2015 HCM PACA Reform

A Regional Approach to Health
Care Reform
The Texas Border
Jose Luis Manzanares Rivera, ScD, MSc;
Genny Carrillo Zuniga, ScD, MD, MPH
The purpose of this article is to analyze health insurance disparities related to labor environment
factors in the Texas-Mexico border region. A logistic regression model was performed using
microdata from the 2010 American Community Survey to estimate the probability of having
employer-based insurance, controlling labor environment factors such as hours worked, occupa-
tion industry, and the choice of private, nonprofit or public sector jobs. Industries primarily
employing the Mexican American population are less likely to offer employer-based health in-
surance. These industries have the North American Industry Classification System (NAICS) code
770 construction, including cleaning, and NAICS code 8680, restaurants and other food services.
Although it was found that working in public sector industries such as code 9470, administration
of justice, public order, and safety, or NAICS code 7860, elementary and secondary schools, im-
proved by 60% the probability of the Mexican American population having employer-based health
insurance, these occupations ranked at the bottom of the main occupation list for Mexican
Americans. These findings provide evidence that the labor environment plays an important role in
understanding current health insurance access limitations within the Mexican American community
under 2010 Patient Protection and Affordable Care Act provisions, which are directed to small
business and lower-income individuals. Key words: health care, labor environment, Medicaid,
poverty, Texas border
HEALTH CARE REFORM as set forth by
the 2010 Patient Protection and Afford-
able Care Act, henceforth known as the ACA,
has been implemented in the United States
within its defined timeframe. However, among
the many debates generated regarding the ACA,
a particular provision of the bill, Medicaid Ex-
pansion, has created an intense debate across
the country. According to the ACA, effective
January1,2014,Americansyoungerthan65years
with incomes less than 133% of the federal pov-
erty level, became eligible to enroll in Medicaid
(Department of Health and Human Services, Eli-
gibility Changes, x435.912).
Considering that middle-class workers and
low-income Americans are the principal targets
of the ACA, the decision to opt out of Medicaid
Expansion by 15 US states (as of September 30,
2013)1
is an issue that merits academic attention.
Texas is one of the 15 states that chose to opt
out of Medicaid Expansion, which, from a public
policy perspective, presents a particularly inter-
esting case because 100 of its poorest counties
have the highest proportion of low per-capita
income in the entire country.1
These counties
are located in the South Texas region where
health issues have been the focus of attention for
decades and are characterized by high chronic
health disease prevalence such as diabetes2
and,
in some areas, the highest obesity rates nation-
wide.3
These types of public health issues are
important not only because they represent a
The Health Care Manager
Volume 34, Number 1, pp. 44–53
Copyright # 2015 Wolters Kluwer Health,
Inc. All rights reserved.
Author Affiliations: Department of Urban and
Environmental studies at El Colegio de la Frontera
Norte A.C., Mexico (Dr Rivera); and Environmental
and Occupational Health, Texas A&M Health Science
Center, School of Public Health (Dr Zuniga).
The authors have no conflict of interest.
Correspondence: Jose Luis Manzanares Rivera,
ScD, MSc, El Colegio de la Frontera Norte, Jalisco 1050,
Colonia Nisperos, Piedras Negras, Coahuila, México
(jlmanzanares@colef.mx).
DOI: 10.1097/HCM.0000000000000045
44

risk factor for the development of other chronic
conditions such as cancer and cardiovascular
disease,4
but also, given the socioeconomic sta-
tus in the South Texas region, health care af-
fordability issues, which are already significant,
are likely to be exacerbated.
While diverse studies have emerged related
to financial barriers for low-income population
groups and their impact on public insurance
programs such as Medicaid, the implications of
health insurance constraints go beyond this in-
surance program. While employer-based health
coverage is the main form of insurance provided
in the United States, it has barely been studied
from a regional perspective. Therefore, a study
of employer-based insurance may be key to un-
derstanding the situation faced by those in South
Texas.
