The Health and Wealth of a Nation Employer-Based Health Insurance.docx

The Health and Wealth of a Nation: Employer-Based Health
Insurance and the Affordable Care Act
falseValletta, Robert G
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.American Economist58.1 (Spring 2013): 60-61.
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Insurance and the Affordable Care Act, by Nan L. Maxwell, is
reviewed.
Insurance and the Affordable Care Act, by Nan L. Maxwell, is
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Insurance and the Affordable Care Act, by Nan L. Maxwell,
Kalamazoo, MI: The W.E. Upjohn Institute for Employment
Research, 2012
This book provides a valuable service by conducting an
empirical assessment of the potential impacts of the 2010
Patient Protection and Affordable Care Act (ACA) on employer-

sponsored health insurance (ESI). As the book notes, this
legislation represents the first major reform of national health
care policy in 45 years. The ACA specifies extensive changes in
private and government provision of health care, including
provisions related to the required amounts, types, and financing
of health insurance and care. The law requires deep and broad
changes in the U.S. health care system, but it largely leaves the
relative roles of government and private institutions intact. As
such, most U.S. residents will likely continue to receive health
insurance and health care through ESI policies obtained through
their own or a family member's job.
The book's focus on ESI therefore is well-placed. The empirical
analyses rely on the California Health and Employment Survey
(CHES), conducted in California during 2005-06. The survey
provides information for 1 ,427 private-sector firms with five or
more employees regarding their workforce, the detailed
characteristics of their health plans, and employee benefits more
generally. Importantly, firms are distinguished not only by size
(number of employees) but also by the skill attainment of their
workforce, as reflected in survey responses regarding the
educational and experience requirements of jobs in the firm.
These data enable analyses of the different effects not only
between large and small firms, which are explicitly
distinguished in the law based on a cutoff of 50 or more full-
time employees, but also between firms with primarily high-
skill or low-skill positions, which corresponds closely to high-
wage and low-wage jobs.
Early chapters of the book provide an extensive discussion of
the pre-reform features of U.S. health care provision and the
history of ESI, including its primary origins during World War
II and the factors underlying its subsequent spread. I found the
background discussion to be one of the book's strongest
features, providing a cogent explanation of and compelling
backdrop for the subsequent discussion of the ACA' s likely
effects on ESI markets. The book also provides extensive
discussion of the specific features of the ACA that are likely to

affect employer and employee incentives surrounding ESI.
Although the key information all appears to be present, I found
it somewhat difficult to absorb, either because it is spread out
over multiple chapters and subsections, or else simply because
the legislation is complicated and therefore difficult to describe
in a straightforward manner.
The main findings of the analyses revolve around differential
effects of the ACA on ESI for small versus large firms and
firms with a preponderance of low-skill versus high-skill jobs.
The ACA eventually requires that large firms offer ESI
coverage to employees who work at least 30 hours per week and
have at least three months of tenure or else pay a penalty. The
author argues that coverage will be expanded for such
employees under ACA, because many large firms do not
currently offer them coverage. By contrast, the author argues
that ACA support to the small firm group market will not
generally incentivize small firms to expand coverage, largely
because ESI is expensive and most small firms will not be
eligible for the tax credit included in the legislation. This
suggests that the ACA will widen the ESI coverage gap between
small and large firms. Among employees covered by ESI, the
ACA' s requirements for plan choice and features are likely to
cause partial convergence in plan quality between low-wage and
high-wage workers.
Like any analysis of the economic impacts of complicated
legislation that is not based on direct observation, the book's
conclusions are subject to caveats arising from an imperfect
match between the data and analytical techniques available and
the specific outcomes being analyzed. The CHES data used to
infer likely employer responses to the requirements of the ACA
have a couple of drawbacks. While the descriptive statistics
suggest that the sample of California firms is broadly
representative of national firms, there is no guarantee that the
results for the California labor market will mimic those
nationwide, given possible differences in the industrial
distribution of large versus small firms and high- wage versus

low-wage firms between California and the rest of the nation.
More crucially, the survey responses pertaining to health plan
offers are largely qualitative, which limits any inference about
the likely size of employer responses to changes in the costs and
requirements for ESI programs. Indeed, the key survey
questions about ESI elicit responses based on opinions, such as
the perceived likelihood that the firm will respond in specific
ways to increased costs. It is likely that employers' responses
under actual shifts in market conditions will differ from their
speculative responses to such questions, limiting the inferences
that can be drawn about post-ACA behavior.
My biggest concern about the analyses revolves around the
assumption that the ACA will increase the costs of ESI
provision, which forms much of the basis for the author's
empirical predictions. As the book notes, a wide range of
estimates of varying signs and magnitudes are available
regarding the expected impacts of the ACA on the costs of ESI.
This is especially important for smaller firms, which may
benefit from the availability of tax credits and reduced ESI
administrative costs. The book's conclusions could have been
bolstered by more discussion of the likely correctness of the
assumption of cost increases and corresponding implications for
ESI outcomes. Indeed, the assumption that costs will increase
implies a reduction in ESI and overall health insurance
coverage, which suggests that the ACA may backfire in its goal
of expanding health coverage. This is a critical and potentially
controversial claim, and the arguments in the book would have
been more convincing had the author grappled with it more.
Despite these caveats, the book represents a valuable initial
foray and a useful basis or citation for subsequent work - which
I hope will be voluminous - regarding the impacts of health care
reform on ESI, related labor market outcomes, and health care
outcomes more generally. Readers who are interested in
conducting such analyses, or who are interested more generally
in the likely effects of the ACA, should read this book.
AuthorAffiliation

ROBERT G. VALLETTA*
Federal Reserve Bank of San Francisco
* The views expressed are solely those of the author and are not
attributable to other staff or management of the Federal Reserve
Bank of San Francisco or the Federal Reserve System.
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Copyright Omicron Delta Epsilon Fraternity Spring 2013
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Subject
Book reviews;
Health insurance;
Patient Protection & Affordable Care Act 2010-US
Location

United States--US
Classification
8210: Life & health insurance4320: Legislation9190: United
States
Title
Insurance and the Affordable Care Act
Author
Valletta, Robert G
Publication title
American Economist
Volume
58
Issue
1
Pages
60-61
Number of pages
2
Publication year
2013
Publication date
Spring 2013
Year
2013
Section
BOOK REVIEW
Publisher
Omicron Delta Epsilon Fraternity
Place of publication
Los Angeles
Country of publication
United States
Publication subject
Business And Economics
ISSN

