there is community support for further CHW education. We discuss implications for CHW participation in recovery from future disasters and we highlight the work of Cynthia Carriere, a CHW from the Lower 9th Ward in New Orleans.     

Population aging,consumption budget allocation and sectoral growth

This paper assesses the heterogeneous effects of population aging on personal budget allocation across sectors. Using China's household survey data, we break down each household expenditure component into its constituent members. We find consistent and robust age profiles of the composition of personal consumption expenditures. Young people spend larger proportions of their budget on food and education, culture, and recreation services. The middle-aged spend significantly more on clothing and transportation and communication. Lastly, the elderly spend substantially more on food and health care and medical services. After controlling for period and cohort effects as well as other socio-economic factors, we still find age to be a fundamental driver of consumption budget allocation. We also incorporate the estimated results into the population forecast data and predict the evolution of China's consumption budget allocation patterns driven by demographic change.     

Endogenous fertility cycles and childcare services

We construct a two-sector overlapping generation model with endogenous fertility, where one sector produces goods and the other produces childcare services. The elasticity of fertility-related expenditures on services is crucial for determining labor participation and whether fertility converges to a steady state with monotone or oscillation. If capital intensity in the goods sector is greater than the products of elasticity and capital intensity in the service sector, then capital per capita and fertility converge to a steady state monotonically. Conversely, they converge to a steady state with oscillations, otherwise. We find an inverse J-shaped relationship between fertility and elasticity.     

Rotating Saving and Credit Associations in Rural East Africa

Theoretical arguments suggest that rotating savings and credit associations (ROSCAs) improve welfare by reducing the utility cost of saving for a consumer durable. Data from two communities in East Africa reveal major differences in the incidence of ROSCAs participation arising, conjecturally, from differences in the relative depths of market penetration and perceptions about the efficacy of alternative strategies for compensating for failures in the financial markets. Participation in ROSCAs in these communities is partly driven by the need to raise school fees, meet medical expenses and buy food. ROSCAs funds are also used to start or promote small businesses and acquire assets, including livestock. Households owning smaller landholdings and those enjoying higher expenditures are more likely to participate in ROSCAs. The number of schemes in which a household participates is closely related to the main uses of ROSCAs funds while contributions and value of receipts are determined by total expenditures and frequency of turns respectively.     

Incomplete property rights, exposure to markets and the provision of environmental services in China

This paper uses data from a 2003 rural survey to examine the determinants of household provision of environmental services under China's Sloping Land Conversion Program (SLCP), the largest payments for environmental services program in the developing world. The paper examines the determinants of plot-level survival rates of program-planted trees and grasses. It finds that household rights over retired land as well as autonomy in program decision-making (which we argue on the basis of supportive evidence are plausibly exogenous to post-retirement outcomes) have important and potentially countervailing impacts on the provision of environmental services targeted by the program. Households permitted to select what to plant obtain better program outcomes, but do not make the choices that the government would like them to, while those permitted to decide what land to retire perform worse. The analysis also finds that households more vested and experienced in agriculture and with less exposure to off-farm labor markets fare better in managing their planted trees. Significant learning-by-doing effects are also evident, suggesting that greater technical support to farmers could improve outcomes and lower program costs.     

What about Mom? The Forgotten Beneficiary of the Medicaid Expansions

This paper contributes to evidence regarding the effectiveness of the Medicaid expansions by focusing on a key beneficiary—the mother—who has previously been overlooked. Using the Natality Detail Files for 1989-1996, we estimate the relationship between Medicaid eligibility and maternal health outcomes for several treatment groups and a control group. Potential biases caused by improved reporting are addressed by using a “straw man” maternal complication not preventable with prenatal care. Our results indicate that increased Medicaid eligibility may have led to fewer preventable maternal complications among women most likely to have benefited from the Medicaid expansions.     

The Effect of Household Socioeconomic Status on the Demand for Child Health Care Services

The health of the child is an important factor for proper childhood development. Unfortunately, efforts to improve child health in many countries have not yielded the desired results as many children do not receive appropriate health care, hence contributing to high child mortality and morbidity from avoidable causes. To address this problem, it is important that we understand the factors that drive the demand for child health care services. This study, employing the binary and multinomial logistic regression models, examines the effect of household socioeconomic status on the demand for child health care in Ghana, Kenya and Zambia using data from the 2014 Demographic and Health Surveys. The results indicate that the likelihood of seeking appropriate health care for the child is higher when both parents make decisions. The findings further indicate that the odds of seeking treatment for the child falls with the birth order and age of the child, but increases with household wealth, insurance status and proximity to the health facility. Working women are more likely to demand child health care than their counterparts who are unemployed. Our results, therefore, suggest that improving child health will need the participation of both parents in the household on such decisions. Besides, there is the need to educate parents on the importance of seeking appropriate care for all the children born irrespective of the birth order and age of the child. There should also be deliberate efforts to improve the economic lot of households to enhance their purchasing power and encourage them to participate in health insurance schemes to enable effective utilization of health care services for the child in the efforts to improve child health.