In addition, labor environment characteristics
play a vital role among the provisions contained
in the ACA, in particular employer-based health
insurance; accordingly, understanding the differ-
ences in access between population groups may
be useful in order to evaluate benefits of the ACA
in specific areas of the country. This need be-
comes more evident in isolated social settings
such as the Texas-Mexico border, where a mix
of cultural patterns influences medical services
demand and health practices. Given these facts,
this article argues that a regional approach rep-
resents an opportunity to evaluate the effects of
health care reform at the local level, which, in
itself, is another challenge for health policy
design.
Using data drawn from the 2010 American
Community Survey (ACS), this study examines
patterns of insurance coverage along the Texas-
Mexico border, compares potential effects of
Medicaid Expansion against other regions of
the country that have already implemented this
provision, and provides an analysis of employer-
based health insurance demand among popula-
tion groups along the South Texas border.
PREVIOUS STUDIES
Why is a Texas regional approach case study
important to understanding the potential im-
pacts of ACA provisions such as Medicaid Ex-
pansion or changes in employer-based health
insurance? Social sciences literature and rural
sociology in particular indicate a consensus that
Texas represents a mix of at least 3 social factors
that make the state a relevant case study in the
context of health care reform. First, there is com-
pelling academic evidence concerning the health
challenges faced by the population in the Texas-
Mexico border region. Through empirical studies
about diabetes prevalence conducted by Hanis
et al2
(1983) to the work in 2010 by Fisher-
Hoch et al,3
it has been found that the ‘‘Rates of
obesity and diabetes in this border community
are among the highest in the United States.’’
Recent empirical evidence ‘‘concentrating on
the Hispanic population was developed that fol-
lows a public health approach and emphasizes
the correlation between obesity with metabolic
syndrome,’’5
a health condition associated in the
development of a series of chronic cardiovascular
health problems.
Second, based on the socioeconomic status
associated with particular population segments
in the southernmost part of the state, afford-
ability issues are likely to rise. A relatively vast
amount of work has been developed using a
constrained access perspective. Along these
lines, some authors emphasize the fact that some
population subgroups present considerably lower-
income levels relative to the rest of the popu-
lation,6
thus representing an important access
issue to the acquisition of private health insurance.
Adding to the debate on the high demand
and existence of financial barriers for public
health insurance has led some scholars to sug-
gest that this demand for public health insur-
ance encourages the development of a string
of studies related to Medicaid usage applying
the ‘‘crowding out’’ concept to document the
extent to which Medicaid demand expansions
reduce private insurance coverage.7-9
However,
in this research string, access to employer-
based health insurance, the main form of pri-
vate insurance in the United States, has been
limited and not explicitly considered for high-
demand populations, nor is it analyzed using a
desegregated approach that may yield useful
information in understanding how public pol-
icy actually works at the local level.
Third, Texas is a state with a demographic
composition that features the changing trends
Regional Approach to Health Care Reform 45

of the nation, with some population groups
becoming an increasing driving demand force
for health insurance both public and private,
in this instance Hispanics. From an empirical
perspective, the effects of health insurance con-
straints have been an issue of particular concern
in the literature for the United States–Mexico
border region.10-12
Studies such as that of Ortiz,
Arizmendi, and Cornelius using a nonproba-
bilistic sample of 271 individuals, argue that
‘‘. . .seeking care in Mexico may be a viable
solution for many people of Mexican descent
living in close geographic proximity to the bor-
der because it surmounts the political, cultural,
linguistic, or economic barriers to health care
services in the United States.’’13(p246)
Although Ortiz’s conclusions may not be gen-
eralizable, given the nature of his methodology
(he uses a nonprobabilistic small sample based
on face-to-face interviews in 2 counties of the
Lower Rio Grande Valley in Texas, Hidalgo, and
Pharr), his research highlights a practice already
common on the Texas-Mexico border, which is
that of cross-border demand for medical services.
