Three Essays on the Impact of the Affordable Care Act Expansion of Dependent Coverage for

114 Pages·2017·0.8 MB·English

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Economics Dissertations
Summer 8-11-2015
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Yanling Qi
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Qi, Yanling, "Three Essays on the Impact of the Affordable Care Act Expansion of Dependent Coverage for
Young Adults." Dissertation, Georgia State University, 2015.
doi: https://doi.org/10.57709/7292739
This Dissertation is brought to you for free and open access by ScholarWorks @ Georgia State University. It has
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ABSTRACT
THREE ESSAYS ON THE IMPACT OF THE AFFORDABLE CARE ACT EXPANSION OF
DEPENDENT COVERAGE FOR YOUNG ADULTS
By
YANLING QI
AUGUST, 2015
Committee Chair: Dr. James H. Marton
Major Department: Economics
To achieve the goal of universal coverage of health insurance for the Americans, in
March 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law. The
ACA targets at providing help to improve access to affordable health coverage for everyone and
protect consumers from abusive insurance company practices. One of the precedent mandates,
implemented in September 2010, is to expand coverage on young adults of age 19 to 26, who
may lose insurance coverage due to the remove from their parents’ plan after age 18 and lacking
of productivity to bargain with employers in the labor market.
This dissertation looks into the impact of the ACA health insurance coverage expansion
for young adults on the subsequent health outcomes, health care utilization, and further social
impact on traffic fatalities. Difference-in-differences models are used with different treatment
groups and corresponding control groups. Chapter I uses survey data (BRFSS) to evaluate health
care access, health behavior and self-assessed health status. The results suggest an improvement
in health care access and self-assessed health but more risky behavior. Chapter II uses hospital
discharge data (NIS) to estimate avoidable hospitalization in order to assess primary care
utilization. The result shows that less primary care was consumed, which leads to more avoidable
hospitalization but health may have been improved by using more hospital care. The results from
both chapters imply potential ex ante moral hazard among young adults in the policy targeting
age group. Thus, chapter III uses accident records data (FARS) to examine the impact of the
health insurance expansion on traffic fatality for young adults, to see whether young drivers
perform ex ante moral hazard through risky behavior like drunk and/or reckless driving after they
get covered by the health insurance expansion policy. Primary result shows that there is an
increase in traffic accidents and fatalities for those younger adults as a result of the ACA
dependent coverage expansion.
THREE ESSAYS ON THE IMPACT OF THE AFFORDABLE CARE ACT EXPANSION OF
DEPENDENT COVERAGE FOR YOUNG ADULTS
BY
YANLING QI

A Dissertation Submitted in Partial Fulfillment
of the Requirements for the Degree
of
Doctor of Philosophy
in the
Andrew Young School of Policy Studies
of
Georgia State University

GEORGIA STATE UNIVERSITY
2015
Copyright by
Yanling Qi
2015
ACCEPTANCE
This dissertation was prepared under the direction of the candidate’s Dissertation
Committee. It has been approved and accepted by all members of that committee, and it has been
accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in
Economics in the Andrew Young School of Policy Studies of Georgia State University.

Dissertation Chair: Dr. James H. Marton

Committee: Dr. Charles J. Courtemanche
Dr. M. Melinda Pitts
Dr. Erdal Tekin

Electronic Version Approved:

Mary Beth Walker, Dean
Andrew Young School of Policy Studies
Georgia State University
August, 2015
DEDICATION

To Dr. James H. Marton for his unwavering support and encouragement over the years.