05694345
Source type
Scholarly Journals
Language of publication
English
Document type
Book Review-Favorable
ProQuest document ID
1371385688
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http://search.proquest.com.ezproxy2.apus.edu/docview/1371385
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Copyright Omicron Delta Epsilon Fraternity Spring 2013
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Subject
Studies
Young adults
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The Affordable Care Act Has Led To Significant Gains In
Health Insurance And Access To Care For Young Adults
falseSommers, Benjamin D
; Buchmueller, Thomas
; Decker, Sandra L
; Carey, Colleen
; Kronick, Richard
.Health Affairs32.1 (Jan 2013): 165-74.
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Headnote
ABSTRACT The Affordable Care Act enables young adults to
remain as dependents on their parents' health insurance until
age twenty-six, and recent evidence suggests that as many as
three million young adults have gained coverage as a result.
However, there has been no evidence yet on the policy's effect
on access to care, and questions remain about the coverage
impact on important subgroups. Using data from two nationally
representative surveys, comparing young adults who gained
access to dependent coverage to a control group (adults ages 26-
34) who were not affected by the new policy, we found sizable
coverage gains for adults ages 19-25. The gains continued to
grow throughout 2011 (up 6.7 percentage points from
September 2010 to September 2011), with the largest gains seen
in unmarried adults, nonstudents, and men. Analysis of the
timing of the policy impact suggested that early gains in
coverage were greatest for people in worse health. We found
strong evidence of increased access to care because of the law,
with significant reductions in the number of young adults who
delayed getting care and in those who did not receive needed
care because of cost.
When fully implemented, the Affordable Care Act is expected to

increase the number of Americans with insurance by more than
thirty million.1 The main drivers of this coverage expansion-
increases in Medicaid eligibility (at states' option) and tax
credits for private health coverage purchased through health
insurance exchanges-take effect in 2014. However, one
provision of the law that has already been implemented allows
people to remain as dependents on their parents' private
insurance policies until age twenty-six. This provision, which
took effect for insurance plan renewals on or after September
23, 2010, extended coverage for many young adults by as much
as seven years, depending on previous state regulations related
to dependent insurance.
Many adults have already gained insurance under this
Affordable Care Act provision, according to multiple sources.2-
5 By one estimate, more than three million uninsured young
adults gained coverage between September 2010 and December
2011.6 The pattern of coverage seems to be attributable to the
law: More young adults became covered as dependents, and this
increase was partially offset by a decrease in the number of
young adults with private insurance in their own names.7
Evidence is mounting from several studies that this provision
has raised rates of insurance among young adults.8-10 However,
key questions remain: Which young adults were most likely to
gain coverage? And, more important, did changes in coverage
lead to improvements in access to care?
For several reasons, some young adults might benefit more from
the law than others. Even before the policy went into effect,
many insurers allowed full-time students to remain on their
parents' plans. This suggests that nonstudents might experience
greater benefits from the law than other young adults.
Health status probably also plays a role. Prior to September
2010, for young adults without employer-sponsored or public
insurance, the nongroup insurance market was the main option
for purchasing coverage. People in poorer health face higher
premiums and more restricted access to coverage in this market,
and therefore they may be more likely to benefit from the new

law.
The ultimate goal of this policy, however, was not only to
increase coverage for young adults but also to improve access to
care. Historically, access for young adults has often been
disrupted by the loss of coverage when they "age out" of their
parents' plans.11 People without health insurance are more than
four times as likely as others are to delay or defer obtaining
needed medical care because of cost.12 Prior insurance
expansions have improved access to care,13,14 although such
gains have typically been via Medicaid or the Children's Health
Insurance Program rather than private insurance. To our
knowledge, ours is the first study to examine whether the new
policy affected access to care for young adults.
In this article we first document gains in coverage over the first
year of the policy. Next we examine the policy's effect across
subgroups, hypothesizing greater gains for people with fewer
coverage options before the Affordable Care Act, such as
nonstudents and those in worse health. Finally, we test the
hypothesis that the policy not only increased young adults'
insurance coverage but also improved their access to care.
Study Data And Methods
Data We used data from two nationally representative surveys.
Our primary data source was the National Health Interview
Survey-an annual household survey conducted by the Centers
for Disease Control and Prevention's National Center for Health
Statistics. This survey contains questions related to access to
health care services, unlike the Census Bureau data used in
previous analyses of the dependent coverage provision.7-10
The National Health Interview Survey also provides quarterly
estimates for both insurance status and access measures, making
it possible to account for the timing of the policy's
implementation in September 2010. Quarterly data also allowed
us to distinguish early effects of the policy from effects several
months later.We used the survey's final data files for 2005-10
and earlyrelease data for the first three quarters of 2011.
Our second data source was the Annual Social and Economic

Supplement to the Census Bureau's Current Population Survey,
a nationally representative survey of the US civilian,
noninstitutionalized population. We used the 2006-11 data sets,
covering calendar years2005- 10. This survey has a
substantially larger sample than the National Health Interview
Survey, providing us with greater power to detect differential
effects of the policy among subgroups.
However, the Census Bureau's survey lacks information on
access to care and does not allow for quarterly coverage
estimates. Thus, it is difficult with the Current Population
Survey to precisely identify the "pre" and "post" periods or to
test whether the effect of the policy strengthened over time.We
treated data from the 2011 survey as being from the
postimplementation period, although it contains some
preimplementation data and captures policy effects only through
December 2010. For these reasons, we expected the National
Health Interview Survey to capture a larger effect of the
provision than the Census Bureau survey does.
Together, these two data sets have unique features that provide
a more complete picture of the effects of the dependent
coverage provision. Looking ahead to the Affordable Care Act's
major insurance expansions of 2014, it is critical for researchers
and policy makers to understand whether different national
surveys are likely to produce different estimates of policy
effects. The dependent coverage provision presents a useful
case study for comparing these data sets.
Analysis Our analytical approach was a difference- in-
differences linear regression. This approach compared outcomes
before and after the policy's implementation for the treatment
group (those ages 19-25) and a control group (those ages 26-
34), to measure the impact of the dependent coverage provision
on coverage and access to care.15 Because people ages 26-34
faced roughly similar conditions in the workforce and in the
health insurance market as those ages 19-25 (other than under
the provisions of the new law that allowed them to remain on
their parents' health plans), we believe they represented a

plausible control group. Our analysis produced similar results
with alternative control groups (people ages 26-30 and ages 27-
29).
We used linear regression to compare the change in coverage
among all people ages 19-25 before and after the policy went
into effect, versus the coverage change in the control group. We
assumed for simplicity that the provision was in effect for the
entire fourth quarter of 2010 but for none of the third quarter,
thereby lagging the provision one week after its implementation
on September 23.
We included linear and quadratic time trend variables to adjust
for preexisting coverage trends unrelated to the law.We adjusted
for race or ethnicity, sex, education, marital status, employment
status, and region, although this adjustment had little effect on
our results.
The primary outcome for our coverage analyses was whether a
person reported having "any insurance."We conducted
additional analyses of private coverage and public coverage
separately.
We then examined the following three measures of access to
care for adults in our sample: whether they said they had a usual
source of care other than an emergency department, whether
they had delayed care because of cost in the prior year, and
whether they had not received needed care in the prior year.
Information on usual source of care is available for only one
adult per household in the National Health Interview Survey,
which means that our sample size and ability to detect changes
in this measure were smaller than for the other measures.
Our base analysis estimated the policy's average effect on
coverage and access throughout the period after it was
implemented, beginning with the fourth quarter of 2010.
However, the policy's full impact probably did not occur
immediately.
Plans were required to offer dependent coverage to young adults
on renewal after September 23, 2010. Since coverage is often
extended on a calendar year basis, it is likely that many families

