1

1PL 8LCLn1 SLCWuCWn ln

NISSEB 0PP0RT0NITIES:
TBE C0NSEQ0ENCES 0F STATE
BECISI0NS N0T T0 EXPANB NEBICAIB



The Council of Economic Auviseis
}uly 2u14


2

!"##$%& $'( )'*%+(",*-+'

1he Affordable Care AcL has expanded hlghquallLy, affordable healLh lnsurance coverage Lo
mllllons of Amerlcans. Cne lmporLanL way ln whlch Lhe Affordable Care AcL ls expandlng
coverage ls by provldlng generous flnanclal supporL Lo SLaLes LhaL opL Lo expand Medlcald
ellglblllLy Lo all nonelderly lndlvlduals ln famllles wlLh lncomes below 133 percenL of Lhe lederal
overLy Level.

1o daLe, 26 SLaLes and Lhe ulsLrlcL of Columbla have selzed Lhls opporLunlLy, and slnce Lhe
beglnnlng of Lhe Affordable Care AcL's flrsL open enrollmenL perlod, 3.2 mllllon people have
galned Medlcald or Chlldren's PealLh lnsurance rogram (CPl) coverage ln Lhese SLaLes, a Lally
LhaL wlll grow ln Lhe monLhs and years ahead as Medlcald enrollmenL conLlnues. ln conLrasL, 24
SLaLes have noL yeL expanded Medlcald-lncludlng many of Lhe SLaLes LhaL would beneflL mosL
and someLlmes because SLaLe leglslaLures have defled even Lhelr own governors-and denled
healLh lnsurance coverage Lo mllllons of Lhelr clLlzens. 8esearchers aL Lhe urban lnsLlLuLe
esLlmaLe LhaL, lf Lhese SLaLes do noL change course, 3.7 mllllon people wlll be deprlved of healLh
lnsurance coverage ln 2016. Meanwhlle, Lhese SLaLes wlll forgo bllllons ln lederal dollars LhaL
could boosL Lhelr economles.

1hls analysls uses Lhe besL evldence from Lhe economlcs and healLh pollcy llLeraLures Lo quanLlfy
several lmporLanL consequences of SLaLes' declslons noL Lo expand Medlcald. 1haL evldence,
whlch ls based prlmarlly on careful analysls of Lhe effecLs of pasL pollcy declslons, ls necessarlly
an lmperfecL gulde Lo Lhe fuLure, and Lhe acLual effecLs of Medlcald expanslon under Lhe
Affordable Care AcL could be larger or smaller Lhan Lhe esLlmaLes presenLed below. Powever,
Lhls evldence ls clear LhaL Lhe consequences of SLaLes' declslons are farreachlng, wlLh
lmpllcaLlons for Lhe healLh and wellbelng of Lhelr clLlzens, Lhelr economles, and Lhe economy of
Lhe naLlon as a whole.













3

.-%/,* 0/'/1-*2 +1 345$'(/( )'2"%$',/ 6+7/%$8/ 1+% *9/ :/;<& )'2"%/(
Cne dlrecL consequence of SLaLes' declslons noL Lo expand Medlcald ls LhaL mllllons of Lhelr
unlnsured clLlzens wlll noL experlence Lhe lmproved access Lo healLh care, greaLer flnanclal
securlLy, and beLLer healLh ouLcomes LhaL come wlLh lnsurance coverage.
)#5%+7/( $,,/22 *+ ,$%/
Pavlng healLh lnsurance lmproves access Lo healLh care. 1hls analysls esLlmaLes LhaL lf Lhe SLaLes
LhaL have noL yeL expanded Medlcald dld so:

!"# $%&&%'( $')* +*'+&* ,'-&. /01* 0 -2-0& 2'-)3* '4 3&%(%3 30)*"

Pavlng healLh lnsurance lncreases Lhe probablllLy LhaL lndlvlduals have a usual source of cllnlc
care, llke a prlmary care physlclan's offlce. lf Lhe 24 SLaLes LhaL have noL yeL expanded
Medlcald dld so, an addlLlonal 1.4 mllllon people would have a usual source of cllnlc care once
expanded coverage was fully ln effecL. SLaLes LhaL have already expanded Medlcald wlll
achleve Lhls ouLcome for 1.0 mllllon people.

56!7888 $')* +*'+&* ,'-&. )*3*%1* 0&& 30)* 9/*: 4**& 9/*: (**. %( 0 9:+%30& :*0)"

Pavlng healLh lnsurance lncreases Lhe probablllLy LhaL lndlvlduals reporL recelvlng all needed
care" over Lhe prlor year. lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald dld so, an
addlLlonal 631,000 people would recelve all needed care" over a glven year once expanded
coverage was fully ln effecL. SLaLes LhaL have already expanded Medlcald wlll achleve Lhls
ouLcome for 494,000 people.

;-(.)*.2 '4 9/'-20(.2 $')* +*'+&* ,'-&. )*3*%1* )*3'$$*(.*. +)*1*(9%1* 30)* *03/ :*0)"

Pavlng healLh lnsurance lncreases Lhe probablllLy of recelvlng many Lypes of recommended
and poLenLlally llfesavlng prevenLlve care, lncludlng:

CholesLerollevel screenlngs: lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald dld so,
Lhen each year an addlLlonal 829,000 people would recelve cholesLerollevel screenlngs
once expanded coverage was fully ln effecL. SLaLes LhaL have already expanded Medlcald
wlll achleve Lhls ouLcome for 630,000 people.

Mammograms: lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald dld so, Lhen each
year an addlLlonal 214,000 women beLween Lhe ages of 30 and 64 would recelve
mammograms once expanded coverage was fully ln effecL. SLaLes LhaL have already
expanded Medlcald wlll achleve Lhls ouLcome for 161,000 women ln Lhls age group.

apanlcolaou LesLs (pap smears"): lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald
dld so, Lhen each year an addlLlonal 343,000 women would recelve pap smears once
expanded coverage was fully ln effecL. SLaLes LhaL have already expanded Medlcald wlll
achleve Lhls ouLcome for 261,000 women.
4

<%&&%'(2 '4 +*'+&* ,'-&. =* =*99*) 0=&* 9' '=90%( '9/*) (**.*. $*.%30& 30)*"

Pavlng healLh lnsurance also lncreases recelpL of oLher Lypes of medlcal care. lor example,
lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald dld so, Lhey would enable an addlLlonal
13.4 mllllon physlclan offlce vlslLs each year once expanded coverage was fully ln effecL.
SLaLes LhaL have already expanded Medlcald wlll enable an addlLlonal 11.7 mllllon physlclan
offlce vlslLs each year.
=%/$*/% 1-'$',-$< 2/,"%-*&
Pavlng healLh lnsurance provldes proLecLlon from flnanclal hardshlp ln Lhe face of slckness. 1hls
analysls esLlmaLes LhaL lf Lhe SLaLes LhaL have noL yeL expanded Medlcald dld so:

>667888 4*,*) +*'+&* ,%&& 403* 309029)'+/%3 '-9'4+'3?*9 $*.%30& 3'292 %( 0 9:+%30& :*0)"

PlghquallLy healLh lnsurance coverage dramaLlcally reduces Lhe rlsk LhaL lndlvlduals face
caLasLrophlc ouLofpockeL medlcal cosLs (deflned as cosLs ln excess of 30 percenL of lncome).
lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald dld so, 233,000 fewer people would
face caLasLrophlc medlcal cosLs each year once expanded coverage was fully ln effecL. SLaLes
LhaL have already expanded Medlcald wlll ellmlnaLe caLasLrophlc medlcal cosLs for 194,000
people each year.

@!87888 4*,*) +*'+&* ,%&& /01* 9)'-=&* +0:%(A '9/*) =%&&2 .-* 9' 9/* =-).*( '4 $*.%30& 3'292"

Pavlng healLh lnsurance reduces lndlvlduals' rlsk of havlng Lo borrow money Lo pay bllls or
sklp a paymenL enLlrely ln order Lo pay medlcal bllls. lf Lhe 24 sLaLes LhaL have noL yeL
expanded Medlcald dld so, 810,000 fewer people would reporL Lhls Lype of flnanclal sLraln
over Lhe course of a year once expanded coverage was fully ln effecL. SLaLes LhaL have already
expanded Medlcald wlll achleve Lhls ouLcome for 614,000 people each year.
0/**/% #/'*$< 9/$<*9
Pavlng lnsurance lmproves menLal healLh. 1hls analysls esLlmaLes LhaL lf Lhe 24 SLaLes LhaL have
noL yeL expanded Medlcald dld so, Lhere would be 438,000 fewer people experlenclng depresslon
once expanded coverage was fully ln effecL. SLaLes LhaL have already expanded Medlcald wlll
reduce Lhe number of people experlenclng depresslon by 348,000.
0/**/% +7/%$<< 9/$<*9
Pavlng lnsurance coverage lmproves overall healLh. 1hls analysls esLlmaLes LhaL lf Lhe 24 SLaLes
LhaL have noL yeL expanded Medlcald dld so, 737,000 addlLlonal people would reporL belng ln
excellenL, very good, or good healLh once expanded coverage was fully ln effecL. SLaLes LhaL have
already expanded Medlcald wlll achleve Lhls ouLcome for 373,000 people.



3

0/'/1-*2 +1 345$'(-'8 >/(-,$-( 1+% !*$*/ 3,+'+#-/2
PealLhler workers who are less flnanclally sLressed and ln beLLer menLal healLh may be more
llkely Lo parLlclpaLe ln Lhe workforce or have hlgher producLlvlLy on Lhe [ob, economlc beneflLs
LhaL could be lmporLanL over Lhe long run. More lmmedlaLely, SLaLes LhaL fall Lo expand Medlcald
are also passlng up bllllons of lederal dollars LhaL could boosL Lhelr economles Loday. 8y
lncreaslng lowlncome lndlvlduals' ablllLy Lo access care, rellevlng cashsLrapped famllles of hlgh
ouLofpockeL cosLs, and reduclng uncompensaLed care, Lhe expanslon ln lnsurance coverage
enabled by Lhose lederal dollars would boosL demand for medlcal and nonmedlcal goods and
servlces. Cver Lhe nexL few years, whlle Lhe recovery from Lhe 20072009 recesslon remalns
lncompleLe and slack remalns ln Lhe economy, Lhls lncrease ln demand would boosL overall
employmenL and economlc acLlvlLy.

1hls analysls esLlmaLes LhaL expandlng Medlcald would generaLe Lhe followlng beneflLs for SLaLes'
economles Loday:
?((-*-+'$< @/(/%$< 1"'(2
8y expandlng Medlcald, SLaLes can pull bllllons ln addlLlonal lederal fundlng lnLo Lhelr economles
every year, wlLh no SLaLe conLrlbuLlon over Lhe nexL Lhree years and only a modesL one LhereafLer
for coverage for newly ellglble people. lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald had
done so as of !anuary 1, Lhose SLaLes and Lhelr clLlzens would have recelved an addlLlonal $88
bllllon ln lederal supporL Lhrough calendar year 2016. SLaLes LhaL have already expanded
Medlcald wlll recelve $84 bllllon over LhaL perlod.
>+%/ A+B2
8y pumplng more lederal dollars lnLo Lhelr economles, SLaLes' declslons Lo expand Medlcald
creaLe [obs. lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald had done so as of !anuary 1,
Lhey would have boosLed employmenL by 83,000 [obs ln 2014, 184,000 [obs ln 2013, and a LoLal
of 379,000 [obyears Lhrough 2017. SLaLes LhaL have already expanded Medlcald wlll boosL
employmenL by 79,000 [obs ln 2014, 172,000 [obs ln 2013, and a LoLal of 336,000 [obyears
Lhrough 2017.
=%/$*/% +7/%$<< /,+'+#-, $,*-7-*&
8y pumplng more lederal dollars lnLo Lhelr economles, SLaLes' declslons Lo expand Medlcald
lncrease Lhe overall level of economlc acLlvlLy. lf Lhe 24 SLaLes LhaL have noL yeL expanded
Medlcald had done so as of !anuary 1, Lhey would have creaLed an addlLlonal $66 bllllon ln LoLal
economlc acLlvlLy Lhrough 2017. SLaLes LhaL have already expanded Medlcald wlll creaLe $62
bllllon ln LoLal economlc acLlvlLy Lhrough 2017.

1he remalnder of Lhls reporL provldes more deLall on SLaLes' opLlon Lo expand Medlcald under
Lhe Affordable Care AcL, dlscusses Lhe effecLs of SLaLes' cholces for Lhelr unlnsured clLlzens and
Lhelr economles, presenLs Lhe meLhodology used Lo quanLlfy Lhose effecLs, and provldes Lables
and flgures wlLh SLaLebySLaLe deLall.

6

)C 0$,D8%+"'( +' !*$*/2E F5*-+' *+ 345$'( >/(-,$-( G'(/% *9/
?11+%($B</ 6$%/ ?,*

Medlcald ls a program [olnLly funded by Lhe lederal governmenL and Lhe SLaLes LhaL provldes
healLh lnsurance Lo ellglble lowlncome people. Lach SLaLe operaLes lLs own Medlcald program
and has conslderable flexlblllLy ln deLermlnlng ellglblllLy crlLerla. 1he Affordable Care AcL (ACA)
glves SLaLes Lhe opLlon Lo expand Lhelr Medlcald programs Lo all nonelderly lndlvlduals ln
famllles wlLh lncomes below 133 percenL of Lhe lederal overLy Level (lL). rogram rules
provlde for an addlLlonal flve percenL lncome dlsregard," brlnglng Lhe effecLlve ellglblllLy
Lhreshold Lo 138 percenL of lL: $16,103 for a slngle adulL or $32,913 for a famlly of four ln 2014.
8ecause chlldren aL Lhese lncome levels are generally already ellglble for Medlcald or Lhe
Chlldren's PealLh lnsurance rogram, Lhls expanslon prlmarlly affecLs lowlncome adulLs. rlor
Lo Lhe Affordable Care AcL's Medlcald expanslon, Lhe medlan ellglblllLy level for worklng parenLs
was only 61 percenL of Lhe lL, and, ln nearly all SLaLes, nondlsabled adulLs wlLhouL chlldren
were noL ellglble aL all (Peberleln eL al. 2013). As deplcLed ln llgure 1, as of !uly 2, 2014, 26 SLaLes
and Lhe ulsLrlcL of Columbla had Laken advanLage of Lhls opLlon Lo expand Lhelr Medlcald
programs.


7

1he lederal governmenL wlll cover Lhe vasL ma[orlLy of Lhe cosLs of expandlng Medlcald ellglblllLy
under Lhe Affordable Care AcL. 1hrough 2016, Lhe lederal governmenL wlll pay 100 percenL of
Lhe cosLs of coverlng newly ellglble lndlvlduals, falllng gradually Lo 90 percenL ln 2020 and
subsequenL years. 1hls ls a conslderably larger lederal conLrlbuLlon Lhan for ellglblllLy caLegorles
ln exlsLence before Lhe Affordable Care AcL, for whlch program cosLs are shared beLween Lhe
lederal governmenL and Lhe SLaLes accordlng Lo a formula LhaL LargeLs addlLlonal asslsLance Lo
lowerlncome SLaLes, wlLh Lhe lederal share averaglng around 37 percenL and ranglng from 30
percenL Lo [usL under 74 percenL ln flscal year 2014.
1


SLaLes elecLlng Lo expand Lhelr Medlcald programs are llkely Lo reallze large savlngs ln oLher areas
of Lhelr budgeLs LhaL offseL even Lhe modesL lncrease ln SLaLe Medlcald spendlng afLer 2016.
8esearchers aL Lhe urban lnsLlLuLe have esLlmaLed LhaL, lf all SLaLes expanded Medlcald,
reducLlons ln uncompensaLed care currenLly flnanced by SLaLe governmenLs would more Lhan
offseL any addlLlonal Medlcald cosLs, generaLlng $10 bllllon ln savlngs over Len years for all SLaLes,
alLhough Lhe neL lmpacL wlll vary by SLaLe (Polahan, 8ueLLgens, and uorn 2013). 1haL analysls
also omlLs oLher poLenLlal SLaLe savlngs, lncludlng reduced cosLs Lo SLaLes of provldlng menLal
healLh servlces LhaL would now be covered by Medlcald. 8elaLed research by some of Lhese same
auLhors has concluded LhaL Lhese oLher savlngs may be subsLanLlal (8ueLLgens eL al. 2011).