With respect to urban areas on the border, the
study of Landeck and Garza14
estimates that
41.2% of Hispanics in the Laredo, Texas, area are
using physician health care services in Mexico.
However, using a different methodological ap-
proach (qualitative), other studies15
highlight
the cultural factor as an important determinant
of cross-border demand even in the presence of
US medical insurance.
Despite this fairly large body of work show-
ing the implications of access constraints on
health care in a binational context, a subset of
empirical research focusing on the relationship
between the labor environment and health in-
surance accessibility is still relatively scarce.16,17
Questions remain about labor environment de-
terminants of employer-based health insurance,
leading to a rise in academic attention.
It is argued that the labor force environment
deserves attention in order to explain access con-
straints for particular population groups. These
labor environment factors may include hours
worked, occupation industry, or the choice of
private nonprofit or public sector employment.
Other factors related to the labor structure
such as industry size have already been reported
as relevant access factors. According to informa-
tion based on the biennial health insurance sur-
vey conducted by The Common Wealth Fund,
‘‘54% of workers in industry with fewer than
50 employees who earned less than $15 an
hour reported being uninsured during 2010.’’18
Moreover, given the provisions on accessibility
directed to small business and low-income pop-
ulations set forth by the ACA, labor environment
determinants of employer-based health insur-
ance become a relevant issue, particularly for
the border region.
In some respects, these academic efforts con-
stitute a multidisciplinary bridge for studying
the relationship between the rising cost of care,
higher prevalence rates of health issues among
minorities, and the need for regional multidisci-
plinary research. As some authors from a broader
social science perspective indicate, the focus on
the unique social position of minorities in rural
areas presents an opportunity from which much
can be learned.19
CONSIDERATIONS ABOUT THE
PATIENT PROTECTION AND
AFFORDABLE CARE ACT
The ACA is a comprehensive set of rules for
the US health care system that has been imple-
mented in successive stages. It not only makes
changes in eligibility, but also considers health
insurance adjustments for employers, private
insurance companies, and pharmaceutical manu-
facturers. Three provisions are particularly rel-
evant for the population living on the Texas-
Mexico border:
(1) Effective 2014, Medicaid expanded cover-
age for the lowest income populations, that is,
‘‘coverage for individuals with income at or be-
low 133% of the poverty line.20
(2) Small Business Health Options Program
and small business health care affordability tax
credits. These provisions are of special interest
for the region given the labor market structure.
The first Small Business Health Options Pro-
gram strategy aims to reduce the administrative
burden that small businesses face when offer-
ing health plans. Whereas the tax credit strategy
will ‘‘. . .provide tax credit to small employers
with fewer than 25 employees and average
46 THE HEALTH CARE MANAGER/JANUARY–MARCH 2015

annual wages of less than $50000 that pur-
chase health insurance for employees, the full
credit will be available to employers with 10 or
fewer employees and average annual wages
of less than $25000. To be eligible for a tax
credit, the employer must contribute at least
50% of the total premium cost.’’21(p69)
(3) Access to insurance for uninsured individuals
with a preexisting condition.21(p30)
This provi-
sion refers to access to coverage that does not
impose exclusions for preexisting health con-
ditions, before the ACA insurers could exclude
health care coverage based on preexisting health
conditions, for example, diabetes.
Given the historically high prevalence rates
of chronic diseases such as diabetes in the
area,21
this is of particular interest among the
Mexican population living on the Texas bor-
der. Predisposition to diabetes for the Mexican
American population has been extensively docu-
mented since the 1980s. At that time, ‘‘prevalence
and mortality rates for non–insulin-dependent
(type 2) diabetes mellitus [were] 2 to 5 times
greater than those found in the general US
population.22
METHODS
A logistic regression model is implemented
based on cross-section Public Use Microdata
(PUMS) from the 2010 ACS.