and insurers did not renew policies until January 2011, or
perhaps even later. Because coverage and access gains probably
increased over time, we estimated models in which we traced
the timing of the effect of the policy by each quarter, instead of
averaging all of the quarters together for an overall annual
increase in coverage.
We also assessed the policy's impact on different subgroups.We
tested for these effects separately using the National Health
Interview Survey and the Current Population Survey, since the
former data set offers more precise timing and more recent data,
while the latter data set offers larger sample sizes and
additional variables. We measured changes in "any insurance"
with our sample stratified by sex, marital status, race or
ethnicity, employment status, respondent- reported health
status, and full-time student status (available in the Census
Bureau data only).We then tested for subgroup differences in
the policy's impact on coverage and access to care.
Our sample from the National Health Interview Survey
contained 116,536 respondents, after we dropped 1,605
observations (1.3 percent) that were missing information on
insurance status and 5,336 (4.3 percent) that were missing
information on control variables. The analysis of usual source
of care had 47,372 observations for sample adults, after we
dropped 2,065 (4.2 percent) that had missing values.
Our sample from the Census Bureau data included 247,370
subjects. All analyses used weighting to produce national
estimates and standard errors that accounted for the complex
survey design.
Limitations Each of our two data sources has distinct
advantages, as well as limitations. As noted, the National
Health Interview Survey is ideal for analyzing the timing of the
policy's impact. The main limitation of this survey is its
relatively small sample size, which reduced our power to detect
differences among subgroups.
With its larger sample size, the Census Bureau survey is better
suited for subgroup analyses. However, this survey is limited by

the imprecision of the timing of insurance coverage data. The
survey is conducted in March of each year and asks respondents
to report all forms of coverage over the prior calendar year. The
last date of coverage that should be captured in the 2011 data
set is December 31, 2010, although some individuals may
mistakenly respond with statements about their current
coverage.16 As a result, our analysis of Census Bureau data
might capture some effect through March 2011.
In addition, our strategy relied on the assumption that people
ages 26-34 are a good control group for those ages 19-25.
Several factors support the assumption that, in the absence of
the policy, coverage would have trended similarly for the two
groups. For the period just before the policy went into effect,
we found no significant difference between the coverage trends
for the two groups. Although other provisions of the Affordable
Care Act did go into effect at the same time-namely, the
creation of new insurance pools to cover people with
preexisting conditions-enrollment in these pools was modest
(21,000 people of all ages, by April 2011).17
Ideally, we would like to understand how the effect of the
insurance expansion varied by socioeconomic status. However,
assessing socioeconomic status is challenging for young adults.
Family income measures may be misleading since household
surveys capture information only on family members living in
the same home. Thus, for young adults living separately from
their parents, estimates of "family income" do not include their
parents' income. Similarly, many adults ages 19-25 have not yet
completed their education, meaning educational attainment as
reported in the survey may not accurately reflect their ultimate
level of schooling. Because of these limitations, we did not
analyze income or education as subgroups of interest, although
our analyses did control for educational attainment.
Another minor limitation is that student status was not yet
available in the 2011 National Health Interview Survey data at
the time of our analysis, and it was reported only for people
under twentyfive in the Census Bureau survey.This means that

our analysis of student status did not have a natural control
group of older adults. Instead, we compared students and
nonstudents directly among people ages 19-24.
Study Results
Insurance Coverage For Young Adults, 2005-11 Exhibit 1
presents quarterly data from 2005 to the third quarter of 2011
on the percentages of people ages 19-25 and of those ages 26-34
with any health insurance coverage. Similar graphical
presentations for private and public health insurance coverage
are presented in the online Appendix (Exhibit A1).18
Historically, people in their early twenties generally had the
lowest rate of insurance coverage of any age group.3 In 2005
the proportion of people ages 19-25 covered by health insurance
was roughly six percentage points lower than the rate for those
ages 26-34.
From2005 to early 2010, coverage rates for the two groups
experienced similar year-to-year changes. A test of the
prepolicy trends showed no significant difference between the
two groups (p = 0:95), which supports our choice of control
group.19 Although the quarterly estimates fluctuated somewhat,
for both groups we saw a slight downward trend in overall
coverage rates.
The two groups diverged sharply after September 2010 (the
third quarter). At that point overall coverage for younger adults
increased significantly, while the older group experienced no
major change. Private insurance rates similarly increased for
people ages 19-25 after September 2010. For both groups,
public coverage has been growing over the past six years, with
no differential change in trend by age after September 2010.
Effect On Rates Of Coverage Exhibit 2 presents the regression-
based estimates for insurance coverage using data from the
National Health Interview Survey. Over the entire
postimplementation period, coverage among those ages 19-25
increased by a significant 4.7 percentage points more than
among the control group (those ages 26-34). The chance of
having private coverage increased by 5.1 percentage points

more for those ages 19-25 than for the control group. Public
coverage was increasing for both age groups at the time of the
policy's implementation, although this increase was not
significantly different between the two groups.
Exhibit 2 also presents estimates of the magnitude and timing of
the policy's coverage effect by quarter. The law was associated
with an immediate increase in insurance coverage for young
adults in the fourth quarter of 2010, with an increasingly large
effect on coverage over time. By the third quarter of 2011, the
coverage rate had increased by 6.7 percentage points for adults
ages 19-25 relative to the control group.
Effect On Rates Of Coverage By Subgroup Exhibit 3
summarizes the coverage effects of the new law on various
subgroups, using data from the National Health Interview
Survey. Appendix Exhibit A2 shows coverage trends for the
additional subgroups of race and sex.18 Coverage gains
occurred among nearly all subgroups, with significant increases
across all racial and ethnic groups, married and unmarried
people, and working and nonworking people. The coverage
increases were not statistically different across racial or ethnic
groups, or for workers compared to nonworkers.
Both men and women ages 19-25 experienced significant gains
in insurance coverage. The net coverage increase was larger for
men (8.2 percentage points) than for women (4.9 percentage
points), though the difference between these two estimates was
not significant (p = 0:08). Similarly, in this data set, we found
larger gains in insurance for unmarried people compared to
married ones in the younger age group, but this difference was
not significant (p = 0:51).
Secondary Analysis Using Census Data We compared the results
above from the National Health Interview Survey, which
extended through the third quarter of 2011, with data from the
Current Population Survey, which showed effects through the
end of 2010 (and possibly some effect through March 2011).17
Overall, both data sets showed the same general pattern.
Although the most recent data from the National Health