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ACKNOWLEDGEMENTS
I am profoundly grateful to a great number of people for helping me bring this work to
fruition. Thanks to these people, my graduate experience has been one that I will cherish forever.
My deepest gratitude is to my advisor, Dr. James Marton, whom without I would not be
where I am today. Any gratitude will be pale in comparison to what he dedicated to me. Thanks
for giving me outstanding guidance, expert advice, innumerable experience, extraordinary
patience and steadily support. I have been amazingly fortunate to have such an advisor who gave
me the freedom to explore on my own, led my research back on track when it faltered, and used
his wisdom to help me overcome the crisis and finish the dissertation. I hope that one day I
would become as good an advisor to my students as he has been to me.
To the rest of my committee, I cannot thank you enough for all the support and
perseverance that allowed me to successfully reach this milestone. I am especially thankful to Dr.
Charles Courtemanche for his great guidance, sincerely friendship, unwavering support and
understanding. Thanks for making me discover my potential for research, teaching me the skills
of the trade, and sharing in my joys and achievements. I am grateful as well to Dr. Melinda Pitts,
who always supported me with candid guidance and insightful suggestions. Finally, I am grateful
for insightful and detailed comments and feedback from Dr. Erdal Tekin.
I also wish to acknowledge the encouragement from Dr. Yongsheng Xu, Dr. Jon Rork
and Dr. Spencer Banzhaf for seeing my passion in research and giving me strength when I faced
challenges early in my graduate studies.
A warm gratitude to the Economists at the Federal Reserve Bank of Atlanta: Chris, Pedro,
Timothy, Federico, Lei, William, Karen, Toni, and most importantly, my supervisor Dr. Julie
Hotchkiss, who provided invaluable help on my research during my two-year stay at the bank.
Many thanks to my colleagues and friends: Subha, Ecky, Zack, Fernando, Ryan, Hal,
Marietou, Melissa, Elena, Lily, and many others who always share their happiness and
experiences with me through my stay at GSU; I am especially grateful to Vladymir and Jinjing,
who steadfastly stood by my side, encouraging me and walking me through a tough job market.
One a very personal note is to my beloved parents and family, none of this would have
been possible without the unconditional love from them, who have always supported me with
great care, faith and concern. Thanks very much for helping me make my dream of being a
scholar come true. Thanks from the bottom of my heart for a harmonious family with
warmth, peace, and love.
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TABLE OF CONTENTS
DEDICATION ........................................................................................................................ iv
ACKNOWLDGEMENTS .........................................................................................................v
LIST OF TABLES ................................................................................................................. vii
LIST OF FIGURES .............................................................................................................. viii
INTRODUCTION .....................................................................................................................1
CHAPTER I: Impacts of the ACA Dependent Coverage Provision on Health-Related
Outcomes of Young Adults .......................................................................................................2
I. Introduction .............................................................................................................................2
II. Health Insurance and Health-Related Outcomes......................................................................7
III. Data .................................................................................................................................... 10
IV. Average Effects of the ACA Dependent Coverage Mandate ................................................ 16
V. Placebo Tests........................................................................................................................ 23
VI. Heterogeneity ...................................................................................................................... 24
VII. Discussion ......................................................................................................................... 27
Tables and Figures .................................................................................................................... 33
CHAPTER II: Health Insurance and Young Adults’ Avoidable Hospitalizations ............... 43
I. Introduction ........................................................................................................................... 43
II. Literature Review ................................................................................................................. 46
III. Conceptual Model ............................................................................................................... 50
IV. Methodology ....................................................................................................................... 53
V. Data...................................................................................................................................... 56
VI. Results ................................................................................................................................ 60
VII. Discussion ......................................................................................................................... 64
VIII. Conclusion ....................................................................................................................... 67
Tables and Figures .................................................................................................................... 69
CHAPTER III: Health Insurance and Traffic Fatalities for Young Adults ......................... 77
I. Introduction ........................................................................................................................... 77
II. Literature Review ................................................................................................................. 79
III. Data .................................................................................................................................... 82
IV. Methodology ....................................................................................................................... 84
V. Results ................................................................................................................................. 87
VI. Discussion ........................................................................................................................... 88
Tables and Figures .................................................................................................................... 90
REFERENCES ........................................................................................................................ 96
VITA ...................................................................................................................................... 104
vi
LIST OF TABLES
Table 1.1: Sample Sizes for Different Outcomes ....................................................................... 33
Table 1.2: Pre-Treatment Means and Standard Deviations for Control Variables ....................... 34
Table 1.3: Means and Standard Deviations for Outcome Variables ............................................ 35
Table 1.4: Difference-in-Difference Regression Estimates of Effects of ACA Dependent
Coverage Mandate .................................................................................................................... 36
Table 1.5: Placebo Regressions ................................................................................................. 37
Table 1.6: Heterogeneity by Sex and Education......................................................................... 38
Table 1.7: Full Regression Output for Selected Dependent Variables ........................................ 39
Table 2.1: Means and Standard Deviations for Outcome Variables ............................................ 69
Table 2.2: Pre-reform Means and Standard Deviations for Control Variables ............................ 70
Table 2.3: Difference-in-Differences Estimates of Effects of ACA Dependent Coverage Mandate
on Quality Indicators ................................................................................................................. 71
Table 2.4: Placebo Regressions ................................................................................................. 72
Table 2.5: Robustness Checks ................................................................................................... 73
Table 2.6: Heterogeneity by Gender and Race ........................................................................... 74
Table 2.7: Heterogeneity by Patient’s Zip Code Income Quartile .............................................. 75
Table 3.1: Unadjusted Difference-in-Differences Estimates of the Impact of the ACA Dependent
Coverage Expansion on Traffic Accidents and Fatalities ........................................................... 90
Table 3.2: Multivariate Difference-in-Differences Estimates of the Impact of the ACA
Dependent Coverage Expansion on Traffic Accidents and Fatalities.......................................... 91
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LIST OF FIGURES
Figure 1.1: Trends in Access to Care and Preventive Care Variables by Age Group .................. 40
Figure 1.2: Trends in Health Behavior Variables by Age Group ................................................ 41
Figure 1.3: Trends in Self-Assessed Health Variables by Age Group ......................................... 42
Figure 2.1: Trends in Prevention Quality Indicators by Age Group............................................ 76
Figure 3.1: Traffic Accident / Fatality Counts for Young Adults Aged 20 VS 18 ....................... 92
Figure 3.2: Alcohol-Related Traffic Accident / Fatality Counts for Young Adults Aged 20 VS 18
................................................................................................................................................. 92
Figure 3.3: Traffic Accident / Fatality Counts for Young Adults Aged 20 VS 17-18 ................. 93
Figure 3.4: Alcohol-Related Traffic Accident / Fatality Counts for Young Adults Aged 20 VS 17-18
................................................................................................................................................. 93
Figure 3.5: Traffic Accident / Fatality Counts for Young Adults Aged 20-21 VS 17-18 ............ 94
Figure 3.6: Alcohol-Related Traffic Accident / Fatality Counts for Young Adults Aged 20-21 VS
17-18 ........................................................................................................................................ 94
Figure 3.7: Traffic Accident / Fatality Counts for Young Adults Aged 20-22 VS 16-18 ............ 95
Figure 3.8: Alcohol-Related Traffic Accident / Fatality Counts for Young Adults Aged 20-22 VS
16-18 ........................................................................................................................................ 95
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