Public Use Microdata from the 2010 ACS was
analyzed. This data set was selected given its
disaggregation level, which allows for distin-
guishing between first- and second-generation
Mexican origin population. The sample for the
state contained 741823 observations. Once the
sampling weight was applied, representative es-
timations were obtained for specific geographic
areas.
Data analysis
The statistical analysis was conducted in 3
parts: The first was descriptive and explored
the characteristics of the Mexican origin pop-
ulation in terms of access to health coverage
on the Texas-Mexico border area. The second
was inferential focusing on Medicaid coverage
and determined the expected change in demand
caused by expansion of the poverty eligibility
threshold set out by the ACA. The third part
examined employer-based health insurance by
analyzing labor environment determinants using
a logistic regression approach. The data were
analyzed using STATA 11 (StataCorp, College
Station, Texas) software to fully integrate survey
characteristics in order to obtain statistical rep-
resentative estimates.
Geographic area selection
Based on Medicaid enrollment statistics, a
total of 34 counties on the Texas-Mexico bor-
der, which on average comprise the highest
Medicaid enrollment levels in the State, were
considered. There are 4 major population cen-
ters in the area with adjacent urban locations
on the Mexican side, with Hispanics representing
an average of 90% more than the total. These
cities are El Paso-Cd. Juárez, Laredo-Nuevo
Laredo, McAllen-Reynosa, and Brownsville-
Matamoros.23
Descriptive statistics for health
insurance coverage
Health insurance programs in the United
States can be classified as public or private. The
4 major public health programs reported in the
ACS are Medicare, Medicaid, VA, and TRICARE.
Medicaid alone covers 23.4% of the total popu-
lation in the study area, representing 661873
enrollments.24
Private insurance refers to coverage either
purchased directly from a private company or
provided by an employer. The primary source of
health insurance in the study area and the United
States is employer based and covered 988994
individuals or 32.75% of the total population in
the study area.25
However, a state-level compar-
ison in the study area revealed an important gap
in employer-based health insurance. Whereas the
employer-based coverage rate for the state is
an average of 52.13%, the coverage rate in the
study area is only 32.75%. This gap is partially
absorbed through public coverage via Medic-
aid (10.43%). In this case, the rate of coverage
of 25.5% is higher than the state level of 15.07%,
in what appears to be a crowding-out effect
as applied to the interaction between private

and public health insurance by other authors
elsewhere.25
The implications of such regional patterns
for the Medicaid Expansion debate become
clear from a national perspective when consid-
ering the projected Medicaid expenditure at the
national level already reaches US $281 billion, or
1.8% of GDP, for fiscal year 2013, with an esti-
mated increase of 130% within the next de-
cade. (According to the Congressional Budget
Office, Medicaid expenditure is projected to
reach US $605 billion, or 2.5% of GDP, by the
beginning of the next decade, a 130% increase
in just 10 years.)26
The concentration of Med-
icaid enrollment on the border region is shown
in Figure 1.
Descriptive statistics for coverage rates among
population subgroups in the region revealed that
the Mexican American population presented the
lowest coverage rates in the private insurance
category: 53% when compared with 78% of the
non-Hispanic white population group, or 70%
for the African American population. In contrast,
Mexican Americans showed the highest rate of
Medicaid enrollment rates with a proportion
almost 7 times higher than the non-Hispanic
white population, and close to 3 times as much
as the African American subgroup.25
These
gaps depict access disparities between popu-
lation subgroups and highlight the importance
of employer-based health insurance as a resource
for improving insurance coverage for popula-
tion groups that are already placing a high de-
mand on public programs.
The Medicaid Expansion scenario in Texas
as originally proposed by the ACA was to cover
those individuals with incomes up to 133% of
the federal poverty level, thereby reducing ac-
cess restrictions for the Mexican American pop-
ulation in the region by increasing the eligibility
base by 22%. Although alternative strategies to
overcome access limitations such as cross-border
demand27,28
have recently been documented in
the literature, given such factors as geographic
proximity to Mexican cities, price differentials,
and cultural affinity, the state alternative to Med-
icaid Expansion to the Medicaid program de-
signed to benefit low-income individuals remains
a key issue for minority population groups in
the area.