Interview Survey indicated a larger effect, the estimates were
quite close when we used the same time frame. The Census
Bureau data showed a 3.1-percentage-point increase in
insurance for people ages 19-25 relative to the control group
(Appendix Exhibit A3),18 which is very similar to the 2.7-
percentage-point estimate through the first quarter of 2011
using data from the National Health Interview Survey (Exhibit
2).
Appendix Exhibit A3 also shows results by subgroup using
Census Bureau data.18 This survey's larger sample size enabled
us to detect several significant differences in the impact of the
new law. In this survey, the larger estimated increases in
coverage for men compared to women (p = 0:004) and for
unmarried compared to married adults (p = 0:02) were both
significant. In addition, coverage gains were more than twice as
large among nonstudents (5.2; p < 0:001) than among students
(1.9; p = 0:24), although this between-group difference did not
reach statistical significance (p = 0:12).
The pattern of coverage gains based on health status was more
complex. The Census Bureau data show that, shortly after
implementation, the policy's effect on coverage was largest
among adults ages 19-25 in worse health: There was a 6.1-
percentage-point difference-in-difference effect for those in fair
or poor health, a 4.7-percentage-point effect for those in good
health, a 2.9-percentage-point effect for those in very good
health, and a 2.0-percentage-point effect for those in excellent
health (all significant, with p < 0:05).We observed a similar
pattern in the early data from the National Health Interview
Survey, with a 7.2-percentage-point increase for adults ages 19-
25 in fair or poor health (p = 0:10), a 5.3-percentage-point
increase for those good health (p = 0:02), a 2.7- percentage-
point increase for those in very good health (p = 0:17), and a
0.8-percentage-point increase for those in excellent health (p =
0:65) (see Appendix Exhibit A4).18
However, in the more recent National Health Interview Survey
data through the third quarter of 2011 (Exhibit 3), the selective

insurance gain for those in worse health was no longer evident.
Taken together, these results suggest that in the first six months
of the new policy, adults ages 19- 25 in worse health
experienced rapid increases in coverage. However, in later
months, coverage gains were trending similarly across all health
status groups.
Effect On Access To Care Exhibit 4 shows the estimated effect
of the dependent coverage provision on measures of access to
care, using data from the National Health Interview Survey. We
observed a decreased likelihood of people ages 19-25 reporting
that they delayed getting or did not obtain care because of cost,
and an increased likelihood of their reporting that they had a
usual source of care after the provision took effect, compared to
the control group.
The policy's effect was smaller in the first two quarters
following implementation and larger in the subsequent months.
By the third quarter of 2011, the policy had reduced the chance
that a person in the younger group delayed getting care because
of cost by 4.0 percentage points (p = 0:001) and had reduced the
chance that a person in that group did not obtain care because of
cost by 2.3 percentage points (p = 0:02), compared to a person
in the older group. A higher proportion of people in the younger
group reported having a usual source of care after the law took
effect, compared to the control group, but this effect was not
significant (p = 0:30).
Appendix Exhibit A5 shows the policy's effects on delaying or
not obtaining care because of cost for different subgroups.18
Consistent with the pattern observed for coverage, the law's
effect on access was significantly greater for unmarried adults
than for married adults (p = 0:001). Otherwise, there were no
significant differences in the policy's effects between
subgroups.
Discussion
Before passage of the Affordable Care Act, millions of young
adults were unable to be covered on their parents' plans, and
many of them could not obtain affordable private insurance. The

dependent coverage provision of the Affordable Care Act
substantially changed the insurance options for adults under age
twenty-six.
We found that the policy significantly increased private health
insurance for people ages 19-25 and also resulted in a
significant improvement in access to care. The gains in
coverage and access grew steadily after the policy's
implementation in September 2010. The largest gains were
evident in the most recent data we examined, for the second and
third quarters of 2011. Over this same time period, we did not
find any significant changes in coverage or access to care for a
control group of people ages 26-34 who were not affected by
this policy.
The policy's benefits for people ages 19-25 were widely
distributed.We found significant increases in coverage across
all racial and ethnic groups, and for both working and
nonworking adults. However, some groups benefited in
particular. Unmarried adults were more likely than married
adults to gain coverage, and men were more likely than women
to gain coverage. These findings, confirmed by other
researchers,10 indicate that the benefits of the new requirement
were greatest for people who previously had limited access to
affordable coverage. Single people have fewer insurance options
than their married peers because they cannot be covered by a
spouse. And young women, compared to their male peers, had
higher coverage rates at baseline (largely because of Medicaid)
and were more likely to be full-time students (37 percent versus
33 percent of those ages 19-24 in our Census Bureau data).
We found evidence suggesting that coverage gains were larger
among nonstudents than students, and among those in worse
health than those in better health. Both of these groups with
larger gains were likely to have had fewer insurance options
prior to the law-sicker people because of exclusions and denials
of coverage in the nongroup market, and nonstudents because
insurance plans prior to 2010 typically allowed parents to claim
children ages 18-22 as dependents only if they were full-time

students.
However, the relationship between the new law and health
status is nuanced. Data through early 2011 showed a strong
gradient in coverage gains by health status, but by the third
quarter of 2011 this differential effect was no longer evident.
This change suggests that people with greater health care needs
may have signed up quickly when this new option became
available, while healthier young adults may have signed up at a
more gradual rate.
What are the potential benefits of these gains in coverage?
Health insurance increases access to care, which ultimately may
lead to reduced morbidity and mortality.20 Our study found that
the coverage gains under the Affordable Care Act were indeed
associated with significant reductions in barriers to care for this
age group.We found a 2.3-percentage-point decline in the
proportion of people who said they did not obtain care and a
4.0-percentage-point decline in the proportion of those who said
they delayed getting care because of cost.
These effect sizes are plausible, given baseline differences in
access between uninsured young adults and those with private
coverage. One study from 2008-09 showed that among people in
their twenties, 31 percent of those who were uninsured did not
obtain medical care in the past year because of cost, compared
to 9 percent of those with private insurance.21 This ratio
implies a 2.2-percentage-point decline in care not obtained for
each 10.0-percentage-point gain in coverage. Our estimates are
in this ballpark-a 2.3-percentage-point decline in care not
obtained in the setting of a 6.7-percentage-point coverage gain.
Beyond access to care, there are other potential benefits of the
dependent coverage provision that we were not able to test
directly. First, insurance has been shown to reduce the risk of
financial strain from medical spending,13,22 which is
particularly relevant for young adults in poor health.
Second, young adults covered as dependents are freed from so-
called job lock, in which they stay at a job just to maintain
coverage. Instead, they can pursue additional education or new