Medlcald ls an lmporLanL componenL of Lhe Affordable Care AcL's overall approach Lo expandlng
healLh lnsurance coverage. lndlvlduals wlLh lncomes under 100 percenL of Lhe lL are noL ellglble
for Lax credlLs and cosLsharlng asslsLance Lhrough Lhe PealLh lnsurance MarkeLplaces and, as a
consequence, wlll generally noL have access Lo affordable healLh lnsurance coverage lf Lhelr SLaLe
does noL expand Medlcald. lurLhermore, Medlcald Lyplcally offers lower ouLofpockeL cosLs
Lhan MarkeLplace coverage, so expandlng Medlcald wlll lower Lhe cosL of coverage for lndlvlduals
ln famllles wlLh lncomes above 100 percenL and below 138 percenL of Lhe lL.











1
Chlldren (and, ln some SLaLes, pregnanL women) are ellglble for publlc lnsurance coverage Lhrough a relaLed
program, Lhe Chlldren's PealLh lnsurance rogram. under Lhe maLchlng formula used for CPl, Lhe lederal
governmenL pays a hlgher share of Lhe cosLs, averaglng abouL 70 percenL and ranglng across SLaLes beLween 63 Lo
81 percenL ln flscal year 2014.
8

))C >/*9+(+<+8& 1+% 32*-#$*-'8 *9/ 311/,*2 +1 !*$*/2E ./,-2-+'2 *+
345$'( >/(-,$-(

1o esLlmaLe Lhe consequences of SLaLe declslons Lo expand Medlcald, Lhls analysls proceeds ln
Lwo sLeps. llrsL, CLA obLalned esLlmaLes of SLaLes' Medlcald expanslon declslons on lnsurance
coverage and Lhe amounL of lederal fundlng enLerlng SLaLe economles, Lhese esLlmaLes were
elLher Laken dlrecLly from or derlved from publlcaLlons by Lhe urban lnsLlLuLe and Lhe
Congresslonal 8udgeL Cfflce. Second, CLA used research on Lhe effecLs of pasL pollcy declslons
Lo LranslaLe Lhose dlrecL effecLs lnLo lmpacLs on Lhe ulLlmaLe ouLcomes of lnLeresL: access Lo care,
flnanclal securlLy, healLh and wellbelng, and Lhe naLlon's economlc performance.

1he avallable research llLeraLure unamblguously demonsLraLes LhaL SLaLe declslons Lo expand
Medlcald wlll have large effecLs ln all of Lhese areas, effecLs LhaL are reflecLed ln Lhe esLlmaLes
reporLed ln Lhls analysls. neverLheless, lL ls lmporLanL Lo keep ln mlnd LhaL, whlle all of Lhe sLudles
Lhls reporL draws upon are rlgorous, all research has llmlLaLlons. SLaLlsLlcal analyses are sub[ecL
Lo sampllng errors, as well as oLher lmperfecLlons LhaL can cause esLlmaLes Lo sysLemaLlcally
oversLaLe or undersLaLe Lhe effecLs of Lhe pollcy changes sLudled. ln addlLlon, Lhe effecLs of pasL
pollcy changes may noL be a perfecL gulde Lo Lhe effecLs of fuLure pollcy changes. As a
consequence, whlle Lhe esLlmaLes presenLed ln Lhls analysls represenL Lhe besL avallable
esLlmaLes of Lhe effecLs of expandlng Medlcald, Lhe acLual effecLs could Lurn ouL Lo be larger or
smaller Lhan Lhe esLlmaLes presenLed ln Lhls reporL.

1he remalnder of Lhls secLlon descrlbes CLA's meLhodology ln greaLer deLall.

311/,*2 +' )'2"%$',/ 6+7/%$8/
1he mosL dlrecL consequence of SLaLe declslons Lo expand Medlcald ls Lo lncrease lnsurance
coverage ln LhaL SLaLe. 8ecause Lhe oLher beneflLs of expandlng Medlcald flow from Lhls baslc
effecL, esLlmaLes of how expandlng Medlcald affecLs lnsurance coverage are a cruclal lnpuL lnLo
Lhe resL of Lhe analyses underLaken ln Lhls reporL. ln Lhls reporL, CLA relles upon publlshed resulLs
from Lhe urban lnsLlLuLe's PealLh lnsurance ollcy SlmulaLlon Model (PlSM), whlch provlde
SLaLebySLaLe esLlmaLes of how each SLaLe's declslon abouL wheLher Lo expand Medlcald would
affecL lnsurance coverage ln LhaL SLaLe (Polahan eL al. 2012, Polahan, 8ueLLgens, and uorn 2013).
1he PlSM naLlonal esLlmaLes of how Lhe Affordable Care AcL wlll affecL lnsurance coverage are
broadly slmllar Lo Lhose produced by oLher analysLs, lncludlng Lhe Congresslonal 8udgeL Cfflce
(C8C 2012a) and Lhe 8Anu CorporaLlon (Llbner eL al. 2010).

9

eople wlLh lnsurance Coverage ln 2016
!"# $%# &'()*+,*- .%+,/),+ 012341555
Alabama 233,000
Alaska 26,000
llorlda 848,000
Ceorgla 478,000
ldaho 33,000
lndlana 262,000
kansas 100,000
Loulslana 263,000
Malne 28,000
Mlsslsslppl 163,000
Mlssourl 233,000
MonLana 38,000
nebraska 48,000
norLh Carollna 377,000
Cklahoma 123,000
ennsylvanla 303,000
SouLh Carollna 198,000
SouLh uakoLa 26,000
1ennessee 234,000
1exas 1,208,000
uLah 74,000
vlrglnla 210,000
Wlsconsln 120,000
Wyomlng 16,000
&'()*+,*- .%+,/),+ 617481555
Arlzona 31,000
Arkansas 143,000
Callfornla 1,390,000
Colorado 134,000
ConnecLlcuL 84,000
uelaware 7,000
ulsLrlcL of Columbla 19,000
Pawall 39,000
llllnols 398,000
lowa 20,000
kenLucky 177,000
Maryland 133,000
MassachuseLLs 2,000
Mlchlgan 212,000
MlnnesoLa 42,000
nevada 103,000
new Pampshlre 26,000
new !ersey 227,000
new Mexlco 96,000
new ?ork 167,000
norLh uakoLa 21,000
Chlo 446,000
Cregon 186,000
8hode lsland 26,000
vermonL 4,000
WashlngLon 64,000
WesL vlrglnla 80,000
9):;% 8< =*/>%)?% ,* !@A:%> "B C%"(;% D,#E =*?@>)*/% F"G%>)-% ,B H#)#% &'()*+? .%+,/),+
Source: urban lnsLlLuLe.
10

1he PlSM esLlmaLes show LhaL, lf all SLaLes expanded Medlcald, Lhe number of people ln Lhe
unlLed SLaLes wlLh lnsurance coverage would lncrease by 10 mllllon by 2016, reflecLlng an
lncrease of 4.3 mllllon ln Lhe 26 SLaLes and Lhe ulsLrlcL of Columbla LhaL have already expanded
Lhe program and an lncrease of 3.7 mllllon ln Lhe 24 SLaLes LhaL have yeL do Lo so.
2
1hls reporL
focuses on Lhe PlSM esLlmaLes for 2016 because Lhese should provlde a reasonable gulde of
Lhe longrun effecLs of Medlcald expanslon on lnsurance coverage, afLer Lhe lnlLlal rampup."
ConslsLenL wlLh LhaL, Lhls analysls refers Lo Lhese PlSM esLlmaLes for 2016 as reflecLlng Lhe
effecLs of expanded Medlcald coverage when fully ln effecL." 1he deLalled SLaLebySLaLe
esLlmaLes are reporLed ln 1able 1.

AcLual experlence slnce Lhe beglnnlng of Lhe Affordable Care AcL's flrsL open enrollmenL perlod
has borne ouL modelbased predlcLlons LhaL SLaLes' declslons abouL wheLher Lo expand Medlcald
wlll have slgnlflcanL lmpllcaLlons for lnsurance coverage. ln Lhe SLaLes (and Lhe ulsLrlcL of
Columbla) LhaL have expanded Medlcald, Lhe number of people wlLh healLh lnsurance coverage
Lhrough Medlcald (or CPl) has lncreased by 3.2 mllllon (13.3 percenL) from Lhe Lhlrd quarLer of
2013 Lhrough Aprll 2014 (CMS 2014).
3
8y conLrasL, Medlcald enrollmenL ln SLaLes LhaL have noL
yeL expanded Medlcald has rlsen by 0.8 mllllon (3.3 percenL) over LhaL perlod. (1he modesL
lncrease ln Medlcald enrollmenL ln sLaLes LhaL have noL yeL expanded Medlcald ls llkely
aLLrlbuLable Lo slmpllflcaLlons ln Medlcald ellglblllLy rules requlred of all SLaLes and ouLreach,
publlc awareness, and new enrollmenL opLlons assoclaLed wlLh Lhe openlng of Lhe MarkeLplaces.)

Slmllarly, surveys have shown much larger lncreases ln lnsurance coverage ln SLaLes LhaL have
expanded Medlcald relaLlve Lo sLaLes LhaL have noL. Comparlng Lhe Lhlrd quarLer of 2013 wlLh
early March 2014, Lhe urban lnsLlLuLe's PealLh 8eform MonlLorlng Survey found a 4.0 percenLage
polnL lncrease ln Lhe percenLage of nonelderly adulLs wlLh lnsurance coverage ln SLaLes LhaL had
expanded Lhe program, compared Lo a 1.3 percenLage polnL lncrease ln SLaLes LhaL had noL done
so (Long eL al. 2014). Slmllarly, a survey by Callup has found LhaL SLaLes LhaL expanded Medlcald
and operaLed Lhelr own MarkeLplaces (alone or ln parLnershlp wlLh Lhe lederal governmenL)
experlenced a 2.3 percenLage polnL lncrease ln Lhe share of adulLs wlLh lnsurance coverage from
2013 Lhrough Lhe flrsL quarLer of 2014, compared wlLh a 0.8 percenLage polnL lncrease ln SLaLes
LhaL have noL Laken Lhese acLlons (WlLLers 2014).



2
PlSM flnds LhaL lf all SLaLes expanded Medlcald, Lhe lncrease ln Medlcald enrollmenL would be 13 mllllon,
somewhaL larger Lhan Lhe 10 mllllon lncrease ln Lhe number of people wlLh healLh lnsurance coverage. 1he
lncrease ln Medlcald enrollmenL ls larger Lhan Lhe lncrease ln lnsurance coverage prlmarlly because some
lndlvlduals wlLh lncomes beLween 100 percenL of lL and 138 percenL of lL would swlLch from recelvlng
subsldlzed coverage Lhrough Lhe MarkeLplaces Lo recelvlng coverage Lhrough Medlcald. 1he dlfference beLween
Lhe Lwo esLlmaLes may also reflecL some offseLLlng reducLlon ln employer coverage.
3
ConnecLlcuL, Malne, and norLh uakoLa have noL reporLed sulLable enrollmenL daLa Lo CMS and are Lherefore noL
lncluded ln Lhese LoLals. lor deLalls, see CMS' Aprll 2014 Medlcald enrollmenL reporL (CMS 2014).
11

311/,*2 +' ?,,/22 *+ $'( G2/ +1 >/(-,$< 6$%/
erhaps Lhe mosL obvlous purpose of Lhe Medlcald program ls Lo ensure LhaL enrollees have
access Lo and recelve needed medlcal care. 1o quanLlfy Lhe lmprovemenL ln access Lo medlcal
care LhaL wlll resulLs from SLaLes' declslons Lo expand Medlcald, Lhls analysls relles upon
esLlmaLes from Lhe Cregon PealLh lnsurance LxperlmenL (llnkelsLeln eL al. 2012, 8alcker eL al.
2013a, 8alcker eL al. 2013b, 1aubman eL al. 2014). 1he Cregon PealLh lnsurance LxperlmenL
(CPlL) arose from Lhe SLaLe of Cregon's declslon ln early 2008 Lo reopen enrollmenL under an
earller Medlcald expanslon LhaL had exLended coverage Lo unlnsured adulLs wlLh lncomes under
100 percenL of Lhe lL. 8ecause Lhe SLaLe could noL accommodaLe all lnLeresLed appllcanLs, lL
allocaLed Lhe opporLunlLy Lo enroll ln Medlcald by loLLery.

1he SLaLe of Cregon's declslon Lo allocaLe Medlcald coverage by loLLery creaLed a unlque research
opporLunlLy. 8y comparlng lndlvlduals who won Lhe loLLery Lo lndlvlduals who losL Lhe loLLery, lL
ls posslble Lo lsolaLe Lhe causal effecL of havlng or noL havlng Medlcald coverage, wlLhouL Lhe
concern LhaL Lhe comparlson ls confounded by unobserved dlfferences beLween Lhose who do
and do noL have Medlcald coverage. 8andomlzed research deslgns of Lhls klnd are consldered
Lhe gold sLandard" ln soclal sclence research, and Lhe CPlL ls unlque ln uslng such a deslgn Lo
sLudy Lhe effecLs of havlng healLh lnsurance.

An addlLlonal lmporLanL advanLage of Lhe CPlL for Lhe currenL analysls ls LhaL Lhe populaLlon LhaL
galned coverage ln Lhe Medlcald expanslon sLudled ln Lhe CPlL-lowlncome, unlnsured adulLs-
ls qulLe slmllar Lo Lhe group LhaL wlll galn healLh lnsurance coverage lf SLaLes expand Medlcald
under Lhe Affordable Care AcL. 1hls lncreases Lhe confldence LhaL Lhe resulLs of Lhe CPlL can be
exLrapolaLed Lo Lhe Affordable Care AcL's Medlcald expanslon.

Cf course, as noLed aL Lhe ouLseL, no sLudy based on pasL pollcy changes ln a speclflc envlronmenL
applles perfecLly Lo a fuLure pollcy change ln a dlfferenL envlronmenL. Cregon's healLh care
sysLem dlffers from oLher SLaLes' healLh care sysLems ln some ways, lncludlng Lhe avallablllLy of
medlcal provlders (Puang and llnegold 2013), and oLher SLaLes' lowlncome populaLlons do noL
look preclsely llke Cregon's. ln addlLlon, Lhe CPlL can only speak Lo resulLs over a followup
perlod of approxlmaLely Lwo years, buL Lhe effecLs of lnsurance coverage could dlffer over longer
perlods. llnally, Lhe effecLs of largerscale coverage expanslons could dlffer from Lhe effecLs of
Lhe smallerscale expanslon examlned ln Lhe CPlL. neverLheless, Lhe CPlL clearly provldes Lhe
besL avallable esLlmaLes for quanLlfylng many poLenLlal effecLs of SLaLes' declslons Lo expand
Medlcald under Lhe Affordable Care AcL.

1he CPlL found LhaL Medlcald coverage slgnlflcanLly lmproves enrollees' access Lo medlcal care.
Speclflcally, based on lnperson lnLervlews Lwo years afLer Lhe coverage loLLery, Lhe auLhors
esLlmaLe LhaL Lhose enrolled ln Medlcald were more llkely Lo:

B*3*%1* 0&& (**.*. 30)*"

12

Medlcald coverage lncreased Lhe probablllLy LhaL lndlvlduals reporLed recelvlng all needed
medlcal care over Lhe prlor 12 monLhs by 11.4 percenLage polnLs, relaLlve Lo a basellne raLe
of 61.0 percenL ln Lhe conLrol group.
#

;01* 0 -2-0& 2'-)3* '4 3&%(%3 30)*"

Medlcald coverage lncreased Lhe probablllLy LhaL lndlvlduals reporLed havlng a usual source
of cllnlc care (e.g. a prlmary care physlclan) by 23.8 percenLage polnLs, relaLlve Lo a basellne
probablllLy of 46.1 percenL ln Lhe conLrol group.
3


B*3*%1* )*3'$$*(.*. +)*1*(9%1* 30)*"

Medlcald coverage dramaLlcally lncreased recelpL of several lmporLanL Lypes of
recommended prevenLlve care LhaL have been cllnlcally demonsLraLed Lo lmprove healLh
ouLcomes:

CholesLerollevel screenlngs: Medlcald coverage lncreased Lhe probablllLy LhaL an
lndlvldual recelved a cholesLerollevel screenlng ln Lhe lasL 12 monLhs by 14.6 percenLage
polnLs, relaLlve Lo a basellne probablllLy of 27.2 ln Lhe conLrol group.