Figure 1. Medicaid enrollment by county, 2013. Source: Authors using data from Texas Department of State Health
Services, Texas Health and Human Services Commission, and US Census TiGER Line Shp.

Employer-based health insurance
demands: a logistic regression approach
As noted in previous studies, the lack of
health coverage seems to be primarily associ-
ated with financial barriers as well as to labor
environment structure as defined by a company’s
size,29,30
type of employment, and other labor
environment factors. In order to more closely
analyze this relationship, a logistic model was
constructed to evaluate underlying labor en-
vironment determinants for employer-based
health insurance in the area. The logistic model
is specified in Equations (1) and (2).
PðEmp insr ¼ 1jx1; x2:::xkÞ ¼
1
ð1þð þ i xi ÞÞ
ð1Þ
PðE insr ¼ 1jx1; x2:::xkÞ ð2Þ
¼
1
ð1 þ eð þ 1wkhþ 2class wrkþ 3industryþ 4pop grpÞÞ
The binary response variable for employer-
based insurance (Emp_insr) measured whether
the individual had employer-based health insur-
ance and used the values 1 if the response was
affirmative and 0 otherwise. The explanatory
variables were as follows: weekly work hours
(wkh), which referred to hours worked per
week by the individual and was put into 3 cate-
gories: (1) part-time, between 1 and 32 hours;
(2) full-time regular, between 33 and 48 hours;
and (3) extended, between 49 and 60 hours.
Variable class work (class_wrk) refers to type
of employment and is placed in 4 categories:
(1) private for-profit company or business; (2)
. . .sector (local, state, or federal level); (3)
entrepreneur (working in own business); and
(4) private nonprofit, tax-exempt, or charitable
organization. Variable ‘‘industry’’ refers to the
industry in which the individual worked. To
record this variable, the top 5 industries by em-
ployment were based on their North American
Industry Classification System (NAICS) code, using
the following categorical transformation: 1,
NAICS code 7860 (elementary and secondary
schools); 2, NAICS code 770 (construction, in-
cluding cleaning during and after); 3, NAICS
code 8680 (restaurants and other food services);
4, NAICS code 9470 (justice, public order, and
safety activities); 5, NAICS code 8170 (med-home
health care services).
To identify possible differences across pop-
ulation groups a control variable ‘‘pop_grp’’
was introduced in the model and included 3
categories: (1) non-Hispanic white population, (2)
second-generation Mexican American population,
and (3) first-generation Mexican American Popula-
tion. Results from the regression are shown in the
Table.
Table. Labor Environment Determinants for Employer-Based Health Insurance
Employer-Provided Health Insurance Odds Ratio SE z P z 95% Confidence Interval
Class work
Public 3 1.17 2.83 0.01 1.4-6.43
Entrepreneur 0.73 0.83 0.28 0.78a
0.08-6.84
Nonprofit 3.69 2.12 2.27 0.02 1.2-11.37
Weekly work hours
Full time 2.73 0.76 3.58 0 1.58-4.72
Extended 5.49 2.38 3.93 0 2.35-12.83
Industry
Construction 0.27 0.11 3.26 0 0.12-0.59
Restaurants 0.33 0.15 2.45 0.01 0.14-0.8
Justice, public order 1.14 0.36 0.4 0.68b
0.61-2.13
Home health care 0.31 0.16 2.22 0.03 0.11-0.87
Population groups
Second-generation Mexican American 0.43 0.13 2.8 0.01 0.23-0.77
First-generation Mexican American 0.25 0.09 3.78 0 0.12-0.51
Constant 0.77 0.39 0.53 0.6 0.28-2.07
Coefficients are statistically significant at .05, unless otherwise specified.
a,b
Not statistically significant. Dependable variable: employer-provided health insurance. R2
= 0.2861, P 2
= 0.