career opportunities without fear of losing coverage. Lastly,
insurance obtained through parents may be more comprehensive
than the coverage some young adults had previously, offering
improved financial protection and access to care even for those
who had not been uninsured.
Our analysis also provides insight into how results compare
when assessing the same policy using alternative data sets. The
National Health Interview Survey and the Current Population
Survey are two of the most important data sources that
researchers will use to evaluate the Affordable Care Act. The
National Health Interview Survey contains more recent data and
therefore indicates a larger effect of the policy than the Census
Bureau survey. However, when we constructed an analysis with
the National Health Interview Survey that matched the Census
Bureau data in terms of timing, the results from the two surveys
were quite similar. Furthermore, subgroup analyses using the
two data sets showed similar patterns of coverage gains.
Conclusion
To our knowledge, our study is the first to demonstrate that the
dependent coverage provision of the Affordable Care Act
resulted in increased access to careamong young adults.We also
found that although coverage and access gains were broad
based, the policy was particularly beneficial for young men,
unmarried people, and nonstudents.
We used multiple data sources-each with unique features-to
conduct our analyses. Taken together, the consistent results
from multiple sources offer persuasive evidence that the
Affordable Care Act's dependent coverage provision has
significantly expanded insurance coverage and access to care
among young adults as intended.
Sidebar
doi: 10.1377/hlthaff.2012.0552 HEALTH AFFAIRS 32, NO. 1
(2013): 165-174
©2012 Project HOPE- The People-to-People Health Foundation,
Inc.
The ultimate goal of this policy was not only to increase

coverage for young adults but also to improve access to care.
Young adults covered as dependents are freed from so-called
job lock, in which they stay at a job just to maintain coverage.
A previous version of this article was presented at the
AcademyHealth Annual Research Meeting in Orlando, Florida,
June 26, 2012. The authors thank Robin A. Cohen of the
National Center for Health Statistics for help with the National
Health Interview Survey data. The findings and conclusions in
this article are those of the authors and do not necessarily
represent the views of the Centers for Disease Control and
Prevention or the Department of Health and Human Services.
[Published online December 19, 2012.]
Footnote
NOTES
1 Congressional Budget Office. Letter to the Hon. Nancy Pelosi
[Internet]. Washington (DC): CBO; 2010 Mar 18 [cited 2012
Nov 21]. Available from: http://www.cbo.gov/sites/default/
files/cbofiles/attachments/hr4872_ 0.pdf
2 Martinez ME, Cohen RA. Health insurance coverage: early
release of estimates from the National Health Interview Survey,
January-June 2011. Hyattsville (MD): National Center for
Health Statistics; 2011.
3 DeNavas-Walt C, Proctor B, Smith J. Income, poverty, and
health insurance coverage in the United States: 2010.
Washington (DC): Census Bureau; 2011.
4 Mendes E. In U.S., significantly fewer 18- to 25-year-olds
uninsured. Washington (DC): Gallup Organization; 2011.
5 Kaiser Family Foundation, Health Research and Educational
Trust. Employer health benefits: 2011 summary of findings.
Menlo Park (CA): KFF; 2011.
6 Sommers BD. Number of young adults gaining insurance due
to the Affordable Care Act now tops 3 million. Washington
(DC): Department of Health and Human Services; 2012.
7 Sommers BD, Kronick R. The Affordable Care Act and
insurance coverage for young adults. JAMA. 2012;307:913-4.
8 Cantor JC, Monheit AC, Delia D, Lloyd K. Early impact of

the Affordable Care Act on health insurance coverage of young
adults. Health Serv Res. 2012;47:1773-90.
9 Holahan J, Chen V. Changes in health insurance coverage in
the Great Recession, 2007-2010 [Internet]. Washington (DC):
Kaiser Commission on Medicaid and the Uninsured; 2011 Dec
[cited 2012 Nov 21]. (Issue Paper). Available from:
http://www.kff.org/ uninsured/upload/8264.pdf
10 Antwi YA, Moriya AS, Simon K. Effects of federal policy to
insure young adults: evidence from the 2010 Affordable Care
Act's dependent coverage mandate. Cambridge (MA): National
Bureau of Economic Research; 2012.
11 Anderson M, Dobkin C, Gross T. The effect of health
insurance coverage on the use of medical services. American
Economic Journal: Economic Policy. 2012;4(1):1-27.
12 Cohen RA. Trends in health insurance and access to care
from 1997- 2008. Hyattsville (MD): National Center for Health
Statistics; 2008.
13 Finkelstein A, Taubman S,Wright B, Bernstein M, Gruber J,
Newhouse JP, et al. The Oregon health insurance experiment:
evidence from the first year [Internet]. Cambridge (MA):
National Bureau of Economic Research; 2011 Jul [cited 2012
Nov 21]. (NBER Working Paper No. 17190). Available from:
http:// www.nber.org/papers/w17190
14 Long SK, Coughlin T, King J. How well does Medicaid work
in improving access to care? Health Serv Res. 2005;40:39-58.
15 Our regression included binary variables identifying
"treatment" group, "postpolicy" period, and the interaction
"treatment multiplied by postpolicy." The coefficient on
"postpolicy" measures the policy's effect on the control group.
The sum of the coefficients on "postpolicy" and "treatment
multiplied by postpolicy" measures the policy's effect on the
treatment group. The coefficient on "treatment multiplied by
postpolicy" is our difference-indifference estimate.
16 Swartz K. Interpreting the estimates from four national
surveys of the number of people without health insurance. J
Econ Soc Meas. 1986; 14:233-42.

17 Government Accountability Office. Pre-existing condition
insurance plans: program features, early enrollment and
spending trends, and federal oversight activities [Internet].
Washington (DC): GAO; 2011 Jul [cited 2012 Nov 21].
Available from: http://www.gao .gov/assets/330/322006.pdf
18 To access the Appendix, click on the Appendix link in the
box to the right of the article online.
19 A comparable test using Census Bureau data shows that the
prepolicy trends did differ significantly (p = 0:02) by age group
when including the 2005 data, but not for the years from 2006
to 2010 (p = 0:23). Nonetheless, our estimates based on Census
Bureau data were essentially unchanged when we excluded the
2005 data. Thus, for simplicity, we used the same study period
of 2005-11 for both data sets.
20 Hadley J. Sicker and poorer-the consequences of being
uninsured: a review of the research on the relationship between
health insurance, medical care use, health, work, and income.
Med Care Res Rev. 2003; 60(2 Suppl):3S-75S; discussion 76S-
112S.
21 Bloom B, Cohen RA. Young adults seeking medical care: do
race and ethnicity matter? Hyattsville (MD): National Center
for Health Statistics; 2011.
22 Gross T, Notowidigdo MJ. Health insurance and the
consumer bankruptcy decision: evidence from expansions of
Medicaid. J Public Econ. 2011;95:767-78.
AuthorAffiliation
Benjamin D. Sommers ([email protected]) is a senior adviser in
health policy in the Office of the Assistant Secretary for
Planning and Evaluation, Department of Health and Human
Services, and an assistant professor at the Harvard School of
Public Health, Harvard Medical School, and Brigham and
Women's Hospital, in Boston, Massachusetts.
Thomas Buchmueller is the Waldo O. Hildebrand Professor of
Risk Management and Insurance and a professor of business
economics and public policy at the Stephen M. Ross School of
Business, University of Michigan, in Ann Arbor.