Mammograms: Medlcald coverage lncreased Lhe probablllLy LhaL women ages and 30 and
older recelved a mammogram ln Lhe lasL 12 monLhs by 29.7 percenLage polnLs, relaLlve
Lo a basellne probablllLy of 28.9 percenL ln Lhe conLrol group.

apanlcolaou LesLs (pap smears"): Medlcald coverage lncreased Lhe probablllLy LhaL a
woman had recelved a pap smear ln Lhe lasL 12 monLhs by 14.4 percenLage polnLs, relaLlve
Lo a basellne probablllLy of 44.9 percenL ln Lhe conLrol group.
6


4
Many lndlvlduals ln Lhe conLrol group reporLed recelvlng all needed care because no care was necessary or
because Lhey were able Lo access care Lhrough oLher sources (lncludlng, for lndlvlduals who ulLlmaLely quallfled for
Medlcald Lhrough oLher ellglblllLy paLhways, Medlcald lLself). Slmllarly, lndlvlduals wlLh Medlcald coverage may
reporL noL recelvlng all needed care for a varleLy of reasons, lncludlng schedullng or LransporLaLlon dlfflculLles or
challenges ln ldenLlfylng a sulLable provlder.
3
ln oLher work based on Lhe CPlL, Lhe auLhors flnd LhaL Medlcald lncreases emergency room uLlllzaLlon (1aubman
eL al. 2014). 1hls flndlng ls noL lnconslsLenL wlLh Lhe lncrease ln Lhe probablllLy LhaL lndlvlduals had a usual source
of cllnlc care, Medlcald may slmulLaneously lncrease access Lo prlmary care and make lndlvlduals more wllllng Lo
make use of emergency rooms by proLecLlng Lhem from Lhe hlgh ouLofpockeL cosLs LhaL can come wlLh such a
vlslL. ln addlLlon, Lhe flndlng LhaL Medlcald lncreases emergency room uLlllzaLlon could change when looklng over
longer Llme perlods (as enrollees bulld sLronger relaLlonshlps wlLh Lhelr prlmary care physlclans) or as a resulL of
efforLs Lo reform Lhe healLh care dellvery sysLem, lncludlng efforLs seL ln moLlon by Lhe Affordable Care AcL.
6
ApproxlmaLely half of SLaLes' Medlcald programs have underLaken famlly plannlng expanslons" under whlch
Lhey offer Medlcald coverage for famlly plannlng and relaLed servlces, lncludlng pap smears, Lo some lndlvlduals
who are noL ellglble for full Medlcald beneflLs (CuLLmacher lnsLlLuLe 2014). ln almosL all such SLaLes, women who
would galn ellglblllLy for full Medlcald beneflLs lf Lhelr SLaLe expands Medlcald under Lhe Affordable Care AcL could
already have obLalned coverage for pap smears vla Lhe SLaLe's famlly plannlng expanslon.

Cregon had a famlly plannlng expanslon ln place durlng Lhe CPlL under whlch ellglblllLy exLended up Lo 183
percenL of Lhe lL (Sonfleld, Alrlch, and 8enson Cold 2008), Lhe SLaLe has slnce exLended ellglblllLy Lhrough 230
13

B*3*%1* '9/*) 9:+*2 '4 $*.%30& 30)*"

Medlcald coverage also lncreased recelpL of oLher caLegorles of medlcal care. Medlcald
coverage made posslble an addlLlonal 2.7 offlce vlslLs over Lhe course of a year, relaLlve Lo
3.3 vlslLs ln Lhe conLrol group. Slmllarly, Medlcald lncreased Lhe number of prescrlpLlon
medlcaLlons an lndlvldual was currenLly Laklng by 0.7 prescrlpLlons, relaLlve Lo 1.8
prescrlpLlons ln Lhe conLrol group.

Whlle Lhe CPlL ls unlquely wellsulLed Lo Lhe currenL analysls ln llghL of lLs randomlzed deslgn
and focus on a populaLlon LhaL ls very slmllar Lo Lhe populaLlon LhaL wlll galn coverage lf more
sLaLes elecL Lo expand Medlcald, Lhe flndlng LhaL havlng healLh lnsurance or more generous
healLh lnsurance lncreases access Lo healLh care servlces has been convlnclngly demonsLraLed ln
many healLh care seLLlngs. PlghquallLy sLudles arrlvlng aL slmllar concluslons lnclude Lhe well
known 8Anu PealLh lnsurance LxperlmenL (newhouse 1993), sLudles of pasL Medlcald
expanslons (e.g. Currle and Cruber 1996, Sommers, 8alcker, and LpsLeln 2012), sLudles of Lhe
effecL of galnlng Medlcare ellglblllLy aL age 63 (e.g. McWllllams eL al. 2007, Card eL al. 2009), and
a promlnenL sLudy of MassachuseLLs healLh reform (Sommers, Long, and 8alcker 2014).

1o LranslaLe Lhe CPlL esLlmaLes lnLo Lhe number of addlLlonal lndlvlduals esLlmaLed Lo have
speclfled Lype of healLh care experlence ln each SLaLe, Lhe relevanL polnL esLlmaLes were slmply
mulLlplled by Lhe PlSM esLlmaLes of Lhe number of lndlvlduals who would galn coverage ln LhaL
SLaLe lf Lhe SLaLe expands Medlcald coverage.
7
Several of Lhe prevenLlve care esLlmaLes apply
only Lo parLlcular age and gender subgroups, CLA esLlmaLed Lhe share of new Medlcald enrollees
who fall ln Lhe relevanL subgroups uslng Lhe Amerlcan CommunlLy Survey and Lhe meLhodology
descrlbed ln Appendlx A and Lhen scaled down Lhe PlSM esLlmaLes accordlngly.

1he resulLlng SLaLebySLaLe esLlmaLes of Lhe lncrease ln recelpL of medlcal care are reporLed ln
1able 2 (prevenLlve care) and 1able 3 (oLher uLlllzaLlon measures). llgure 2 summarlzes Lhe
lncreases ln uLlllzaLlon of prevenLlve care LhaL SLaLes LhaL have noL yeL expanded Medlcald could
achleve once expanded coverage ls fully ln effecL, as well as Lhe galns accrulng Lo SLaLes LhaL have
already expanded Lhe program. llgure 3 maps Lhe SLaLelevel esLlmaLes of Lhe lncrease ln Lhe
annual number of cholesLerollevel screenlngs lf each SLaLe expands Medlcald.

percenL of Lhe lL (CuLLmacher lnsLlLuLe 2014). 1he CPlL neverLheless found LhaL galnlng full Medlcald coverage
lncreased pap smear uLlllzaLlon, perhaps because accesslng such care ls easler ln Lhe conLexL of coverage for a
comprehenslve seL of healLh care servlces. 1hls suggesLs LhaL expandlng ellglblllLy for full Medlcald beneflLs wlll
lncrease pap smear uLlllzaLlon even ln SLaLes wlLh a famlly plannlng expanslon ln place. Lxpandlng ellglblllLy for full
Medlcald beneflLs mlghL be expecLed Lo have a larger effecL ln SLaLes wlLhouL a famlly plannlng expanslon, ln whlch
case Lhe esLlmaLes ln Lhls reporL wlll undersLaLe Lhe lncreases ln Lhose SLaLes. Slmllarly, SLaLe and local healLh
deparLmenLs provlde cerLaln screenlng servlces funded Lhrough federal granL programs or oLher sources. As wlLh
famlly plannlng expanslons, Lhe exlsLence of such programs should noL affecL Lhe concluslon LhaL expandlng
ellglblllLy for Medlcald would lncrease uLlllzaLlon of Lhese servlces.
7
1he resulLs presenLed by Lhe CPlL reflecL Lhe effecL of ever belng on Medlcald durlng Lhe sLudy perlod, so noL all
lndlvlduals were enrolled ln Medlcald for Lhe full perlod over whlch Lhe change ln uLlllzaLlon was measured. 1he
effecL of conLlnuous Medlcald enrollmenL on Lhe ouLcomes examlned ln Lhls reporL would llkely be larger, so Lhese
esLlmaLes are somewhaL conservaLlve.
14



0
200,000
400,000
600,000
800,000
1,000,000
Mammograms apanlcolaou 1esLs CholesLerolLevel Screenlngs
SLaLes Lxpandlng Medlcald
SLaLes noL ?eL Lxpandlng Medlcald
lncrease ln annual number of lndlvlduals recelvlng speclfled Lype of care
I,-@>% 4J C>"K%/#%+ =*/>%)?% ,* L#,;,M)#,"* "B C>%G%*#,G% F)>% ,B H#)#%? &'()*+
.%+,/),+1 :N F@>>%*# &'()*?,"* H#)#@?
Sources: urban lnsLlLuLe, 8alcker eL al. (2013), CLA calculaLlons.
noLe: LsLlmaLes reflecL effecLs when expanded coverage ls fully ln effecL. See LexL for meLhodologlcal
deLalls. lncreases ln recelpL of mammograms reflecL only women 30 and older.
13


CholesLerolLevel Screenlng
ln asL 12 MonLhs
Mammogram
ln asL 12 MonLhs
apanlcolaou Smear
ln asL 12 MonLhs
!"# $%# &'()*+,*- .%+,/),+ O431755 4861855 7661355
Alabama 34,200 9,300 14,200
Alaska 3,800 900 1,300
llorlda 123,600 33,300 32,200
Ceorgla 69,600 17,000 28,900
ldaho 8,000 2,300 3,300
lndlana 38,200 9,000 13,200
kansas 14,600 3,100 3,800
Loulslana 38,600 10,400 16,000
Malne 4,100 1,300 1,700
Mlsslsslppl 24,000 6,200 9,700
Mlssourl 36,900 9,400 14,900
MonLana 3,300 1,600 2,400
nebraska 7,000 1,600 2,900
norLh Carollna 34,900 13,900 23,000
Cklahoma 17,900 4,800 7,300
ennsylvanla 44,400 11,100 17,600
SouLh Carollna 28,800 8,000 12,000
SouLh uakoLa 3,800 900 1,300
1ennessee 34,100 9,300 14,000
1exas 176,000 44,100 73,200
uLah 10,800 1,900 4,300
vlrglnla 30,600 8,000 13,000
Wlsconsln 17,300 3,800 6,700
Wyomlng 2,300 700 1,100
&'()*+,*- .%+,/),+ 2431255 8251255 4281755
Arlzona 7,400 2,600 3,200
Arkansas 20,800 3,600 8,300
Callfornla 202,300 49,300 86,800
Colorado 22,400 3,200 9,000
ConnecLlcuL 12,200 3,100 3,100
uelaware 1,000 300 300
ulsLrlcL of Columbla 2,800 400 1,200
Pawall 3,700 1,600 2,300
llllnols 38,000 14,700 23,800
lowa 2,900 600 1,200
kenLucky 23,800 6,600 10,300
Maryland 19,700 4,600 8,100
MassachuseLLs 300 100 100
Mlchlgan 30,900 7,000 12,000
MlnnesoLa 6,100 1,300 2,300
nevada 13,300 4,300 6,300
new Pampshlre 3,800 1,100 1,600
new !ersey 33,100 8,600 14,000
new Mexlco 14,000 3,700 3,300
new ?ork 24,300 8,400 10,300
norLh uakoLa 3,100 700 1,300
Chlo 63,000 17,400 26,000
Cregon 27,100 7,100 11,300
8hode lsland 3,800 900 1,600
vermonL 600 < 100 < 100
WashlngLon 9,300 2,200 3,900
WesL vlrglnla 11,700 3,300 4,700
9):;% 4< !@A:%> "B P++,#,"*); C%"(;% Q%/%,G,*- C>%G%*#,G% F)>% ,B H#)#% &'()*+? .%+,/),+
Sources: urban lnsLlLuLe, Amerlcan CommunlLy Survey, 20102012, CLA calculaLlons.
noLe: LsLlmaLes reflecL effecLs when expanded coverage ls fully ln effecL. See LexL for deLalls on Lhe meLhodology. numbers may noL sum due
Lo roundlng. Mammogram esLlmaLes reflecL mammograms recelved by women 30 and older only.
16


AddlLlonal eople
wlLh a usual
Source of Cllnlc
Care
AddlLlonal eople
8ecelvlng All
needed Care ln
asL 12 MonLhs
number of
AddlLlonal
hyslclan vlslLs
Lach ?ear
8educLlon ln
number of eople
Lxperlenclng
uepresslon
AddlLlonal eople
8eporLlng Cood,
very Cood, or
LxcellenL PealLh
!"# $%# &'()*+,*- .%+,/),+ 817041555 2081555 80172O1555 60O1555 R0R1555
Alabama 36,000 27,000 633,000 19,000 31,000
Alaska 6,000 3,000 70,000 2,000 3,000
llorlda 201,000 97,000 2,290,000 68,000 113,000
Ceorgla 114,000 33,000 1,291,000 38,000 64,000
ldaho 13,000 6,000 149,000 4,000 7,000
lndlana 62,000 30,000 707,000 21,000 33,000
kansas 24,000 11,000 270,000 8,000 13,000
Loulslana 63,000 30,000 716,000 21,000 33,000
Malne 7,000 3,000 76,000 2,000 4,000
Mlsslsslppl 39,000 19,000 446,000 13,000 22,000
Mlssourl 60,000 29,000 683,000 20,000 34,000
MonLana 9,000 4,000 103,000 3,000 3,000
nebraska 11,000 3,000 130,000 4,000 6,000
norLh Carollna 90,000 43,000 1,018,000 30,000 30,000
Cklahoma 29,000 14,000 332,000 10,000 16,000
ennsylvanla 72,000 33,000 824,000 23,000 41,000
SouLh Carollna 47,000 23,000 333,000 16,000 26,000
SouLh uakoLa 6,000 3,000 70,000 2,000 3,000
1ennessee 36,000 27,000 632,000 19,000 31,000
1exas 287,000 138,000 3,262,000 97,000 161,000
uLah 18,000 8,000 200,000 6,000 10,000
vlrglnla 30,000 24,000 367,000 17,000 28,000
Wlsconsln 29,000 14,000 324,000 10,000 16,000
Wyomlng 4,000 2,000 43,000 1,000 2,000
&'()*+,*- .%+,/),+ 815421555 6361555 88122R1555 76O1555 0R01555
Arlzona 12,000 6,000 138,000 4,000 7,000
Arkansas 34,000 16,000 386,000 12,000 19,000
Callfornla 330,000 139,000 3,733,000 112,000 183,000
Colorado 37,000 18,000 416,000 12,000 20,000
ConnecLlcuL 20,000 10,000 227,000 7,000 11,000
uelaware 2,000 1,000 19,000 1,000 1,000
ulsLrlcL of Columbla 3,000 2,000 31,000 2,000 3,000
Pawall 9,000 4,000 103,000 3,000 3,000
llllnols 93,000 43,000 1,073,000 32,000 33,000
lowa 3,000 2,000 34,000 2,000 3,000
kenLucky 42,000 20,000 478,000 14,000 24,000
Maryland 32,000 13,000 363,000 11,000 18,000
MassachuseLLs <1000 <1000 3,000 <1000 <1000
Mlchlgan 30,000 24,000 372,000 17,000 28,000
MlnnesoLa 10,000 3,000 113,000 3,000 6,000
nevada 23,000 12,000 284,000 8,000 14,000
new Pampshlre 6,000 3,000 70,000 2,000 3,000
new !ersey 34,000 26,000 613,000 18,000 30,000
new Mexlco 23,000 11,000 239,000 8,000 13,000
new ?ork 40,000 19,000 431,000 13,000 22,000
norLh uakoLa 3,000 2,000 37,000 2,000 3,000
Chlo 106,000 31,000 1,204,000 36,000 39,000
Cregon 44,000 21,000 302,000 13,000 23,000
8hode lsland 6,000 3,000 70,000 2,000 3,000
vermonL 1,000 <1000 11,000 <1000 1,000
WashlngLon 13,000 7,000 173,000 3,000 9,000
WesL vlrglnla 19,000 9,000 216,000 6,000 11,000
9):;% 7< &BB%/#? "* P//%?? #" F)>% )*+ S%);#E T@#/"A%? ,B H#)#% &'()*+? .%+,/),+
noLe: LsLlmaLes reflecL effecLs when expanded coverage ls fully ln effecL. See LexL for deLalls on Lhe meLhodology. numbers may noL sum
due Lo roundlng
Sources: urban lnsLlLuLe, Amerlcan CommunlLy Survey, 20102012, CLA calculaLlons.
17

311/,*2 +' @-'$',-$< !/,"%-*&
Whlle one lmporLanL goal of Lhe Medlcald program ls Lo ensure LhaL enrollees have access Lo
medlcal care, an equally lmporLanL goal ls Lo proLecL famllles from large ouLofpockeL medlcal
cosLs and ensure LhaL lllness does noL LhreaLen famllles' ablllLy Lo meeL oLher lmporLanL needs.
1o quanLlfy Lhe lmprovemenLs ln flnanclal securlLy resulLlng from SLaLe declslons Lo expand
Medlcald under Lhe Affordable Care AcL, Lhls analysls Lurns once agaln Lo Lhe CPlL, whlch found
LhaL Medlcald coverage slgnlflcanLly lmproved flnanclal securlLy.

