The Effect of Health Insurance on Mortality: What Can We Learn from the Affordable Care Act Coverage Expansions?

53 Pages Posted: 7 May 2019

See all articles by Bernard S. Black

Bernard S. Black

Northwestern University - Pritzker School of Law; Northwestern University - Kellogg School of Management; European Corporate Governance Institute (ECGI)

Alex Hollingsworth

Indiana University Bloomington - School of Public & Environmental Affairs (SPEA)

Leticia Nunes

Fundação Getulio Vargas

Kosali Ilayperuma Simon

Indiana University Bloomington - School of Public & Environmental Affairs (SPEA); National Bureau of Economic Research (NBER)

Date Written: April 8, 2019

Abstract

A large literature examines the effect of health insurance on mortality. We add to this literature by emphasizing two challenges in using quasi-experimental variation provided by the Affordable Care Act (ACA) coverage expansions to study mortality. The first is non-parallel pre-treatment trends. Mortality was rising in Medicaid non-expansion relative to expansion states prior to Medicaid expansion, making it difficult to estimate the effect of insurance using difference-in-differences (DD). We use various DD, triple difference, age-discontinuity (at Medicare age) and synthetic control approaches, but are unable to find a research design that satisfactorily addresses this concern. Our estimates are not statistically significant at conventional levels, and are imprecise enough to be consistent with both no effect and a large effect of ACA expansion on overall mortality for non-elderly adults over the first three post-ACA years. Thus, our results should not be interpreted as evidence that health insurance has no effect on mortality for this age group, especially in light of the literature documenting greater health care use as a result of the ACA.

Second, we provide a simulation-based power analysis, showing that even the nationwide natural experiment provided by the ACA is underpowered to detect plausibly sized mortality effects in available datasets, and discuss data element and sample size needs for the literature to advance. Our power analysis approach, which applies simulated pseudo-shocks to actual data in the pre-treatment period, is broadly applicable to other natural-experiment studies. Such analyses can reduce the likelihood of false positives and increase the validity of reported results.

The Online Appendix for this paper is available on SSRN at: https://ssrn.com/abstract= 3368192.

Suggested Citation

Black, Bernard S. and Hollingsworth, Alex and Nunes, Leticia and Simon, Kosali Ilayperuma, The Effect of Health Insurance on Mortality: What Can We Learn from the Affordable Care Act Coverage Expansions? (April 8, 2019). Available at SSRN: https://ssrn.com/abstract=3368187 or http://dx.doi.org/10.2139/ssrn.3368187

Bernard S. Black (Contact Author)

Northwestern University - Pritzker School of Law ( email )

375 E. Chicago Ave
Chicago, IL 60611
United States
312-503-2784 (Phone)

Northwestern University - Kellogg School of Management

2001 Sheridan Road
Evanston, IL 60208
United States
847-491-5049 (Phone)

European Corporate Governance Institute (ECGI)

Brussels
Belgium

Alex Hollingsworth

Indiana University Bloomington - School of Public & Environmental Affairs (SPEA) ( email )

1315 East Tenth Street
Bloomington, IN 47405
United States

HOME PAGE: http://alexjhollingsworth.com

Leticia Nunes

Fundação Getulio Vargas ( email )

Brazil

Kosali Ilayperuma Simon

Indiana University Bloomington - School of Public & Environmental Affairs (SPEA) ( email )

1315 East Tenth Street
Bloomington, IN 47405
United States

National Bureau of Economic Research (NBER)

1050 Massachusetts Avenue
Cambridge, MA 02138
United States

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