Sandra L. Decker is an economist and distinguished consultant
at the National Center for Health Statistics, in Hyattsville,
Maryland.
Colleen Carey is a doctoral candidate in the Department of
Economics at the Johns Hopkins University, in Baltimore,
Maryland.
Richard Kronick is the deputy assistant secretary for health
policy in the Office of the Assistant Secretary for Planning and
Evaluation and a professor of family and preventive medicine at
the University of California, San Diego.
AuthorAffiliation
ABOUT THE AUTHORS: BENJAMIN D. SOMMERS,
THOMAS BUCHMUELLER, SANDRA L. DECKER, COLLEEN
CAREY & RICHARD KRONICK
Benjamin D. Sommers is an assistant professor at the Harvard
School of Public Health.
In this month's Health Affairs, Benjamin Sommers and
coauthors report on their study of the effects of an Affordable
Care Act provision enabling young adults to remain as
dependents on their parents' health insurance until age twenty-
six. Using data from two nationally representative surveys, and
comparing young adults who gained dependent coverage to a
control group (adults ages 26-34) who were not affected by the
new policy, the authors found sizable coverage gains for adults
ages 19-25, as well as strong evidence of increased access to
care. Among those who benefited the most were unmarried
adults, nonstudents, men, and those in worse health.
Sommers is a senior adviser in health policy in the Office of the
Assistant Secretary for Planning and Evaluation, Department of
Health and Human Services, as well as an assistant professor of
health policy and economics at the Harvard School of Public
Health and an assistant professor of medicine at Harvard
Medical School and Brigham and Women's Hospital. He is a
health policy researcher and a practicing primary care
physician. His research focuses on several areas of health
economics and health policy, including public health insurance,

health care financing, and medical decision making.
Sommers received the Outstanding Dissertation Award in 2006
from AcademyHealth. He holds a doctorate in health policy,
with a concentration in health economics, and a medical degree,
both from Harvard University.
Risk Management and Insurance at the University of Michigan.
Risk Management and Insurance and a professor of business
economics and public policy at the Stephen M. Ross School of
Business, University of Michigan. He also holds an appointment
in the university's Department of Health Management and
Policy and is a research associate at the National Bureau of
Economic Research.
During 2011-12 Buchmueller was the senior health economist
for the White House Council of Economic Advisers. He
received a doctorate in economics from the University of
Wisconsin-Madison.
Sandra L. Decker is an economist and distinguished consultant
at the National Center for Health Statistics.
Sandra Decker is an economist and distinguished consultant at
the National Center for Health Statistics, Centers for Disease
Control and Prevention. She previously worked as an analyst at
the International Longevity Center-USA; was an assistant
professor at the School of Public Service at New York
University; served as a research economist at the National
Bureau of Economic Research; and had work funded by the
National Institute on Aging, the Robert Wood Johnson
Foundation, and the Commonwealth Fund.
Most of Decker's research focuses on causal connections
between state Medicaid eligibility or provider reimbursement
rules and insurance status, use of health care services, and
health outcomes for vulnerable populations. She holds a
doctorate in economics from Harvard University.
Colleen Carey is a doctoral candidate at the Johns Hopkins
University.

Colleen Carey is a doctoral candidate in the Department of
Economics at the Johns Hopkins University. Recently, she
served as a staffeconomist for the White House Council of
Economic Advisers.
Carey's research focuses on federal regulation of health
insurance markets. She holds a master's degree in economics
from Johns Hopkins.
Richard Kronick is a professor at the University of California,
San Diego.
Richard Kronick is the deputy assistant secretary for health
policy in the Office of the Assistant Secretary for Planning and
Evaluation and a professor of family and preventive medicine at
the University of California, San Diego.
A nationally recognized specialist in health care policy, Kronick
previously served as a senior health care policy adviser in the
Clinton administration, where he contributed to the development
of President Bill Clinton's health care reform proposal. He also
has served as director of policy and reimbursement in the
Massachusetts Department of Public Welfare and assistant
director in the Massachusetts Office of Health Policy.
Kronick has a doctorate in political science from the University
of Rochester.
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Copyright The People to People Health Foundation, Inc.,
Project HOPE Jan 2013
Indexing (details)
Cite
Subject
Studies;
Young adults;
Health insurance;
Patient Protection & Affordable Care Act 2010-US;
Insurance coverage
MeSH
Adult, Female, Humans, Insurance Coverage -- statistics &
numerical data, Male, United States, Young Adult, Health
Services Accessibility -- statistics & numerical data (major),
Insurance, Health -- statistics & numerical data (major), Patient
Protection & Affordable Care Act -- statistics & numerical data
(major)
Location
United States--US
Classification
4320: Legislation9190: United States8210: Life & health
insurance9130: Experiment/theoretical treatment
Title
The Affordable Care Act Has Led To Significant Gains In
Health Insurance And Access To Care For Young Adults
Author
Sommers, Benjamin D; Buchmueller, Thomas; Decker, Sandra

L; Carey, Colleen; Kronick, Richard
Publication title
Health Affairs
Volume
32
Issue
1
Pages
165-74
Number of pages
10
Publication year
2013
Publication date
Jan 2013
Year
2013
Section
WEB FIRST
Publisher
The People to People Health Foundation, Inc., Project HOPE
Chevy Chase
United States
Publication subject
Insurance, Public Health And Safety
ISSN
02782715
Source type
Scholarly Journals
English
Document type
Feature, Journal Article
Document feature

Graphs;Tables;References
Accession number
23255048
1285127928
Document URL
928?accountid=8289
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Copyright The People to People Health Foundation, Inc.,
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2014-01-16
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Achieving Public Health Goals Through Medicaid Expansion:
Opportunities in Criminal Justice, Homelessness, and
Behavioral Health With the Patient Protection and Affordable
Care Act
falseDiPietro, Barbara, PhD; Klingenmaier, Lisa, MPH,
MSW.American Journal of Public Health, suppl.
Supplement103.2 (Dec 2013): E25-E29.
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Abstract (summary)
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States are currently discussing how (or whether) to implement

the Medicaid expansion to nondisabled adults earning less than
133% of the federal poverty level, a key aspect of the Patient
Protection and Affordable Care Act. Those experiencing
homelessness and those involved with the criminal justice
system-particularly when they struggle with behavioral health
diagnoses-are subpopulations that are currently uninsured at
high rates and have significant health care needs but will
become Medicaid eligible starting in 2014. We outline the
connection between these groups, assert outcomes possible from
greater collaboration between multiple systems, provide a
summary of Medicaid eligibility and its ramifications for
individuals in the criminal justice system, and explore
opportunities to improve overall public health through Medicaid
outreach, enrollment, and engagement in needed health care.
[PUBLICATION ABSTRACT]
Protection and Affordable Care Act. Those experiencing
homelessness and those involved with the criminal justice
system-particularly when they struggle with behavioral health
diagnoses-are subpopulations that are currently uninsured at
high rates and have significant health care needs but will
become Medicaid eligible starting in 2014. We outline the
connection between these groups, assert outcomes possible from
greater collaboration between multiple systems, provide a
summary of Medicaid eligibility and its ramifications for
individuals in the criminal justice system, and explore
opportunities to improve overall public health through Medicaid
outreach, enrollment, and engagement in needed health care.
[PUBLICATION ABSTRACT]

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Protection and Affordable Care Act.