1hls analysls focuses on Lwo speclflc ouLcomes measured ln Lhe CPlL, whlch were measured
uslng lnperson lnLervlews Lwo years afLer Lhe coverage loLLery:

C09029)'+/%3 '-9'4+'3?*9 3'292"

Medlcald coverage nearly ellmlnaLed Lhe rlsk of faclng caLasLrophlc ouLofpockeL medlcal
cosLs (deflned ln Lhe sLudy as ouLofpockeL spendlng ln excess of 30 percenL of household
lncome) durlng Lhe prlor year. Speclflcally, belng enrolled ln Medlcald reduced Lhe probablllLy
of experlenclng such an ouLcome by 4.3 percenLage polnLs, relaLlve Lo a basellne rlsk of 3.3
percenL ln Lhe conLrol group.

D)'-=&* +0:%(A =%&&2 .-* 9' $*.%30& *E+*(2*2"

Medlcald coverage dramaLlcally reduced Lhe rlsk LhaL an lndlvldual reporLed havlng borrowed
money or sklpped paylng oLher bllls due Lo medlcal expenses durlng Lhe prlor year.
Speclflcally, belng enrolled ln Medlcald reduced Lhe probablllLy of experlenclng such an
ouLcome by 14.2 percenLage polnLs, relaLlve Lo a basellne rlsk of 24.4 percenL ln Lhe conLrol
group.

1he CPlL also found LhaL Medlcald coverage reduced Lhe average amounL of ouLofpockeL
spendlng and Lhe probablllLy of havlng any medlcal debL. ln addlLlon, ln earller work uslng credlL
reporL daLa, Lhe CPlL lnvesLlgaLors documenLed a large reducLlon ln Lhe probablllLy of havlng had
a medlcal blll senL Lo a collecLlon agency over sllghLly more Lhan one year of followup.

As wlLh Lhe healLh care uLlllzaLlon resulLs dlscussed ln Lhe lasL subsecLlon, Lhe flndlng LhaL healLh
lnsurance lmproves flnanclal securlLy ls noL unlque Lo Lhe CPlL. llnkelsLeln and McknlghL (2008)
demonsLraLe LhaL Lhe lnLroducLlon of Medlcare ln 1963 led Lo sharp reducLlons ln senlors'
exposure Lo large ouLofpockeL medlcal cosLs. Cross and noLowldlgdo (2011) examlne Medlcald
expanslons durlng Lhe 1990s and early 2000s and flnd LhaL Lhose expanslons slgnlflcanLly reduced
Lhe rlsk of consumer bankrupLcy.
8


8
uslng credlL reporL daLa, Lhe CPlL found no evldence of a reducLlon ln Lhe rlsk of bankrupLcy over a followup
perlod exLendlng sllghLly more Lhan one year from Lhe daLe LhaL loLLery wlnners galned coverage, desplLe flndlng
large lmprovemenLs on oLher measures of flnanclal sLraln. 1hls dlfference ln resulLs could reflecL Lhe much longer
followup perlod avallable Lo Cross and noLowldlgdo. AlLernaLlvely, lL could reflecL dlfferences ln Lhe Lypes of
Medlcald expanslons under sLudy, Lhe expanslons sLudled by Cross and noLowldlgdo prlmarlly affecLed chlldren,
whlle Lhe expanslon sLudled ln Lhe CPlL affecLed adulLs. 1he llmlLed sample slze avallable ln Lhe CPlL does noL
appear Lo explaln Lhe dlfference ln resulLs, as Lhe dlfference beLween Lhe esLlmaLe reporLed by Lhe CPlL and Lhe
esLlmaLe reporLed by Cross and noLowldlgdo approaches sLandard Lhresholds for sLaLlsLlcal slgnlflcance.
18


1o LranslaLe Lhe CPlL esLlmaLes lnLo Lhe number of lndlvlduals esLlmaLed Lo avold Lhese negaLlve
flnanclal ouLcomes ln each SLaLe, Lhe CPlL polnL esLlmaLe was mulLlplled by Lhe PlSM esLlmaLes
of Lhe number of lndlvlduals esLlmaLed Lo galn coverage ln LhaL SLaLe lf Lhe SLaLe expands
Medlcald coverage. 1he resulLlng SLaLebySLaLe esLlmaLes of Lhe reducLlon ln Lhe number of
lndlvlduals faclng adverse flnanclal ouLcomes due Lo hlgh ouLofpockeL medlcal cosLs are
reporLed ln 1able 4. llgure 4 summarlzes Lhe reducLlon ln Lhe lncldence of adverse flnanclal
ouLcomes LhaL SLaLes LhaL have noL yeL expanded Medlcald could achleve once expanded
coverage ls fully ln effecL, as well as Lhe galns for SLaLes LhaL have already expanded Lhe program.
llgure 3 maps Lhe SLaLelevel esLlmaLes of Lhe reducLlon ln Lhe number of lndlvlduals borrowlng
money or sklpplng paymenLs on oLher bllls due Lo medlcal expenses lf each SLaLe expands
Medlcald.





1,000,000
800,000
600,000
400,000
200,000
0
CaLasLrophlc CuLofockeL
Medlcal CosLs
8orrowlng Lo ay 8llls or Sklpplng
aymenLs uue Lo Medlcal Lxpenses
SLaLes Lxpandlng Medlcald
SLaLes noL ?eL Lxpandlng Medlcald
Change ln annual number of people experlenclng llsLed ouLcome
I,-@>% 6J C>"K%/#%+ Q%+@/#,"* ,* #E% =*/,+%*/% "B I,*)*/,); S)>+?E,( ,B
H#)#%? &'()*+ .%+,/),+1 :N F@>>%*# &'()*?,"* H#)#@?
Source: urban lnsLlLuLe, 8alcker eL al. (2013), CLA calculaLlons.
noLe: LsLlmaLes reflecL effecLs when expanded coverage ls fully ln effecL. See LexL for
meLhodologlcal deLalls.
19

eople wlLh CaLasLrophlc CuLofockeL
CosLs ln a 1yplcal ?ear
eople 8orrowlng Lo ay 8llls or Sklpplng
aymenLs uue Lo Medlcal 8llls
!"# $%# &'()*+,*- .%+,/),+ 4001555 O531655
Alabama 10,300 33,400
Alaska 1,200 3,700
llorlda 38,000 120,600
Ceorgla 21,400 68,000
ldaho 2,300 7,800
lndlana 11,700 37,300
kansas 4,300 14,200
Loulslana 11,900 37,700
Malne 1,300 4,000
Mlsslsslppl 7,400 23,300
Mlssourl 11,300 36,000
MonLana 1,700 3,400
nebraska 2,200 6,800
norLh Carollna 16,900 33,600
Cklahoma 3,300 17,300
ennsylvanla 13,700 43,400
SouLh Carollna 8,900 28,200
SouLh uakoLa 1,200 3,700
1ennessee 10,300 33,300
1exas 34,100 171,800
uLah 3,300 10,300
vlrglnla 9,400 29,900
Wlsconsln 3,400 17,100
Wyomlng 700 2,300
&'()*+,*- .%+,/),+ 8371255 2861655
Arlzona 2,300 7,300
Arkansas 6,400 20,300
Callfornla 62,300 197,700
Colorado 6,900 21,900
ConnecLlcuL 3,800 11,900
uelaware 300 1,000
ulsLrlcL of Columbla 900 2,700
Pawall 1,700 3,300
llllnols 17,800 36,600
lowa 900 2,800
kenLucky 7,900 23,200
Maryland 6,000 19,200
MassachuseLLs 100 300
Mlchlgan 9,300 30,100
MlnnesoLa 1,900 6,000
nevada 4,700 14,900
new Pampshlre 1,200 3,700
new !ersey 10,200 32,300
new Mexlco 4,300 13,700
new ?ork 7,300 23,700
norLh uakoLa 900 3,000
Chlo 20,000 63,400
Cregon 8,300 26,400
8hode lsland 1,200 3,700
vermonL 200 600
WashlngLon 2,900 9,100
WesL vlrglnla 3,600 11,400
9):;% 6< Q%+@/#,"* ,* !@A:%> "B C%"(;% I)/,*- I,*)*/,); S)>+?E,( ,B H#)#% &'()*+? .%+,/),+
Sources:urban lnsLlLuLe, Amerlcan CommunlLy Survey, 20102012, CLA calculaLlons.
noLe: LsLlmaLes reflecL effecLs when expanded coverage ls fully ln effecL. See LexL for deLalls on Lhe meLhodology. numbers may noL
sum due Lo roundlng. CaLasLrophlc medlcal cosLs deflned as medlcal cosLs exceedlng 30 percenL of lncome.
20



311/,*2 +' H/$<*9 F"*,+#/2
Medlcald also seeks Lo lmprove enrollees' healLh. 1he flndlngs above showlng LhaL Medlcald
lncreases recelpL of recommended medlcal care-care for whlch Lhere ls a sLrong cllnlcal
evldence base demonsLraLlng lLs effecLlveness ln lmprovlng healLh-[usLlfles a sLrong
presumpLlon LhaL Medlcald does lndeed lmprove enrollees' healLh. neverLheless, dlrecL
evldence LhaL healLh lnsurance lmproves healLh ls deslrable.

1o quanLlfy effecLs on menLal healLh, Lhls analysls Lurns once more Lo Lhe CPlL. 1he CPlL found
LhaL Medlcald coverage reduced Lhe probablllLy LhaL an lndlvldual screened poslLlve for
depresslon on Lhe basls of a sLandard elghLquesLlon quesLlonnalre by 9.2 percenLage polnLs,
relaLlve Lo a 30.0 percenL basellne probablllLy ln Lhe conLrol group.
9
Medlcald coverage also

9
As dlscussed below, Lhls analysls does noL use Lhe CPlL Lo quanLlfy Lhe effecLs of Medlcald on physlcal healLh, as
Lhe relevanL esLlmaLes are lmpreclse and noL sLaLlsLlcally dlfferenL from zero. Cne concern wlLh uslng Lhe only Lhe
resulLs from Lhe CPlL LhaL happen Lo be sLaLlsLlcally slgnlflcanL ls LhaL, as Lhe number of healLh ouLcomes under
conslderaLlon rlses, Lhe probablllLy LhaL one wlll be sLaLlsLlcally slgnlflcanL purely by chance rlses as well, even lf, ln
LruLh, Medlcald has no effecL on any of Lhese ouLcomes. ln Lhls case, focuslng on Lhe sLaLlsLlcally slgnlflcanL
esLlmaLes and dlsregardlng Lhe oLhers can be mlsleadlng, a problem sLaLlsLlclans and economeLrlclans refer Lo as
Lhe problem of mulLlple comparlsons."
21

generaLed lmprovemenLs ln selfreporLed menLal healLh, as measured uslng a sLandard Lhree
quesLlon baLLery on Lhe effecL of menLal healLh on quallLy of llfe.

1wo sLeps were used Lo LranslaLe CPlL's esLlmaLe LhaL Medlcald reduced Lhe probablllLy of
screenlng poslLlve for depresslon lnLo Lhe reducLlon ln Lhe number of people acLually
experlenclng depresslon lf each SLaLe expanded Medlcald. llrsL, Lhe reducLlon ln Lhe number of
people who would 23)**( poslLlve for depresslon was obLalned by mulLlplylng Lhe CPlL polnL
esLlmaLe by Lhe PlSM esLlmaLes of Lhe number of lndlvlduals who wlll galn coverage ln each
SLaLe lf LhaL sLaLe expands lLs Medlcald program. rlor research has esLlmaLed LhaL 88 percenL
of Lhose who screen poslLlve for depresslon uslng Lhls screenlng Lool are found Lo be experlenclng
ma[or depresslon on Lhe basls of a cllnlcal lnLervlew (kroenke eL al. 2001). 1hus, Lo obLaln Lhe
flnal esLlmaLes of Lhe reducLlon ln Lhe lncldence of depresslon, Lhe reducLlon ln Lhe number of
poslLlve screenlng resulLs was mulLlplled by 0.88.
10
1he resulLlng SLaLebySLaLe esLlmaLes of Lhe
reducLlon ln Lhe number of lndlvlduals experlenclng depresslon are reporLed ln 1able 3.

1urnlng Lo physlcal healLh, Lhe CPlL provldes clear evldence LhaL lndlvlduals recelvlng Medlcald
percelved Lhemselves Lo be ln beLLer healLh. ln resulLs Lhrough approxlmaLely Lwo years of
followup, Medlcald coverage lncreased Lhe share of lndlvlduals reporLlng LhaL Lhelr healLh had
remalned Lhe same or lmproved over Lhe prlor year by 7.8 percenLage polnLs, relaLlve Lo a
basellne probablllLy of 80.4 percenL ln Lhe conLrol group. ln earller resulLs Lhrough sllghLly more
Lhan one year of followup, Medlcald also lncreased Lhe probablllLy LhaL an lndlvldual reporLed
LhaL hls or her healLh was good, very good, or excellenL by 13.3 percenLage polnLs, relaLlve Lo a
basellne probablllLy of 34.8 percenL ln Lhe conLrol group.

1o LranslaLe Lhe CPlL esLlmaLe of Lhe effecL of Medlcald on Lhe number of lndlvlduals reporLlng
LhaL Lhey are ln good, very good, or excellenL healLh lnLo an esLlmaLe of Lhe number of addlLlonal
people who would assess Lhelr healLh ln Lhls way lf each SLaLe expanded Medlcald, Lhe CPlL polnL
esLlmaLe ls slmply mulLlplled by Lhe number of people who wlll galn coverage lf each SLaLe
expands lLs Medlcald program. 1he resulLlng SLaLebySLaLe esLlmaLes are reporLed ln 1able 3
and are mapped ln llgure 6. llgure 7 summarlzes Lhe lmprovemenLs ln Lhls measure of healLh
LhaL SLaLes LhaL have noL yeL expanded Medlcald could achleve once expanded coverage ls fully
ln effecL, as well as Lhe galns for SLaLes LhaL have already expanded Lhe program.