The model parameters show that the vari-
ables selected were statistically significant de-
terminants to explain employer-based health
insurance. The coefficients from the regression
are already expressed as the change in the odds
ratios from the base category. The base categories
are as follows: class work: private sector; weekly
work hours: part time (1-32 hours); industry:
education, elementary and secondary schools;
and population group: non-Hispanic white.
Results were validated against specification
errors using the Turkey test (linktest) whose
purposes in this case were (1) to test the lo-
gistic function adequacy as a link function
between the outcome and predictor variables
and (2) to detect if there are important ex-
plicative variable omissions in relation to the
dependent variable.31(p16)
Standard postestimation tests were conducted
and included the Hosmer and Lemeshow
goodness-of-fit test32
and the multicolinearity
test, in which no indication of unusual values
for the variance inflation factor or tolerance
was found; therefore, multicolinearity issues
were discarded. In order to have a precise es-
timation of the probabilities associated with
the model odds ratios, a marginal effects esti-
mation was conducted and applied to estimate
Equation (3).
E½yjx=xj ¼ expðx
0
þ jÞ expðx
0
Þ
¼ expðx
0
Þðebj
1Þ ð3Þ
Marginal effects at representative values (MER)
instead of the conventional marginal effects at
means values (MEM) method was used to take
advantage of interactions between indepen-
dent variables for specific values.
RESULTS
There are important differences in the
probability of having employer-based health
insurance in respect to the population group
an individual belongs to. For example, an
individual in the non-Hispanic white group
has a 60.6% probability of having this type of
health insurance, whereas an individual in the
second-generation Mexican American group
has a 46.5% probability. The difference is still
more pronounced in the case of individuals in
the first-generation Mexican American group,
where the probability is 37.6%. This pattern
prevails across all industries (Figure 3).
Furthermore, when interaction with the var-
iable industry of employment is included, the
chance of second-generation Mexican Americans
obtaining employer-based health insurance im-
proves dramatically if they work in 2 specific
industries: the administration of justice, public
order, and safety industry, or in the elementary
and secondary school industry, with probabilities
of 59.4% and 56.7%, respectively. Comparing
against the other main industries in the area,
which are construction and restaurants and
other food services, an important disadvantage
for second-generation Mexican Americans can
be noted given the probabilities of only 29.7%
and 33.8%, respectively, for these types of jobs.
Inallcases,second-generationMexicanAmericans
have a higher probability of having employer-
based health insurance than the first-generation
Figure 2. Estimated probabilities by population group and industry/employer-provided health insurance 2010.
Source: Authors using public use microdata from ACS, US Census Bureau 2010. *2gMxA refers to
second-generation Mexican American.

subgroup, which could be an indication of the
education and acculturation process (Figure 2).
Regarding the class of work, the estimation
suggested that working for a private nonprofit,
tax-exempt, or charitable organization is a good
way to acquire health coverage because at 60%
this category presents the highest probability of
receiving this benefit within the class-of-work
categories, which is higher than the probability
for the public sector at 56%. On the other hand,
working for the private sector is the less attrac-
tive option among the 4 classes of work consid-
ered, with the lowest probability of having health
insurance provided by an employer at only 34%
(Figure 3).
Concerning the number of hours worked
per week, a positive correlation was confirmed
between the probabilities of having employer-
based health insurance and the number of hours
worked per week. However, an interaction with
the class of work revealed an interesting fact,
which is that even a part-time employee in the
private nonprofit, tax-exempt, or charitable orga-
nization category had a better chance of having
employer-based health insurance at 42.6% than
a full-time private sector employee in the study
area where the probability is only 19%.