Those experiencing homelessness and those involved with the
criminal justice system-particularly when they struggle with
behavioral health diagnoses-are subpopulations that are
currently uninsured at high rates and have significant health
care needs but will become Medicaid eligible starting in 2014.
We outline the connection between these groups, assert
outcomes possible from greater collaboration between multiple
systems, provide a summary of Medicaid eligibility and its
ramifications for individuals in the criminal justice system, and
explore opportunities to improve overall public health through
Medicaid outreach, enrollment, and engagement in needed
health care. (Am J Public Health. 2013; 103:e25-e29.
doi:10.2105/ AJPH.2013.3
STARTING IN 2014 (OR EARLIER should states choose), the
Patient Protection and Affordable Care Act (ACA)1 will give
states the option to expand Medicaid to most people earning at
or below 133% of the federal poverty level (FPL). Those
experiencing homelessness will greatly benefit from this policy
change because most nondisabled adults were previously
ineligible for Medicaid. Of the 836 980 patients seen in 2012 at
federally funded Health Care for the Homeless clinics, 61.1%
were uninsured (even though the vast majority of these
individuals lived below the poverty level).2 (Health Care for the
Homeless grantees are part of the Health Center Program as
authorized under section 330 of the Public Health Service Act,
as amended, and administered by the Health Resources and
Services Administration. They are also sometimes referred to as
"federally funded health centers" or "Health Resources and
Services Administration-funded health centers.") Although the
health of all those living in poverty is a concern to the public
health community, those who are both homeless and involved
with the criminal justice system are even more vulnerable. In
particular, when individuals experiencing homelessness with a
behavioral health diagnosis are unable to access broad-
basedmental health treatment, untreated symptoms can lead to
incarceration.3 Focusing attention on these subgroups could

yield wider individual and system benefits from the Medicaid
expansion, because these groups tend to have even lower
income, lack health insurance at a higher rate, and need a wider
range of health care services than their stably housed but still
impoverished counterparts.
Providers and administrators in both the criminal justice system
and the community not only share a common set of patients,
they also share important public health goals. Such goals
include increasing community safety, reducing incarceration
and recidivism rates and health care costs, improving patients'
health status, and increasing the community's capacity to
deliver needed medical and behavioral health services to
improve overall individual and public health.
Decisions that directly influence these goals are happening now.
It is critical for health care providers who serve homeless
populations and persons within the criminal justice system to
inform and influence the outcomes of a changing environment
in health care access and delivery. Because of eligibility and
enrollment changes, the ACA creates new possibilities for
stronger partnerships between service providers and
policymakers, and public health advocates can initiate and guide
this process.
HOMELESSNESS, INCARCERATION, AND BEHAVIORAL
HEALTH
Among adults in jail in the United States, 15.3% were homeless
at some point in the year before their incarceration. This is 7.5
to 11.3 times the estimate of homelessness among the entire US
adult population (1%-2%).4 In the state and federal prison
population, this rate drops to 9%, with those who are homeless
more likely to be incarcerated for a property crime, have had
previous criminal justice system involvement for property and
violent crimes, and have mental health problems, substance
abuse problems, or both.5 Individuals experiencing
homelessness who are incarcerated for such offenses can spend
significant time "behind the wall"-more than 40% of
respondents in a recent study in Baltimore, Maryland, spent a

combined total of five or more years incarcerated over their
lifetime.6 These two public health issues have a direct
relationship: homelessness can lead to incarceration, and
incarceration can lead to homelessness.7
Community health care providers who treat homeless
populations often experience patients suddenly dropping out of
care without notice only to reappear weeks or months later to
report having been in jail. During such transitions, medication
regimens and treatment plans are disrupted, possibly with
adverse health implications.
MEDICAID ELIGIBILITY AND HOMELESSNESS
One of the most important provisions of the ACA is the option
for states to expand Medicaid to most low-income people.
Starting January 1, 2014, nonpregnant, nondisabled adults aged
19 to 64 years who earn at or below 133% FPL will become
eligible for Medicaid (a 5% income disregard makes the actual
eligibility limit 138% FPL).1 Using 2012 FPL guidelines,138%
FPL is equivalent to an individual earning $15 856 per year, or
about $26 951 for a family of three. For the first three years, the
expansion is 100% federally funded (dropping to 90% in 2020
and thereafter).
An Urban Institute analysis found that if all states expand
Medicaid to individuals at or below 138% FPL, more than 15
million adults will be eligible to enroll.8 Although the Supreme
Court upheld the ACA as constitutional, it determined that the
Medicaid expansion would be a state option rather than
mandatory. 9 At the same time, 4.3 million adults in the United
States are currently eligible for Medicaid but not enrolled.10
Because of state expansion variance and past experiences with
enrollment among eligible populations, the Congressional
Budget Office has projected that only eight million will enroll
in the first year (2014) and only 11 million two years after
implementation (2016).11 Of those remaining uninsured after
2014, just more than one third are projected to be eligible for
Medicaid but not enrolled (36.5%).12 These reports have
demonstrated that eligibility does not automatically equate to

enrollment; hence, it is important for all states to expand and
implement strong outreach and enrollment practices.
Indeed, the ACA requires states to establish procedures to
conduct outreach to and enroll vulnerable and underserved
populations eligible for medical assistance and to include racial
and ethnic minorities, individuals with mental health or
substance-related disorders, and individuals with HIV/ AIDS
(among others).13 Individuals with these characteristics are
overrepresented in the adult homeless population and have
encountered historic barriers to enrollment and accessing care.
Individuals in these populations may currently be eligible for
Medicaid because of disabilities but are not enrolled. For
example, the 2011 Annual Homeless Assessment Report to
Congress found that 38% of those staying in homeless shelters
were disabled, compared with only 15% of the total US
population. 14 As expansion efforts unfold, these individuals no
longer have to demonstrate disability to gain access to health
insurance.
MEDICAID ELIGIBILITY AND CRIMINAL JUSTICE
Nearly all (90%) persons entering local and county jails and
detention centers in the United States are uninsured.15 One
profile of jail inmates found that 69% engaged in regular drug
use, 60% earned less than 133% FPL in monthly income, and
29% were unemployed at the time of their arrest.16 Of all those
potentially eligible for Medicaid under the ACA, more than one
third (35%) had prior criminal justice involvement.17 Those
who are enrolled in Medicaid traditionally have coverage
terminated on incarceration on the basis of a federal law that
prohibits Medicaid expenditures within correction environments
(the ACA does not alter this policy). Federal guidance
recommends suspension of benefits during incarceration, rather
than termination,18 because it simplifies and accelerates
resumption of Medicaid coverage on discharge; however, many
states still terminate. Although the criminal justice system in
general has made efforts to improve connections to health
services as part of reentry planning-particularly for those