Cne way of addresslng Lhls problem ls Lo seL a hlgher Lhreshold for sLaLlsLlcal slgnlflcance when evaluaLlng Lhe
resulLs of mulLlple sLaLlsLlcal LesLs. uslng a sLandard meLhod for compuLlng LhaL hlgher Lhreshold (known as Lhe
8onferronl meLhod") whlle Laklng lnLo accounL LhaL Lhe sLudy also examlned effecLs on hlgh blood pressure,
cholesLerol levels, and blood sugar conLrol, Lhe pvalue for Lhe esLlmaLed effecL of Medlcald coverage on
depresslon remalns below 10 percenL. 1hls lndlcaLes LhaL Lhe CPlL's depresslon resulLs are sLlll unllkely Lo have
arlsen by chance, even afLer accounLlng for mulLlple comparlsons.
10
1hls approach llkely sllghLly undersLaLes Lhe acLual reducLlon ln depresslon as a resulL of expandlng Medlcald.
kroenke eL al. demonsLraLe LhaL Lhe screenlng Lool used by Lhe CPlL researchers also occaslonally mlsses
lndlvlduals who appear depressed ln a cllnlcal lnLervlew. 1o Lhe exLenL LhaL Medlcald also reduces depresslon ln
Lhese lndlvlduals, Lhe effecLs on Lhe overall lncldence of depresslon would be correspondlngly larger.
22




0
100,000
200,000
300,000
400,000
300,000
600,000
700,000
800,000
SLaLes Lxpandlng Medlcald SLaLes noL ?eL Lxpandlng Medlcald
Change ln number of people reporLlng good/very good/excellenL healLh
Source: urban lnsLlLuLe, llnkelsLeln eL al. (2012), CLA calculaLlons.
noLe: LsLlmaLes reflecL effecLs when expanded coverage ls fully ln effecL. See LexL for
meLhodologlcal deLalls.
I,-@>% RJ C>"K%/#%+ =*/>%)?% ,* !@A:%> "B C%"(;% Q%(">#,*- U""+1 V%>N U""+1
"> &'/%;;%*# S%);#E ,B H#)#%? &'()*+ .%+,/),+1 :N F@>>%*# &'()*?,"* H#)#@?
23

1he llmlLed sample slze of Lhe CPlL makes lL more dlfflculL Lo reach flrm concluslons abouL Lhe
effecL of Medlcald on ob[ecLlve measures of physlcal healLh slnce Lhe CPlL esLlmaLes were
generally lmpreclse. 1he CPlL dld aLLempL Lo measure Lhe effecL of Medlcald coverage on several
physlcal healLh ouLcomes, lncludlng Lhe lncldence of hlgh blood pressure, hlgh cholesLerol, and
poor conLrol of blood sugar. 1he sLudy's +'%(9 *29%$09*2 (roughly speaklng, a polnL esLlmaLe ls
Lhe mosL llkely slngle value ln llghL of a sLudy's daLa) showed some lmprovemenL ln each of Lhese
domalns. lor example, Lhe sLudy's polnL esLlmaLe was LhaL Medlcald reduced Lhe lncldence of
elevaLed blood pressure by 1.3 percenLage polnLs, relaLlve Lo a basellne lncldence of 16.3 percenL
ln Lhe conLrol group, Lhe polnL esLlmaLes for Lhe oLher measured dlmenslons of physlcal healLh
were, ln proporLlonal Lerms, slmllar or larger. ln early resulLs, Lhe CPlL also reporLed a polnL
esLlmaLe suggesLlng LhaL Medlcald reduced morLallLy over a followup perlod of sllghLly more
Lhan one year. 1hese polnL esLlmaLes would generally be cllnlcally meanlngful lf Lhey exacLly
reflecLed reallLy (lrakL 2013a, lrakL 2013b).

Powever, Lhe CPlL's sample slze was (by necesslLy) qulLe llmlLed, so Lhe preclslon wlLh whlch
Lhese changes ln healLh ouLcomes could be measured was also llmlLed. As a resulL, Lhese
esLlmaLed lmprovemenLs ln physlcal healLh fell far shorL of sLaLlsLlcal slgnlflcance, and lL ls
lmposslble Lo deLermlne wlLh any confldence wheLher Lhe polnL esLlmaLes descrlbed above arose
because Medlcald acLually generaLed lmprovemenLs ln physlcal healLh or lf Medlcald acLually has
negllglble effecLs on physlcal healLh, and Lhese esLlmaLes were slmply obLalned by chance. lor
example, whlle Lhe sLudy's polnL esLlmaLe was LhaL Medlcald reduced Lhe lncldence of hlgh blood
pressure by 1.3 percenLage polnLs, a 93 percenL confldence lnLerval around LhaL esLlmaLe
sLreLches from a 7.2 percenLage polnL reducLlon ln lncldence Lo a 4.3 percenLage polnL lncrease
ln lncldence. Closely relaLed, lL may noL have been reasonable Lo expecL Lhe CPlL Lo flnd
sLaLlsLlcally slgnlflcanL lmprovemenLs ln physlcal healLh sLemmlng from Medlcald coverage. 1o
be rellably deLecLed by Lhe CPlL, Lhe effecLs of Medlcald on physlcal healLh would have had Lo
be qulLe large, ofLen larger Lhan whaL seems medlcally plauslble (lrakL 2013a, lrakL 2013b,
8lchardson, Carroll, and lrakL 2013, Mulllgan 2013).

ln llghL of Lhe llmlLaLlons of Lhe CPlL for learnlng abouL Lhe effecLs of Medlcald on ob[ecLlve
physlcal healLh ouLcomes, lL ls useful Lo examlne a parallel llLeraLure LhaL uses quasl
experlmenLs" creaLed by pasL pollcy changes Lo sLudy how Medlcald coverage affecLs healLh
ouLcomes. 1he dlsadvanLage of relylng on quaslexperlmenLal research ls LhaL lL ls more
vulnerable Lo unobserved confoundlng facLors Lhan research uslng a randomlzed research
deslgn. Powever, Lhese quaslexperlmenLal sLudles have Lhe lmporLanL advanLage LhaL Lhey can
ofLen draw on much larger samples and, Lhus, dellver much more preclse esLlmaLes.

1wo recenL quaslexperlmenLal sLudles are parLlcularly relevanL ln Lhls conLexL slnce Lhey
examlne lnsurance expanslons LhaL, llke SLaLe Medlcald expanslons under Lhe Affordable Care
AcL, prlmarlly affecL low or moderaLelncome adulLs. Sommers, Long, and 8alcker (2014) sLudy
Lhe morLallLy effecLs of MassachuseLLs healLh reform, whlch prlmarlly affecLed adulLs wlLh
lncomes slmllar Lo or modesLly hlgher Lhan Lhose affecLed by Lhe Affordable Care AcL's Medlcald
expanslon, by comparlng morLallLy Lrends ln MassachuseLLs counLles Lo morLallLy Lrends ln
demographlcally slmllar counLles ln Lhe resL of Lhe counLry. 1hey flnd LhaL Lhe morLallLy raLe for
24

MassachuseLLs adulLs fell by 2.9 percenL from Lhe years before reform Lo Lhe years afLer reform,
relaLlve Lo Lhe comparlson counLles. 1he auLhors documenL LhaL morLallLy followed slmllar
Lrends ln MassachuseLLs counLles and comparlson counLles before reform, LhaL Lhe morLallLy
galns were concenLraLed ln counLles wlLh lower lncomes and lower lnsurance coverage raLes
prlor Lo reform, and LhaL Lhe lmprovemenLs were prlmarlly ln causes of deaLh belleved Lo be
avoldable wlLh beLLer healLh care, all of Lhese flndlngs are conslsLenL wlLh Lhe lnLerpreLaLlon LhaL
Lhe observed fall ln morLallLy ln MassachuseLLs was caused by Lhe expanslon of lnsurance
coverage. noLably, Lhe auLhors' esLlmaLe falls well wlLhln Lhe very wlde 93 percenL confldence
lnLerval assoclaLed wlLh Lhe lmpreclse correspondlng CPlL esLlmaLe.

Sommers, 8alcker, and LpsLeln (2012) examlne preACA expanslons of Medlcald coverage Lo low
lncome adulLs ln Arlzona, new ?ork, and Malne. Much llke Sommers, Long, and 8alcker, Lhe
auLhors esLlmaLe how Lhese Medlcald expanslons affecLed Lhe rlsk of deaLh by comparlng
morLallLy Lrends ln Lhe Lhree expanslon sLaLes Lo morLallLy Lrends ln nelghborlng sLaLes. 1hey
flnd LhaL Lhe morLallLy raLe for adulLs fell by 6.1 percenL ln Lhe expanslon sLaLes relaLlve Lo non
expandlng SLaLes ln Lhe years around Lhe reform. 1hey documenL LhaL morLallLy Lrends were
slmllar ln expanslon and nonexpanslon sLaLes before reform and LhaL Lhe morLallLy galns were
concenLraLed ln lowerlncome counLles, conslsLenL wlLh Lhe lnLerpreLaLlon LhaL Lhe fall ln
morLallLy ln Lhe expanslon sLaLes was caused by expanded lnsurance coverage. 1hls esLlmaLe ls
also noL sLaLlsLlcally dlfferenL from Lhe lmpreclse correspondlng CPlL esLlmaLe.

1hese are noL Lhe only quaslexperlmenLal sLudles examlnlng Lhe llnk beLween healLh lnsurance
sLaLus and healLh ouLcomes, alLhough Lhey are Lhe Lwo LhaL are mosL relevanL Lo evaluaLlng Lhe
consequences of SLaLes' Medlcald expanslon declslons. Currle and Cruber (1994), Currle and
Cruber (1996), Meyer and Wherry (2012) examlne pasL Medlcald expanslons affecLlng pregnanL
women, chlldren, and Leens, respecLlvely, and flnd LhaL Lhose coverage expanslons reduced
morLallLy. Card, uobkln, and MaesLas (2009) documenL a dlscreLe reducLlon ln morLallLy for
paLlenLs arrlvlng aL Lhe hosplLal wlLh nondeferrable" condlLlons aL age 63, colncldlng wlLh Lhe
beglnnlng of ellglblllLy for Medlcare. Levy and MelLzer (2008) underLake a careful revlew of Lhe
quaslexperlmenLal llLeraLure and conclude LhaL, whlle LhaL llLeraLure ls noL unanlmous on Lhls
quesLlon, Lhe balance of Lhe evldence demonsLraLes LhaL expandlng access Lo healLh lnsurance
coverage lmproves healLh for speclflc wellsLudled populaLlons. 1he resulLs from Sommers, Long,
and 8alcker (2014) and Sommers, 8alcker, and LpsLeln (2012) provlde sLrong evldence LhaL Lhls
general concluslon LhaL expanded coverage lmproves healLh applles Lo coverage expanslons LhaL
affecL low and moderaLelncome adulLs, llke Medlcald expanslons under Lhe Affordable Care
AcL.

311/,*2 +' !*$*/ 3,+'+#-/2 $'( *9/ :$*-+'$< 3,+'+#&
ln addlLlon Lo Lhelr effecLs on lnsurance coverage, access Lo healLh care, and healLh and well
belng, SLaLes declslons Lo expand Medlcald wlll also have lmmedlaLe macroeconomlc beneflLs by
drawlng addlLlonal lederal fundlng lnLo SLaLe economles. As descrlbed ln greaLer deLall below,
Lhls addlLlonal lederal fundlng wlll lncrease demand for boLh medlcal and nonmedlcal goods
and servlces. Cver Lhe nexL few years, whlle Lhe recovery from Lhe 20072009 recesslon remalns
23

lncompleLe and slack remalns ln Lhe economy, Lhls lncrease ln demand wlll boosL overall
employmenL and economlc acLlvlLy.

ln deLall, when a SLaLe elecLs Lo expand lLs Medlcald program, Lhe lederal governmenL flnances
addlLlonal paymenLs Lo medlcal provlders ln Lhe SLaLe ln exchange for provldlng medlcal servlces
Lo Lhe new Medlcald enrollees. 1hese addlLlonal Medlcald ouLlays are only parLlally offseL by
reduced lederal spendlng on premlum Lax credlLs and cosLsharlng asslsLance for lndlvlduals ln
LhaL SLaLe wlLh lncomes beLween 100 and 138 percenL of Lhe lL who swlLch from recelvlng
coverage Lhrough Lhe MarkeLplaces Lo recelvlng coverage Lhrough Medlcald.

CLA has used daLa from Lhe Congresslonal 8udgeL Cfflce and urban lnsLlLuLe daLa Lo esLlmaLe
Lhe addlLlonal lederal ouLlays each SLaLe would have Lrlggered lf lL had expanded Medlcald by
!anuary 1, 2014, Lhe deLalled meLhodology ls presenLed ln Appendlx 8. Cn Lhe basls of Lhls
meLhodology, CLA esLlmaLes LhaL lf Lhe 24 SLaLes LhaL have noL yeL expanded Medlcald had done
so as of !anuary 1, 2014, LhaL would have Lrlggered an lncrease ln lederal ouLlays ln Lhose SLaLes
LoLallng $88 bllllon durlng calendar years 2014 Lhrough 2016. SLaLes LhaL have already expanded
Medlcald wlll generaLe addlLlonal lederal ouLlays of $84 bllllon durlng Lhls perlod. SLaLebySLaLe
esLlmaLes of Lhe addlLlonal lederal ouLlays resulLlng from each SLaLe's declslon Lo expand
Medlcald are reporLed ln 1able 3.
11


ln order Lo quanLlfy Lhe effecLs of Lhese addlLlonal lederal ouLlays on SLaLes' economles and Lhe
economy of Lhe naLlon as a whole, CLA has underLaken a sLandard flscal mulLlpller" analysls. ln
brlef, when Lhe governmenL purchases addlLlonal goods and servlces, LhaL spurs hlrlng and
purchases of lnvesLmenL goods and raw maLerlals Lo produce Lhose goods and servlces. As Lhose
newlyhlred workers and producers spend Lhe lncome Lhey have earned, Lhey spur addlLlonal
hlrlng and purchases, whlch ln Lurn seLs off yeL anoLher round of lncreases ln spendlng, and so
on. LconomlsLs summarlze Lhls sequence of macroeconomlc effecLs vla a flscal mulLlpller,"
whlch measures Lhe LoLal number of dollars of addlLlonal economlc acLlvlLy arlslng from a one
dollar flscal change. 1he 2014 F3'('$%3 B*+')9 '4 9/* G)*2%.*(9 provldes a deLalled dlscusslon of
Lhe LheoreLlcal basls for Lhls Lype of analysls and Lhe emplrlcal llLeraLure underlylng CLA's
esLlmaLes of Lhe mulLlpller for dlfferenL Lypes of flscal changes (CLA 2014). As descrlbed Lhereln,
CLA's mulLlpller esLlmaLes fall well wlLhln Lhe range of esLlmaLes used by oLher analysLs, lncludlng
Lhe Congresslonal 8udgeL Cfflce.

1he approprlaLe mulLlpller Lo use for evaluaLlng Lhe macroeconomlc consequences of SLaLes'
Medlcald expanslon declslons depends on how Lhe addlLlonal lederal ouLlays Lrlggered by SLaLes'
declslons enLer SLaLe economles. ln pracLlce, Lhese ouLlays wlll Lake Lhree maln paLhs:

H..%9%'(0& -9%&%I09%'( '4 $*.%30& 30)*"

11
noLe LhaL, whlle Lhls analysls focuses on calendar years Lhrough 2016 because Lhese are mosL relevanL for
quanLlfylng Lhe shorLrun macroeconomlc lmpacLs, generous lederal supporL for SLaLes LhaL elecL Lo expand
Medlcald would conLlnue ln subsequenL years. Lxpandlng Medlcald would Lhus remaln an aLLracLlve proposlLlon
for SLaLes slnce Lhey could conLlnue Lo reallze Lhe dlrecL beneflLs of expanded coverage aL llmlLed cosL, even
Lhough SLaLes' declslons would no longer boosL overall economlc ouLpuL.
26


ConslsLenL wlLh Lhe evldence descrlbed earller ln Lhls reporL, much of Lhe addlLlonal lederal
fundlng wlll fund addlLlonal medlcal care for newly enrolled Medlcald enrollees, lncreaslng
overall demand for medlcal goods and servlces. lor dollars enLerlng Lhe economy Lhls way,
CLA uses a Cu mulLlpller of 1.3, conslsLenL wlLh CLA's esLlmaLe of Lhe mulLlpller for dlrecL
governmenL spendlng.

J',*) '-9'4+'3?*9 $*.%30& 3'292"

Also conslsLenL wlLh Lhe evldence presenLed earller ln Lhls reporL, some of Lhe addlLlonal
lederal fundlng wlll proLecL enrollees from hlgh ouLofpockeL medlcal cosLs, permlLLlng
famllles Lo redlrecL dollars Lo oLher presslng needs and boosLlng demand for a wlde varleLy
of goods and servlces.
12
lor dollars enLerlng Lhe economy Lhls way, CLA uses a Cu mulLlpller
of 1.3, conslsLenL wlLh CLA's esLlmaLe of Lhe mulLlpller for paymenLs Lo lowlncome
households.

B*.-39%'(2 %( -(3'$+*(209*. 30)*"

1he remalnder of Lhe addlLlonal lederal fundlng wlll compensaLe provlders for Lhe cosL of
provldlng care LhaL prevlously wenL unrelmbursed. ln Lurn, Lhose funds wlll flow Lhrough Lo
Lhe enLlLles LhaL were prevlously bearlng Lhe cosL of LhaL uncompensaLed care, some
comblnaLlon of SLaLe and local governmenLs, prlvaLelylnsured lndlvlduals, and medlcal
provlders.
13
1hose addlLlonal funds wlll permlL Lhose enLlLles Lo lncrease Lhelr demand for
goods and servlces (or, ln Lhe case of governmenLs, reduce Laxes on households, lncreaslng
households' demand for goods and servlces).

lor reducLlons ln uncompensaLed care cosLs borne by SLaLe and local governmenLs, CLA uses
a mulLlpller of 1.1, conslsLenL wlLh CLA's esLlmaLe of Lhe mulLlpller for paymenLs Lo SLaLe and
local governmenLs. lor oLher reducLlons ln uncompensaLed care cosLs, CLA uses a Cu
mulLlpller of 0.8, conslsLenL wlLh CLA's esLlmaLe of Lhe mulLlpller appllcable Lo lndlvldual Lax
cuLs.