Overall model results provided additional
information toward understanding the lack of
access due to nonfinancial barriers on the de-
mand for health insurance. According to the
logistic regression results, the private sector pre-
sents the lowest probability of having employer-
based health insurance. Within the private sector,
2 key industries where insurance constraints pre-
vailed among the Mexican American community
were construction and restaurants. The fact that
2 of 5 second-generation Mexican American
adults in the study area work in occupations
within these 2 industries provides evidence of
insurance coverage constraints faced by the
Mexican American community on the Texas-
Mexico border.
DISCUSSION
The results from the analysis of the labor mar-
ket determinates suggest that the provisions for
small business tax credits in the ACA may have
a balance effect regarding public and private
insurance coverage disparities, rather than a
crowding-out scenario induced by the increase
in Medicaid enrollees among the Mexican
American community.
Although further evaluation of this is needed,
the magnitude of this effect will be constrained
by the characteristics of the Mexican American
population labor force participation, given that
labor environment determinants of private health
insurance and the occupational characteristics
of the Mexican American population largely ex-
plain the lack of employer-based insurance access
in the Texas-Mexico border area.
Furthermore, results indicate that industries
in which the Mexican American population is
primarily employed are characterized by the
lowest probability of having insurance. Those
industries are NAICS code 770 (construction,
including cleaning) and NAICS code 8680 (res-
taurants and other food services).
Although it was found that working in public
sector industries such as code 9470 (administration
Figure 3. Estimated probabilities by class of work and hours worked per week/employer-provided health insurance
2010. Source: Authors using public use microdata from ACS, US Census Bureau 2010.

of justice, public order, and safety activities) or
NAICS code 7860 (elementary and secondary
schools) improved by a 60% probability the
opportunities of Mexican Americans obtaining
employer-based health insurance, these occupa-
tions rank at the bottom of the main occupation
list for Mexican Americans.
In addition, consistent with previous studies
describing existing pressures on public programs
such as Medicaid,33,34
the study revealed an
important gap in employer-based insurance in
relation to the State of Texas coverage level,
which is partially absorbed by a 10.43% overload
for public coverage via Medicaid in the study
area. According to the results, the ACA provision
regarding poverty eligibility levels may generate
in the area a further increase in demand for this
program with an additional 621000 potential
new beneficiaries of whom 481000 are second-
generation Mexican Americans and 140000 in
the first generation.
This scenario does not favor the State of Texas
implementation of an alternative Medicaid Expan-
sion, which in turn may generate an additional
incentive for cross-border demand of medical
services already evident given the price differ-
entials and cultural similarities between border
localities, practice that could have an adverse
effect on health care quality as implied in recent
studies conducted on the border region.35,36
Limitations
Although no previous study linking the af-
fordable care provisions with the labor envi-
ronment for the Mexican American population
has been published to our knowledge, the anal-
ysis presents a series of limitations, regarding the
microdata used, first as a disclosure avoidance
measure the most detailed unit of geography
contained in the PUMS files is the Public Use
Microdata Area. Public Use Microdata Areas are
special nonoverlapping areas that partition each
state into geographic units containing no fewer
than 100000 people each; this implies that the
analysis cannot be replicated at a county level,
which would be of interest for other parts of
the country with high proportion of Mexican
American populations. Instead, to conduct a
statistical representative analysis at regional level,
Public Use Microdata Area geographies should
be selected to match the region of study, as was
the case for the present article.
Finally, Public Use Microdata from the ACS
does not provide information about the firm
size in which individuals are employed, so com-
plementary sources need to be developed to
more closely analyze public policy impacts.
CONCLUSIONS
This study shows that ACA provisions directed
to small business and lower-income individuals
have the potential to reduce health insurance
constraints among the Mexican American com-
munity. Positive externalities may include a di-
minishing incentive for cross-border demand of
medical services in the event that an alternative
Medicaid Expansion is enacted in Texas.
Regarding labor environment, because the selec-
tion of industry or sector appears to be important
determinants of employer-based health insur-
ance, other factors such as the gradual shift in the
occupational pattern toward occupations of higher
human capital appear to be an important element
within the Mexican American community; how-
ever, this issue warrants further evaluation.
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