12
8educLlons ln famllles' exposure Lo ouLofpockeL medlcal cosLs could boosL currenL demand for goods and
servlces Lhrough anoLher channel by causlng famllles Lo draw down precauLlonary savlngs" LhaL Lhey have
prevlously used Lo self lnsure" agalnsL medlcal rlsk. ln Lhe slmplesL models, reducLlons ln precauLlonary savlng
lmprove economlc efflclency even ln Lhe long run slnce precauLlonary savlng represenLs a hlghcosL way of
proLecLlng agalnsL rlsk, alLhough more compllcaLed models can lead Lo dlfferenL concluslons. Cruber and ?elowlLz
(1999) provlde some evldence LhaL pasL Medlcald expanslons have lndeed reduced precauLlonary savlng. 8ecause
Lhe macroeconomlc esLlmaLes presenLed ln Lhls reporL do noL accounL for effecLs of Medlcald expanslons on
precauLlonary savlng, Lhey are somewhaL conservaLlve.
13
1he lederal governmenL ls sharlng ln reducLlons ln uncompensaLed care cosLs under Lhe Affordable Care AcL
Lhrough sLaLuLory reducLlons ln dlsproporLlonaLe share hosplLal (uSP) paymenLs made vla Lhe Medlcald and
Medlcare programs. 1he reducLlons occur regardless of SLaLe declslons Lo expand Medlcald, so Lhey are noL
relevanL Lo Lhe macroeconomlc analysls underLaken here.
27

8ased on recenL esLlmaLes of per caplLa uncompensaLed care cosLs among Lhe unlnsured
(Coughlln eL al., 2013), a reasonable esLlmaLe ls LhaL around 30 percenL of Lhe addlLlonal
Medlcald spendlng wlll defray uncompensaLed care cosLs.
14
Whlle, ln pracLlce, SLaLe and local
governmenLs are llkely Lo reallze a slgnlflcanL fracLlon of Lhese savlngs, ln Lhe lnLeresL of belng
conservaLlve, CLA has assumed LhaL Lhese savlngs accrue enLlrely Lo provlders and oLher payers,
whlch leads Lo a composlLe mulLlpller of 1.29 for each addlLlonal dollar of lederal ouLlays
resulLlng from a SLaLe's declslon Lo expand Medlcald. 1he magnlLude of Lhls composlLe mulLlpller
ls noL parLlcularly senslLlve Lo alLernaLlve assumpLlons abouL Lhe exLenL Lo whlch expandlng
Medlcald defrays uncompensaLed care cosLs versus enLerlng Lhe economy Lhrough oLher
channels.

1o generaLe esLlmaLes of Lhe macroeconomlc effecL of SLaLe Medlcald expanslon declslons, Lhe
esLlmaLed flscal effecLs of SLaLe declslons Lo expand Medlcald and Lhe mulLlpller esLlmaLes
descrlbed above were used as lnpuLs lnLo Lhe CLA mulLlpller model, whlch has been descrlbed ln
prevlous CLA publlcaLlons (CLA 2014). 1he CLA model Lhen produces quarLerly esLlmaLes of Lhe
effecL of SLaLes' declslons abouL wheLher Lo expand Medlcald on employmenL and overall
economlc acLlvlLy.
13


1he esLlmaLes generaLed by Lhe CLA mulLlpller model assume LhaL, as ls Lhe case now, Lhere ls
slack ln Lhe economy and producLlve resources are noL fully employed.
16
When Lhe economy
reLurns Lo full employmenL, Lhese demandslde effecLs wlll become much smaller and evenLually
dlsappear enLlrely because an lncrease ln labor demand ln one secLor wlll mosLly Lend Lo
reallocaLe workers away from oLher secLors. Looklng forward, Lhe lederal 8eserve and many
prlvaLe forecasLers expecL Lhe economy Lo remaln shorL of full employmenL unLll laLe 2016. lor
Lhe purposes of Lhls analysls, Lhe CLA assumes LhaL lederal ouLlays spurred by SLaLes' Medlcald
expanslon declslons wlll have Lhelr full macroeconomlc effecLs Lhrough Lhe mlddle of 2013 and
LhaL Lhese effecLs phase down gradually LhereafLer, reachlng zero by Lhe beglnnlng of 2017.
Whlle Lhls approach ls somewhaL ad hoc, lL llkely provldes a reasonable approxlmaLlon of Lhe
acLual effecLs.

14
1hls esLlmaLe ls broadly conslsLenL wlLh uncompensaLed care esLlmaLes produced by PlSM, Lhe source for Lhe
coverage esLlmaLes used elsewhere ln Lhls reporL. 1he PlSM esLlmaLes lmply LhaL SLaLe declslons Lo expand
Medlcald wlll reduce overall uncompensaLed care cosLs by $183 bllllon over Len years, whlch ls 28 percenL of Lhe
$643 bllllon lncrease ln neL lederal ouLlays lf all SLaLes expand Lhe program LhaL was esLlmaLed by PlSM (Polahan
eL al. 2012). 1o Lhe exLenL LhaL reducLlons ln uncompensaLed care represenL a smaller share of Lhe addlLlonal
ouLlays, Lhe macroeconomlc effecLs of SLaLe declslons Lo expand Medlcald would be commensuraLely larger.
13
1he esLlmaLes produced by Lhls model reflecL Lhe naLlonal effecLs on employmenL and economlc acLlvlLy
resulLlng from each SLaLe's declslon Lo expand Medlcald. Whlle Lhe beneflLs of each SLaLe's declslon are llkely Lo
fall dlsproporLlonaLely ln LhaL SLaLe, because SLaLes are economlcally lnLerconnecLed, some of Lhose beneflLs wlll
accrue Lo oLher SLaLes. lor example, Callfornla has llkely reallzed some economlc beneflLs from Arlzona's declslon
Lo expand Lhe program and vlce versa. SLaLes' declslons Lo expand Medlcald are, Lhus, lmporLanL for Lhe naLlon as
a whole, noL [usL Lhe SLaLes maklng Lhose declslons.
16
8ecause all of Lhe SLaLebySLaLe esLlmaLes use Lhe same naLlonal mulLlpller model, Lhese esLlmaLes do noL
accounL for dlfference ln Lhe exLenL Lo whlch Lhere ls slack ln parLlcular SLaLe labor markeLs. ln general, Lhls means
LhaL Lhe [ob creaLlon effecLs of SLaLes' Medlcald expanslon declslons may be larger (and longerlasLlng) ln SLaLes
wlLh weaker labor markeLs and smaller (and shorLerllved) ln SLaLes wlLh sLronger labor markeLs.
28

SLaLebySLaLe esLlmaLes of Lhe effecL on employmenL and LoLal ouLpuL lf each SLaLe decldes Lo
expand Medlcald are reporLed ln 1ables 3 and 6. llgure 8 summarlzes Lhe number of [obs LhaL
SLaLes LhaL have noL yeL expanded Medlcald could have creaLed lf Lhey had expanded Lhe
program as of !anuary 1, 2014, as well as Lhe galns LhaL wlll be achleved by SLaLes LhaL have
already expanded Lhe program. llgure 9 maps Lhe cumulaLlve [obyears from 2014 Lhrough
2017 LhaL would have been creaLed lf each SLaLe had expanded Medlcald as of !anuary 1, 2014.

Whlle Lhls subsecLlon focuses on Lhe shorLrun macroeconomlc beneflLs of expanded lnsurance
coverage, SLaLes' declslons Lo expand Medlcald could affecL employmenL and economlc acLlvlLy
over Lhe longer run as well. PealLhler workers who are less flnanclally sLressed and ln beLLer
menLal healLh may be more able Lo effecLlvely parLlclpaLe ln Lhe labor force and have hlgher
producLlvlLy on Lhe [ob. Cn Lhe oLher hand, access Lo coverage Lhrough Medlcald would llkely
cause some workers Lo reduce Lhelr labor supply, elLher because havlng Medlcald coverage
ellmlnaLe Lhe need Lo work ln order Lo obLaln healLh lnsurance or because Medlcald causes
lndlvlduals Lo choose Lo work less ln order Lo avold loslng access Lo Medlcald coverage.
17

8educLlons ln labor supply of Lhe laLLer klnd generally reduce economlc efflclency. ln conLrasL,
reducLlons ln labor supply of Lhe former klnd can lmprove economlc efflclency lf Lhey permlL
workers Lo choose Lo pursue a hlghervalue alLernaLlve acLlvlLy llke carlng for chlldren or oLher
famlly members, pursulng addlLlonal educaLlon, or sLarLlng a buslness, some reducLlons ln Lhls
caLegory are commonly descrlbed as reflecLlng reducLlons ln [ob" or employmenL lock."

1he evldence on Lhe neL effecLs of Medlcald on labor supply for populaLlons llke Lhose affecLed
Lhe Affordable Care AcL's Medlcald expanslon ls mlxed. 1he hlghesLquallLy evldence comes from
Lhe CPlL, whlch concluded LhaL Medlcald enrollmenL had small and sLaLlsLlcally lnslgnlflcanL
effecLs on labor supply (8alcker eL al. 2013b). Some nonrandomlzed quaslexperlmenLal sLudles
have, however, found LhaL Medlcald causes sLaLlsLlcally slgnlflcanL reducLlons ln labor supply.
uague, ueLelre, and Lelnlnger (2014) sLudy an eplsode ln whlch a porLlon of Wlsconsln's Medlcald
program was closed Lo new enrollmenL and conclude LhaL Medlcald enrollmenL drove modesL
reducLlons ln labor supply. CarLhwalLe, Cross, and noLowldlgdo (2014) sLudy a largescale
dlsenrollmenL from 1ennessee's 1ennCare program ln Lhe mld2000s and esLlmaLe much larger
effecLs on labor supply. lL ls generally noL clear whaL porLlons of Lhese labor supply responses
occur Lhrough channels LhaL lncrease, reduce, or do noL affecL economlc efflclency.

1he reasons why dlfferenL sLudles have reached wldely dlfferlng concluslons abouL Lhe effecL of
Medlcald on labor supply ls noL well undersLood. 1he dlfferences could reflecL dlfferences ln Lhe
populaLlons affecLed by Lhese dlfferenL pollcy changes or Lhe Llme perlod durlng whlch Lhose
changes occurred. noLably, Lhe populaLlon sLudled by CarLhwalLe, Cross, and noLowldlgdo ls
somewhaL hlgher lncome Lhan Lhe populaLlon affecLed by Lhe Affordable Care AcL's Medlcald
expanslon. AnoLher posslblllLy ls LhaL Lhe dlfferences reflecL sLaLlsLlcal sampllng errors, because

17
CLher porLlons of Lhe Affordable Care AcL's coverage expanslon could drlve lncreases ln labor supply. lor
example, for lndlvlduals who were ellglble for Medlcald before Lhe Affordable Care AcL, expanded Medlcald
ellglblllLy and Lhe avallablllLy of MarkeLplace coverage means LhaL Lhey can now lncrease Lhelr labor supply
wlLhouL worrylng LhaL Lhey wlll lose Lhelr healLh lnsurance coverage.
29

none of Lhe sLudles are able Lo measure effecLs on labor supply wlLh absoluLe preclslon (wlLh Lhe
CarLhwalLe, Cross, and noLowldlgdo sLudy belng parLlcularly lmpreclse), lL would noL be
surprlslng Lo see some dlsperslon ln Lhese esLlmaLes even lf all Lhe sLudles are measurlng Lhe
same underlylng response. llnally, Lhe dlfferences could arlse because Lhe quaslexperlmenLal
esLlmaLes are conLamlnaLed by unobserved dlfferences beLween Lhose who do and do noL enroll
ln Medlcald LhaL Lhe auLhors are unable Lo fully conLrol for, ln whlch case Lhe experlmenLal resulL
from Lhe CPlL would provlde Lhe only rellable esLlmaLe.

ln any case, labor supply responses are noL llkely Lo be parLlcularly relevanL Lo macroeconomlc
ouLcomes durlng Lhe perlod examlned ln Lhls reporL. As long as slack remalns ln Lhe labor markeL
and Lhere are more workers seeklng work Lhan Lhere are avallable [ob openlngs, a worker who
reduces hls labor supply due Lo Lhe avallablllLy of Medlcald coverage wlll ofLen slmply be replaced
by anoLher [obseeker (C8C 2014a). 1hus, any labor supply effecLs LhaL do exlsL are llkely Lo be
subsLanLlally aLLenuaLed for Lhe nexL few years.


















30




0
40,000
80,000
120,000
160,000
200,000
2014 2013 2016
SLaLes Lxpandlng Medlcald
SLaLes noL ?eL Lxpandlng Medlcald
number of [obs
Source: Congresslonal 8udgeL Cfflce, urban lnsLlLuLe, CLA calculaLlons.
I,-@>% OJ C>"K%/#%+ =*/>%)?% ,* &A(;"NA%*# ,B H#)#%? &'()*+ .%+,/),+1
:N F@>>%*# &'()*?,"* H#)#@?
31

2014 2013 2016
CumulaLlve,
20142016
2014 2013 2016
CumulaLlve
!ob ?ears,
20142017
!"# $%# &'()*+,*- .%+,/),+ 4216O5 431R25 781OR5 OO1885 O61O55 8O71O55 8571855 7RO1R55
Alabama 1,020 1,220 1,390 3,630 3,200 7,300 4,300 13,100
Alaska 100 110 120 330 300 700 400 1,400
llorlda 4,410 3,060 3,330 13,010 14,100 30,900 17,600 63,800
Ceorgla 2,270 2,620 2,880 7,770 7,200 13,900 9,100 32,900
ldaho 200 210 210 620 600 1,300 700 2,700
lndlana 930 940 860 2,760 3,100 6,300 3,100 12,800
kansas 290 280 230 820 1,000 1,900 900 3,800
Loulslana 1,010 1,120 1,200 3,330 3,200 7,000 3,900 14,400
Malne 210 240 260 710 700 1,300 800 3,000
Mlsslsslppl 1,020 1,210 1,370 3,600 3,200 7,200 4,300 13,000
Mlssourl 1,170 1,330 1,440 3,930 3,700 8,200 4,600 16,900
MonLana 120 120 110 330 400 800 400 1,600
nebraska 160 160 140 460 300 1,100 300 2,200
norLh Carollna 2,740 3,220 3,600 9,360 8,700 19,400 11,300 40,200
Cklahoma 320 360 370 1,630 1,700 3,300 1,900 7,300
ennsylvanla 2,460 2,770 2,970 8,200 7,900 17,100 9,600 33,200
SouLh Carollna 1,030 1,160 1,230 3,430 3,300 7,200 4,000 14,800
SouLh uakoLa 130 140 130 420 400 900 300 1,900
1ennessee 1,300 1,730 1,900 3,130 4,800 10,300 6,000 21,700
1exas 4,180 4,640 4,910 13,730 13,400 28,800 16,000 39,400
uLah 200 120 < 10 310 700 1,100 300 2,100
vlrglnla 940 1,030 1,110 3,090 3,000 6,300 3,600 13,300
Wlsconsln 790 870 920 2,380 2,300 3,300 3,000 11,200
Wyomlng 80 90 100 270 300 600 300 1,200
&'()*+,*- .%+,/),+ 4612O5 4O1455 751R65 O71245 RO1255 8R41655 3O1455 7021855
Arlzona 430 280 60 760 1,300 2,400 700 4,700
Arkansas 810 910 980 2,690 2,600 3,600 3,200 11,300
Callfornla 4,740 3,330 6,160 16,430 13,000 33,400 19,400 69,100
Colorado 680 780 830 2,310 2,200 4,800 2,700 9,900
ConnecLlcuL 330 390 630 1,760 1,700 3,700 2,100 7,600
uelaware 120 130 130 400 400 800 300 1,700
ulsLrlcL of Columbla 30 60 60 180 200 400 200 800
Pawall 210 240 260 710 700 1,300 800 3,000
llllnols 1,430 1,610 1,730 4,770 4,600 9,900 3,600 20,300
lowa 200 180 130 330 700 1,300 600 2,600
kenLucky 1,220 1,430 1,390 4,240 3,900 8,600 3,000 17,800
Maryland 980 1,230 1,470 3,680 3,000 7,100 4,400 14,900
MassachuseLLs 460 330 630 1,640 1,400 3,300 1,900 6,800
Mlchlgan 1,120 1,230 1,340 3,710 3,600 7,800 4,300 16,000
MlnnesoLa 300 290 230 840 1,000 2,000 900 4,000
nevada 400 480 340 1,420 1,300 2,800 1,700 3,900
new Pampshlre 160 180 190 330 300 1,100 600 2,300
new !ersey 1,140 1,380 1,390 4,110 3,600 8,200 4,900 17,000
new Mexlco 190 110 < 10 290 700 1,000 300 2,000
new ?ork 3,630 4,340 4,920 12,910 11,300 23,900 13,300 33,800
norLh uakoLa 160 190 220 380 300 1,200 700 2,400
Chlo 3,690 4,330 4,860 12,870 11,700 26,100 13,200 34,000
Cregon 620 340 390 1,330 2,100 3,900 1,700 7,800
8hode lsland 200 240 260 700 600 1,400 800 2,900
vermonL 70 90 110 280 200 300 300 1,100
WashlngLon 310 330 330 1,370 1,600 3,400 1,800 7,000
WesL vlrglnla 620 730 830 2,180 1,900 4,400 2,600 9,100
neL lncrease ln lederal Spendlng
(Mllllons of uollars, Calendar ?ears)
lncrease ln LmploymenL
(number of Workers, Calendar ?ears)
9):;% 0< =*/>%)?% ,* I%+%>); H(%*+,*- )*+ &A(;"NA%*# ,B H#)#% &'()*+? .%+,/),+
Sources: urban lnsLlLuLe, Congresslonal 8udgeL Cfflce, CLA calculaLlons.
noLes: See LexL for deLalls on Lhe meLhodology. numbers may noL sum due Lo roundlng.
32

2014 2013 2016
CumulaLlve,
20142017
!"# $%# &'()*+,*- .%+,/),+ 831285 741805 8612R5 221665
Alabama 740 1,280 620 2,630
Alaska 70 120 60 230
llorlda 3,230 3,420 2,320 11,190
Ceorgla 1,670 2,790 1,310 3,770
ldaho 130 230 100 480
lndlana 730 1,080 430 2,240
kansas 220 320 130 670
Loulslana 730 1,220 330 2,320
Malne 130 260 120 330
Mlsslsslppl 740 1,280 620 2,640
Mlssourl 870 1,430 660 2,960
MonLana 90 140 60 280
nebraska 130 180 70 380
norLh Carollna 2,010 3,410 1,630 7,040
Cklahoma 390 620 270 1,280
ennsylvanla 1,820 2,990 1,370 6,180
SouLh Carollna 760 1,230 380 2,390
SouLh uakoLa 100 160 70 330
1ennessee 1,100 1,830 870 3,810
1exas 3,100 3,040 2,270 10,420
uLah 170 180 30 370
vlrglnla 690 1,130 310 2,340
Wlsconsln 390 930 430 1,970
Wyomlng 60 100 40 210
&'()*+,*- .%+,/),+ 8O1455 751465 861565 2416R5
Arlzona 330 400 80 830
Arkansas 600 980 430 2,020
Callfornla 3,470 3,870 2,790 12,130
Colorado 300 840 390 1,730
ConnecLlcuL 390 640 290 1,330
uelaware 90 140 70 300
ulsLrlcL of Columbla 40 70 30 140
Pawall 160 260 120 330
llllnols 1,060 1,740 800 3,390
lowa 160 220 80 430
kenLucky 890 1,310 720 3,120
Maryland 700 1,270 630 2,610
MassachuseLLs 340 380 280 1,190
Mlchlgan 830 1,360 620 2,800
MlnnesoLa 230 340 130 690
nevada 290 300 240 1,040
new Pampshlre 120 190 90 400
new !ersey 830 1,440 710 2,980
new Mexlco 130 170 20 340
new ?ork 2,660 4,370 2,210 9,440
norLh uakoLa 120 200 100 420
Chlo 2,700 4,390 2,190 9,470
Cregon 490 660 220 1,360
8hode lsland 130 230 120 320
vermonL 30 100 30 200
WashlngLon 380 390 230 1,230
WesL vlrglnla 430 770 370 1,390
9):;% 2< =*/>%)?% ,* U>"?? W"A%?#,/ C>"+@/# ,B H#)#% &'()*+? .%+,/),+
AddlLlonal Cu (Mllllons of uollars, Calendar ?ears)
Sources: urban lnsLlLuLe, Congresslonal 8udgeL Cfflce, CLA calculaLlons.
noLes: See LexL for deLalls on Lhe meLhodology. numbers may noL sum due Lo roundlng.
33

)))C 6+',<"2-+'

1hls reporL documenLs Lhe farreachlng beneflLs LhaL SLaLes LhaL have already expanded Medlcald
under Lhe Affordable Care AcL wlll recelve, and Lhe beneflLs LhaL SLaLes LhaL have noL yeL
expanded Lhe program could achleve lf Lhey elecLed Lo do so. ln parLlcular, Lhls analysls shows
LhaL by expandlng Lhelr Medlcald programs, SLaLes can lmprove access Lo essenLlal medlcal care,
reduce flnanclal hardshlp, lmprove Lhelr clLlzens' menLal healLh and wellbelng, and clalm bllllons
of dollars ln lederal fundlng LhaL could boosL Lhelr economles Loday. 1he AdmlnlsLraLlon hopes
LhaL more SLaLes wlll declde Lo Lake advanLage of Lhese opporLunlLles ln Lhe monLhs and years
ahead and sLands ready Lo work wlLh SLaLes Lo make Lhese opporLunlLles a reallLy.



34

I/1/%/',/2

8alcker, kaLherlne, eL al. 2013. 1he Cregon LxperlmenL - Medlcald's LffecLs on Cllnlcal
CuLcomes." K*, F(A&0(. L'-)(0& '4 <*.%3%(* 368, no. 18: 17131722.
_____. 2013. 1he lmpacL of Medlcald on Labor lorce AcLlvlLy and rogram arLlclpaLlon:
Lvldence from Lhe Cregon PealLh lnsurance LxperlmenL." Worklng aper 19347.
Cambrldge, MA: naLlonal 8ureau of Lconomlc 8esearch.
Card, uavld, Carlos uobkln, nlcole MaesLas. 2009. uoes Medlcare Save Llves?" D/* M-0)9*)&:
L'-)(0& '4 F3'('$%32 124, no 2: 397636.
(C8C) Congresslonal 8udgeL Cfflce. 2012a. LsLlmaLes for Lhe lnsurance Coverage rovlslons of
Lhe Affordable Care AcL updaLed for Lhe 8ecenL Supreme CourL ueclslon."
hLLp://www.cbo.gov/publlcaLlon/43472.
_____. 2012b. updaLed 8udgeL ro[ecLlons: llscal ?ears 2012 Lo 2022."
hLLp://www.cbo.gov/publlcaLlon/43119.
_____. 2014a. 1he 8udgeL and Lconomlc CuLlook: 2014 Lo 2024."
hLLp://www.cbo.gov/publlcaLlon/43010.
_____. 2014b. updaLed LsLlmaLes of Lhe LffecLs of Lhe lnsurance Coverage rovlslons of Lhe
Affordable Care AcL, Aprll 2014."
hLLp://www.cbo.gov/publlcaLlon/43231.
(CLA) Councll of Lconomlc Advlsers. 2014. Lconomlc 8eporL of Lhe resldenL."
(CMS) CenLers for Medlcare and Medlcald Servlces. 2014. Medlcald & CPl: Aprll 2014
MonLhly AppllcaLlons, LllglblllLy ueLermlnaLlons, and LnrollmenL 8eporL."
hLLp://www.medlcald.gov/AffordableCareAcL/MedlcaldMovlnglorward
2014/uownloads/Aprll2014LnrollmenL8eporL.pdf.
Cohen 8oss, uonna, eL al. 2009. A loundaLlon for PealLh 8eform: llndlngs of a 30 SLaLe Survey
of LllglblllLy 8ules, LnrollmenL and 8enewal rocedures, and CosLSharlng racLlces ln
Medlcald and CPl for Chlldren and arenLs uurlng 2009, uaLa 1ables."
hLLp://kalserfamllyfoundaLlon.flles.wordpress.com/2013/01/8028_L.pdf.
Coughlln, 1eresa A., eL al. 2014. An LsLlmaLed $84.9 8llllon ln uncompensaLed Care Was
rovlded ln 2013, ACA aymenL CuLs Could Challenge rovlders." ;*0&9/ H440%)2 33, no 3:
807814.
Currle, !aneL and !onaLhan Cruber. 1996. PealLh lnsurance LllglblllLy, uLlllzaLlon of Medlcal
Care, and Chlld PealLh." D/* M-0)9*)&: L'-)(0& '4 F3'('$%32 111, no 2: 431466.
_____. 1994. Savlng 8ables: 1he Lfflcacy and CosL of 8ecenL Changes ln Lhe Medlcald
LllglblllLy of regnanL Women." D/* L'-)(0& '4 G'&%9%30& F3'('$: 104, no 6: 12631296.
uague, Laura, and 1homas ueLelre, and Llndsey Lelnlnger. 2014. 1he LffecL of ubllc
lnsurance Coverage for Chlldless AdulLs on Labor Supply." Worklng aper 20111.
Cambrldge, MA: naLlonal 8ureau of Lconomlc 8esearch.
Llbner, ChrlsLlne, eL al. 2010. LsLabllshlng SLaLe PealLh lnsurance Lxchanges: lmpllcaLlons for
PealLh lnsurance LnrollmenL, Spendlng, and Small 8uslnesses."
hLLp://www.rand.org/conLenL/dam/rand/pubs/Lechnlcal_reporLs/2010/8Anu_18823.p
df.
33

llnkelsLeln, Amy and 8obln McknlghL. 2008. WhaL dld Medlcare uo? 1he lnlLlal lmpacL of
Medlcare on MorLallLy and CuL of ockeL Medlcal Spendlng." L'-)(0& '4 G-=&%3
F3'('$%32 92, no. 7: 16441668.
llnkelsLeln, Amy, eL al. 2012. 1he Cregon PealLh lnsurance LxperlmenL: Lvldence from Lhe
llrsL ?ear." D/* M-0)9*)&: L'-)(0& '4 F3'('$%32 127, no 3: 10371106.
lrakL, AusLln. 2013a. My 8eply Lo !lm Manzl."
hLLp://LhelncldenLaleconomlsL.com/wordpress/myreplyLo[lmmanzl/.
______. 2013b. 1he Cregon Medlcald SLudy and CholesLerol."
hLLp://LhelncldenLaleconomlsL.com/wordpress/LheoregonmedlcaldsLudyand
cholesLerol/.
CarLhwalLe, Cralg, 1al Cross, and MaLLhew noLowldlgdo. 2014. ubllc PealLh lnsurance, Labor
Supply, and LmploymenL Lock." M-0)9*)&: L'-)(0& '4 F3'('$%32 129, no. 2: 633696.
Cruber, !onaLhan and Aaron ?elowlLz. 1999. ubllc PealLh lnsurance and rlvaLe Savlngs."
L'-)(0& '4 G'&%9%30& F3'('$: 107, no. 6: 12491274.
CuLLmacher lnsLlLuLe. 2014. Medlcald lamlly lannlng LllglblllLy Lxpanslons."
hLLp://www.guLLmacher.org/sLaLecenLer/splbs/splb_SMlL.pdf.
Cross, 1al and MaLLhew !. noLowldlgdo. 2011. PealLh lnsurance and Lhe consumer
bankrupLcy declslon: Lvldence from expanslons of Medlcald." L'-)(0& '4 G-=&%3
F3'('$%32 93, no 78: 767778.
Peberleln, MarLha eL al. 2013. CeLLlng lnLo Cear for 2014: llndlngs from a 30SLaLe Survey of
LllglblllLy, LnrollmenL, 8enewal, and CosLsharlng ollcles ln Medlcald and CPl, 2012
2013." hLLp://kalserfamllyfoundaLlon.flles.wordpress.com/2013/03/8401.pdf.
Polahan, !ohn, MaLLhew 8ueLLgens, SLan uorn. 2013. 1he CosL of noL Lxpandlng Medlcald."
hLLp://kalserfamllyfoundaLlon.flles.wordpress.com/2013/07/8437LhecosLofnoL
expandlngmedlcald4.pdf.
Polahan, !ohn, eL al. 2012. 1he CosL and Coverage lmpllcaLlons of Lhe ACA Medlcald
Lxpanslon: naLlonal and SLaLebySLaLe Analysls."
hLLp://kalserfamllyfoundaLlon.flles.wordpress.com/2013/01/8384.pdf.
Puang, LlberL S. and kenneLh llnegold. 2013. Seven Mllllon Amerlcans Llve ln Areas Where
uemand for rlmary Care May Lxceed Supply by More Lhan 10 ercenL." ;*0&9/ H440%)2
32, no. 3: 614621.
(kll) kalser lamlly loundaLlon. 2009. Lxpandlng PealLh Coverage for Lowlncome AdulLs:
lllllng Lhe Caps ln Medlcald LllglblllLy."
hLLp://kalserfamllyfoundaLlon.flles.wordpress.com/2013/01/7900.pdf.
______.2010. Lxpandlng Medlcald Lo Lowlncome Chlldless AdulLs under PealLh 8eform: key
Lessons from SLaLe Lxperlences."
hLLp://kalserfamllyfoundaLlon.flles.wordpress.com/2013/01/8087.pdf.
kenney, Cenevleve M., eL al. 2012. CpLlng ln Lo Lhe Medlcald Lxpanslon under Lhe ACA: Who
Are Lhe unlnsured AdulLs Who Could Caln Coverage?"
hLLp://www.urban.org/uploadedul/412630opLlnglnmedlcald.pdf.
kroenke, kurL, 8oberL L. SplLzer, !aneL 8.W. Wllllams. 2001. 1he PC9: valldlLy of a 8rlef
uepresslon SeverlLy Measure." L'-)(0& '4 N*(*)0& O(9*)(0& <*.%3%(* 16, no. 9: 606613.
Levy, Pelen and uavld MelLzer. 2008. 1he lmpacL of PealLh lnsurance on PealLh." H((-0&
B*1%*, '4 G-=&%3 ;*0&9/ 29, 399409.
36

Long, Sharon k. eL al. 2014. Larly LsLlmaLes lndlcaLe 8apld lncrease ln PealLh lnsurance
Coverage under Lhe ACA: A romlslng SLarL."
hLLp://hrms.urban.org/brlefs/earlyesLlmaLeslndlcaLerapldlncrease.hLml.
McWllllams, Mlchael !. eL al. 2007. use of PealLh Servlces by revlously unlnsured Medlcare
8eneflclarles." K*, F(A&0(. L'-)(0& '4 <*.%3%(* 337, no. 2: 143133.
Meyer, 8ruce u. and Wherry, Laura 8. Savlng 1eens: uslng a ollcy ulsconLlnulLy Lo LsLlmaLe
Lhe LffecLs of Medlcald LllglblllLy." Worklng aper 18309. Cambrldge, MA: naLlonal
8ureau of Lconomlc 8esearch.
Mulllgan, Casey 8. 2013. 1he erlls of SlgnlflcanL MlsundersLandlngs ln LvaluaLlng Medlcald."
D/* K*, P')? D%$*2.
hLLp://moblle.nyLlmes.com/blogs/economlx/2013/06/26/LheperllsofslgnlflcanL
mlsundersLandlngslnevaluaLlngmedlcald/.
newhouse, !oseph . 1993. Q)** 4') H&&R J*22'(2 4)'$ 9/* BHKS ;*0&9/ O(2-)0(3* FE+*)%$*(9.
Parvard unlverslLy ress.
8lchardson, Sam, Aaron Carroll, AusLln lrakL. 2013. More Medlcald SLudy ower CalculaLlons."
hLLp://LhelncldenLaleconomlsL.com/wordpress/moremedlcaldsLudypower
calculaLlonsourre[ecLedne[mleLLer/.
8uggles, SLeven, eL al. 2010. lnLegraLed ubllc use MlcrodaLa Serles: verslon 3.0 [Machlne
readable daLabase]." Mlnneapolls: unlverslLy of MlnnesoLa.
Sommers, 8en[amln u., kaLherlne 8alcker, and Arnold M. LpsLeln. 2012. MorLallLy and Access
Lo Care among AdulLs afLer SLaLe Medlcald Lxpanslons." D/* K*, F(A&0(. L'-)(0& '4
<*.%3%(* 367, no. 11: 10231034.
Sommers, 8en[amln u., Sharon k. Long, and kaLherlne 8alcker. 2014. Changes ln MorLallLy
afLer MassachuseLLs PealLh Care 8eform: A CuaslLxperlmenLal SLudy." H((0&2 '4
O(9*)(0& <*.%3%(* 160, no. 9: 383393.
Sonfleld, Adam, Casey Alrlch, and 8achel 8enson Cold. 2008. SLaLe CovernmenL lnnovaLlon ln
Lhe ueslgn and lmplemenLaLlon of Medlcald lamlly lannlng Lxpanslons."
hLLp://www.guLLmacher.org/pubs/2008/03/28/SLaLeMlLpracLlces.pdf.
1aubman, Sarah L., eL al. 2014. Medlcald lncreases LmergencyueparLmenL use: Lvldence
from Cregon's PealLh lnsurance LxperlmenL." T3%*(3* 343: 263268.
WlLLers, uan. 2014. unlnsured 8aLe urops More ln SLaLes Lmbraclng PealLh Law: Medlcald
Lxpanslon, SLaLe Lxchanges Llnked Lo lasLer 8educLlon ln unlnsured 8aLe."
hLLp://www.gallup.com/poll/168339/unlnsuredraLesdropsLaLesembraclnghealLh
law.aspx.

37

?55/'(-4 ?J 32*-#$*-'8 *9/ ?8/ $'( =/'(/% >-4 +1 )'(-7-("$<2 K9+ K+"<(
=$-' 6+7/%$8/ -1 L9/-% !*$*/ 345$'(2 >/(-,$-(

Several of Lhe CPlL esLlmaLes of Lhe effecL of Medlcald on recelpL of prevenLlve care apply only
Lo parLlcular age or gender subgroups. unforLunaLely, Lhe publlshed PlSM esLlmaLes of Lhe
lncrease ln lnsurance coverage arlslng from SLaLes' declslons Lo expand Medlcald do noL deLall
Lhe ages and genders of Lhe lndlvlduals who would galn coverage. 1o address Lhls lssue, CLA
esLlmaLed Lhe share of new Medlcald enrollees who fall ln Lhe relevanL subgroups uslng Lhe
Census 8ureau's Amerlcan CommunlLy Survey (ACS), a large household survey LhaL collecLs
lnformaLlon on lncome, lnsurance sLaLus, sLaLe of resldence, and oLher relevanL famlly
characLerlsLlcs.
18


ln deLall, Lhls was done ln Lwo sLeps. llrsL, CLA ldenLlfled lndlvlduals llkely Lo galn coverage
Lhrough Medlcald lf Lhelr SLaLe expanded Lhe program uslng Lhe followlng crlLerla, namely,
lndlvlduals who: (1) are adulLs age 19 Lo 64 wlLh famlly lncome under 138 percenL of Lhe lL, (2)
were noL ellglble for Medlcald under preACA SLaLe Medlcald lncome ellglblllLy crlLerla,
19
(3) do
noL reporL belng enrolled ln Medlcald,
20
and (4) do noL reporL belng enrolled ln employer
sponsored coverage. Among LhaL group, lL ls sLralghLforward Lo esLlmaLe Lhe share of poLenLlal
new enrollees falllng ln each agegender subgroup of lnLeresL. 1hese shares can Lhen be applled
Lo Lhe SLaLelevel PlSM esLlmaLes Lo obLaln Lhe lncrease ln lnsurance ln each relevanL age
gender subgroup as a resulL of each SLaLe's declslon Lo expand Medlcald.

ln lmplemenLlng Lhls approach, lncome ls deflned as LoLal cash lncome mlnus SupplemenLal
SecurlLy lncome and meansLesLed cash asslsLance (e.g. 1emporary AsslsLance for needy
lamllles), a deflnlLlon LhaL closely maLches modlfled ad[usLed gross lncome (MACl), Lhe lncome
deflnlLlon used Lo assess ellglblllLy for Medlcald under Lhe Affordable Care AcL. uue Lo daLa
llmlLaLlons, cerLaln oLher Lypes of lncome LhaL are noL lncluded ln MACl (e.g. chlld supporL) could
noL be excluded from Lhe lncome measure used, buL any resulLlng blases are llkely Lo be small.
lamllles unlLs were deflned uslng an algorlLhm for deflnlng healLh lnsurance unlLs" (Plus)
developed by SLaLe PealLh Access uaLa AsslsLance CenLer (SPAuAC). A descrlpLlon of Lhls
algorlLhm and programs for lmplemenLlng lL are avallable from Lhe SPAuAC webslLe.
21


lL ls lmporLanL Lo noLe LhaL Lhls approach has cerLaln llmlLaLlons. llrsL, Medlcald coverage ls only
avallable Lo clLlzens and cerLaln legal resldenLs, and Lhls approach makes no aLLempL Lo accounL
for Lhe facL LhaL Lhe ACS lncludes many lnellglble nonclLlzens. Second, Lhe meLhod used Lo model

18
1hls analysls uses Lhe luMSuSA preprocessed exLracLs of Lhe ACS for years 20102012 (8uggles eL al. 2010).
19
lnformaLlon on preACA ellglblllLy crlLerla are obLalned from varlous reporLs produced by Lhe kalser lamlly
loundaLlon (Cohen 8oss, eL al. 2009, kll 2009, kll 2010). reACA ellglblllLy crlLerla as Lhose ln effecL ln 2009, Lhls
approach ls conslsLenL wlLh PlSM, whlch also uses LreaLs preACA ellglblllLy crlLerla as Lhose ln effecL ln 2009
(Polahan eL al. 2012).
20
1hls provldes a crude way of excludlng lndlvlduals who were ellglble for Medlcald before Lhe Affordable Care AcL
as a resulL vla more expanslve ellglblllLy crlLerla LhaL are appllcable only Lo speclflc groups, llke Lhose wlLh
dlsablllLles. 1hese more deLalled ellglblllLy crlLerla are challenglng Lo model ln survey daLa.
21
See hLLp://www.shadac.org/publlcaLlons/deflnlngfamllysLudleshealLhlnsurancecoverage.
38

preACA Medlcald ellglblllLy rules ls somewhaL crude, and more sophlsLlcaLed meLhods mlghL
glve beLLer resulLs. noLably, however, kenney eL al. (2012) handle boLh of Lhese lssues ln more
sophlsLlcaLed ways and arrlve aL broadly slmllar esLlmaLes of Lhe share of poLenLlal new enrollees
falllng ln speclfled age and gender groups. llnally, lndlvlduals' propenslLy Lo acLually enroll ln
Medlcald coverage may dlffer across age and gender groups, falllng Lo accounL for Lhese dlfferlng
enrollmenL propenslLles could cause Lhls approach Lo oversLaLe or undersLaLe Lhe number of
lndlvlduals galnlng coverage ln each of Lhese groups.

39

?55/'(-4 0J 32*-#$*-'8 311/,*2 +' @/(/%$< F"*<$&2 -1 !*$*/2 345$'(
>/(-,$-(

1he mosL lmporLanL lnpuL lnLo analyzlng how SLaLe declslons Lo expand Medlcald affecL LoLal
employmenL and overall economlc acLlvlLy ls how each SLaLe's declslon affecLs lederal ouLlays.
CLA esLlmaLed Lhese amounLs ln Lwo sLeps. llrsL, esLlmaLes from Lhe Congresslonal 8udgeL Cfflce
(C8C) were used Lo esLlmaLe Lhe LoLal change ln lederal ouLlays lf all sLaLes expanded Medlcald
relaLlve Lo lf no sLaLes expanded Lhe program. Second, CLA dlsLrlbuLed LhaL naLlonal LoLal across
SLaLes uslng PlSM esLlmaLes. 1hls appendlx descrlbes each sLep ln greaLer deLall.

locuslng flrsL on Lhe naLlonal LoLals, Lhe neL change ln lederal ouLlays lf all sLaLes elecL Lo expand
Medlcald conslsLs of Lwo componenLs: (1) an lncrease ln lederal ouLlays reflecLlng addlLlonal
spendlng on Medlcald coverage, and (2) a reducLlon ln lederal cosLs Lo provlde premlum Lax
credlLs and cosLsharlng asslsLance. 1he second, offseLLlng, componenL reflecLs Lhe facL LhaL
some lndlvlduals ln famllles wlLh lncomes beLween 100 and 138 percenL of Lhe lL wlll recelve
coverage Lhrough Medlcald lf Lhelr SLaLe does expand Lhe program and would lnsLead obLaln
coverage Lhrough Lhe MarkeLplace lf Lhelr sLaLes does noL expand Medlcald. CLA used C8C
esLlmaLes Lo esLlmaLe Lhe slze of each of Lhese Lwo componenLs ln a scenarlo ln whlch all SLaLes
expanded Medlcald, relaLlve Lo a scenarlo ln whlch no SLaLes expanded Medlcald.

1o esLlmaLe Lhe dlrecL effecL on lederal Medlcald ouLlays, Lhe sLarLlng polnL was C8C's March
2012 esLlmaLes of Lhe effecL of Lhe Affordable Care AcL's coverage expanslon on lederal Medlcald
spendlng (C8C 2012a). 8ecause Lhese esLlmaLes predaLe Lhe Supreme CourL's declslon ln KQOU
1" T*=*&%-2, Lhey lmpllclLly reflecL Lhe lncrease ln lederal Medlcald ouLlays lf all SLaLes expand Lhe
program.
22
CLA Lhen ad[usLed Lhese amounLs Lo reflecL changes ln C8C's assumpLlons regardlng
perenrollee Medlcald cosLs from C8C's March 2012 basellne Lo lLs Aprll 2014 basellne (C8C
2014b).
23


1o esLlmaLe Lhe offseLLlng savlngs on premlum Lax credlLs and cosLsharlng asslsLance, CLA used
C8C's esLlmaLe of how Lhe Supreme CourL's declslon ln KQOU 1" T*=*&%-2 affecLed Lhe cosLs of
Lhese programs (C8C 2012b). C8C esLlmaLed LhaL Lhe Supreme CourL declslon caused a $28
bllllon lncrease ln MarkeLplace subsldy cosLs ln flscal year 2022. C8C also lndlcaLed LhaL Lhey
assumed LhaL LwoLhlrds of Lhe overall expanslon populaLlon would llve ln SLaLes LhaL decllned Lo
expand Lhe Medlcald program for lndlvlduals beLween 100 and 138 percenL of Lhe lL. 1hls
esLlmaLe lmplles LhaL, lf all SLaLes decllned Lo expand Lhe program, Lhe reducLlon ln premlum Lax

22
ln prlnclple, Lhese esLlmaLes also lnclude lederal spendlng assoclaLed wlLh prevlously ellglble lndlvlduals who
would newly enroll ln Medlcald even lf Lhelr SLaLe falled Lo expand Lhe program, perhaps due Lo enhanced
ouLreach assoclaLed wlLh Lhe MarkeLplaces. ln pracLlce, Lhe number of such lndlvlduals ls llkely Lo be relaLlvely
small, so lncludlng Lhem ls unllkely Lo slgnlflcanLly affecL Lhe resulLs of Lhls analysls.
23
Speclflcally, CLA used Lhe percenL change ln C8C's pro[ecLlon of perenrollee cosLs for chlldren. Whlle cosL
Lrends for chlldren may dlffer sllghLly from Lhose for adulLs, Lhe changes ln C8C's reporLed perenrollee cosLs for
adulLs lncorporaLe changes ln Lhe composlLlon of Lhe Medlcald populaLlon caused by changes ln SLaLes' declslons
abouL wheLher or noL Lo expand Medlcald. As such, Lhey cannoL be used Lo ad[usL for changes ln underlylng per
enrollee cosLs across dlfferenL vlnLages of C8C's pro[ecLlons.
40

credlL and cosLsharlng asslsLance cosLs would be 30 percenL larger Lhan Lhe $28 bllllon
referenced above, so CLA scaled up Lhe $28 bllllon esLlmaLe accordlngly. CLA Lhen pro[ecLed Lhls
flscal year 2022 esLlmaLe back Lo Lhe presenL by assumlng lL would grow ln proporLlon Lo LoLal
MarkeLplace subsldy cosLs reporLed ln C8C's March 2012 basellne. llnally, slmllar Lo Lhe
Medlcald esLlmaLes, Lhe resulLlng sLream of cosLs was ad[usLed for changes ln perenrollee
subsldy cosLs from C8C's March 2012 basellne Lo lLs Aprll 2014 basellne.
24,23

1o dlsLrlbuLe Lhese naLlonal amounLs across sLaLes, CLA relled upon esLlmaLes from Lhe urban
lnsLlLuLe's PlSM (descrlbed ln Lhe maln LexL). Speclflcally, lncremenLal Medlcald ouLlays were
dlsLrlbuLed across SLaLes uslng PlSM's SLaLebySLaLe esLlmaLes of Lhe lncremenLal Medlcald
ouLlays ln 2016 lf each SLaLe elecLs Lo expand coverage. 1he offseLLlng savlngs on premlum Lax
credlLs and cosLsharlng asslsLance were dlsLrlbuLed uslng Lhe SLaLespeclflc dlfference beLween
Lhe lncrease ln Medlcald enrollmenL and Lhe lncrease ln overall lnsurance coverage LhaL occurs lf
LhaL SLaLe expends Medlcald (once agaln, uslng esLlmaLes for 2016), Lhls dlfference approxlmaLes
Lhe number of lndlvlduals who would swlLch from recelvlng coverage Lhrough Lhe MarkeLplace
Lo recelvlng coverage Lhrough Medlcald lf Lhe SLaLe expanded Medlcald.
26


As a flnal noLe, for Lhe purposes of uslng Lhese esLlmaLes wlLh Lhe CLA mulLlpller model, lL ls
necessary Lo converL Lhe flscal year esLlmaLes LhaL resulL from Lhe meLhodology descrlbed above
Lo quarLerly esLlmaLes. ln dolng so, CLA assumed LhaL Medlcald and MarkeLplace ouLlays
occurrlng durlng flscal year 2014 wlll occur smooLhly over Lhe flnal Lhree quarLers of Lhe flscal
year (conslsLenL wlLh Lhe facL LhaL Lhe maln coverage expanslons under Lhe Affordable Care AcL
Look effecL on !anuary 1, 2014). ln subsequenL flscal years, CLA assumed LhaL ouLlays occurred
smooLhly over Lhe flscal year. Whlle Lhe acLual Llme paLh of Lhese ouLlays llkely dlffers sllghLly
from Lhls assumed paLh, any error ln he assumed paLh ls llkely Lo have very small effecLs on Lhe
overall concluslon of Lhls analysls.

24
C8C's perenrollee subsldy esLlmaLes are for calendar years, whlle Lhe ouLlay esLlmaLes are for flscal years. ln
maklng Lhls ad[usLmenL, CLA used an approprlaLe blend of Lhe calendar year perenrollee esLlmaLes Lo ad[usL each
flscal year esLlmaLe.
23
1he overall change ln perenrollee subsldy cosLs from C8C's March 2012 basellne Lo lLs Aprll 2014 basellne may
dlffer from Lhe change ln perenrollee cosLs for a glven enrollee wlLh lncome beLween 100 and 138 percenL of lL,
for several reasons. llrsL, premlum Lax credlL covers a larger share of Lhe LoLal premlum for Lhls group Lhan for Lhe
average enrollee, and Lhese lndlvlduals recelve cosLsharlng asslsLance, unllke some hlgherlncome enrollees. ln
addlLlon, some of Lhe change ln perenrollee cosLs from C8C's March 2012 basellne Lo lLs Aprll 2014 basellne may
reflecL composlLlonal changes lf lndlvlduals who were swlLched from Medlcald Lo Lhe MarkeLplaces by Lhe
Supreme CourL ueclslon dlffer from Lhe Lyplcal MarkeLplace enrollee. 1he effecL of Lhese lmperfecLlons on Lhe
overall resulLs of Lhls analysls are llkely Lo be qulLe small.
26
1hls dlfference may also reflecL some offseLLlng reducLlon ln Lhe number of lndlvlduals enrolled ln employer
coverage, buL lL appears LhaL Lhe reducLlon ln MarkeLplace coverage ls Lhe prlmary componenL. ln any case, Lhe
SLaLelevel ouLlay esLlmaLes are relaLlvely lnsenslLlve Lo Lhe preclse meLhod used Lo dlsLrlbuLe Lhe offseLLlng Lax
credlL and cosLsharlng asslsLance cosLs.