serving longer terms in prison-greater eligibility for health
insurance once released can help bolster those community
connections to care.
Jails and Detention Centers
At midyear 2010, nearly 750 000 individuals were incarcerated
in county and city jails in the United States on a single day; of
these, 61% were awaiting court action on the current charge
(e.g., the pretrial population).19 In 2010, 12.9 million people
were admitted to these types of facilities, making them a prime
population to target for Medicaid enrollment and services on
release. This policy development offers a wide range of
possibilities for increasing access to community health care,
reducing recidivism, improving the reentry process, and
engaging criminal justice agencies in Medicaid enrollment.
The size of the jurisdiction's jail or detention center may affect
the opportunities for intervention, because this population has a
wide range of average weekly turnover (51.5%-136.7%).
Overall, smaller jails see greater turnover than larger jails
(Table 1), so the time needed for enrollment and other reentry
planning will need to be tailored to the length of time an
individual is incarcerated.
Prison and Community Corrections
Those released from prison are also likely to benefit from the
expansion of Medicaid to childless adults starting in 2014.
Although 1.6 million adults were incarcerated in federal and
state prisons in 2009, 730 000 were released that year (21%
higher than releases in 2000).20 A recent study has estimated
that as many as one third (33.6%) of those released from prisons
annually could enroll in Medicaid after the expansion becomes
effective.21Of the nearly five million people already involved
in community corrections, most are on active supervision
(which may require participation in some type of treatment).22
("Community corrections" refers to the supervision of criminal
offenders in the resident population, as opposed to confining
them to secure correctional facilities; the two main types of
community corrections supervision are probation and parole.)

Hence, opportunities also exist to expand Medicaid enrollment
for those reentering from prisons and those already in the
community but still in need of services. Those able to access
adequate treatment may be at reduced risk of probation
violation or re-arrest for behaviors related to untreated mental
health problems or addictions.
IMPROVED ENROLLMENT
The new Medicaid enrollment guidelines include a number of
changes that should make it much easier to enroll in the
program than the current process.23 In general, the new system
is designed to enable individuals to apply independently
(including via a home computer connection), although many of
those in the homeless population will want or need assistance in
doing so. Improvements include moving to a modified adjusted
gross income, faster determination timelines, electronic
verification of information, more flexible residency and address
options, limited use of paper documentation, a 12-month
renewal process, and application assistance if needed.
These improvements should make applying for Medicaid (and
reenrollment) easier for both clients and those assisting them.
Because under the new system an application can be submitted
online with electronically verified information, personnel
working in jails and prisons now have a greater opportunity to
participate in the enrollment process as part of reentry standard
operating procedures.
HEALTH STATUS OF THE CRIMINAL JUSTICE
POPULATION
A wide body of literature has focused on the health status of
those involved with the criminal justice system, who
demonstrate poorer health than the general population,
increased rates of chronic and infectious disease, and very high
rates of behavioral health disorders.24,25
Chronic and Infectious Disease
One report on medical problems of jail inmates found that half
of women (53%) and one third of men (35%) reported a current
medical problem; the most commonly reported conditions were

arthritis (19% and 12%, respectively), hypertension (14% and
11%, respectively), asthma (19% and 9%, respectively), and
heart disease (9% and 6%, respectively). 26 One study
conducted in Maryland jails found that nearly 7% tested
positive for HIV, and the prevalence of HCV reached nearly
30% and that of hepatitis B reached just more than 25%.27
Overall, persons released from criminal justice venues (both
jails and prisons) have been found to represent 17% of the total
AIDS population, 13% to 19% of those with HIV, 12% to 16%
of those with hepatitis B, 29% to 32% of those with HCV, and
25% of those with tuberculosis.28 These conditions pose
important public health implications, as well as significant
fiscal expenditures for criminal justice agencies responsible for
providing needed health care.
Behavioral Health
Behavioral health conditions are particularly prevalent in a
criminal justice setting. One study found that 64% of those in
jail have some form of mental illness,29 and another study
found serious mental illnesses in nearly 15% of the men and
31% of the women, which is more than three to six times those
rates found in the general population.30 Other research has
found that 10% to 15% of those in state prisons also have severe
mental illness.31 The prevalence of substance use is even
higher. More than two thirds of jail inmates are dependent on or
have abused alcohol or drugs (with men and women having
similar rates).32 The rates of substance abuse among jail
inmates can be as much as seven times that of the general
public.33 Often, mental illness and substance abuse are co-
occurring conditions in this population. In jails, an estimated
72% of individuals with serious mental illness have a substance
use disorder.34 In prisons, individuals with co-occurring
disorders ranged from 3% to 11% of the total incarcerated
population. 35 Clearly, addressing mental health and substance
use disorders must be a priority for both community health care
providers and the criminal justice system.
ESSENTIAL HEALTH SERVICES

The ACA requires Medicaid coverage for the newly eligible
population to include 10 categories of services: ambulatory
services, emergency services, hospitalization, maternity and
newborn care, mental health and substance use disorder services
(including behavioral health treatment), prescription drugs,
rehabilitative and habilitative services, laboratory services,
preventive and wellness services and chronic disease
management, and pediatric services, including oral and vision
care.1
Many of those who have criminal justice system involvement-
and those individuals who might experience homelessness-will
have access to insurance that covers a wide range of health care
services, particularly behavioral health care. Increasing the
availability of ongoing communitybased health care services has
the potential to improve health and stabilize behavior, thereby
decreasing the risks of (re)arrest, incarceration, and
homelessness. It is possible that those who do enter the justice
system could have improved health status, and those who leave
could be better connected to community care that helps maintain
stability after release. As one example, a Washington State
study found that rates of rearrest were 21% to 33% lower in
three groups treated for chemical dependency than among other
adults needing, but not receiving, treatment. This reduction
saved $5000 to $10 000 for each person treated.36,37 At the
same time, future funding for services targeted to this
population such as mental health and substance abuse treatment
grants, Services in Supportive Housing, and Ryan White HIV/
AIDS programs are uncertain. Framing the conversation in
terms of cost savings and a larger public health interest may
help engage a broader range of support among public
policymakers.
A CALL TO ACTION
Rarely are the needs of those who are homeless and those who
are involved with the criminal justice system incorporated into
policy decisions unless those who work most closely with these
vulnerable populations make a concerted effort. Indeed, a major

challenge may be first to convince corrections officials that
improving health care should be a priority issue to which they
should dedicate resources. State and local governments-along
with myriad partners-are (or should be) currently attempting to
redesign the health care system, and they are likely focused on
the health and service utilization patterns of the general public
in their quest to meet federal deadlines and other mandates.
Because Medicaid expansion is initially 100% federally funded
and current health services in correction settings are 100% state
and locally funded, officials in these venues should take note of
the significant cost savings possible if an adequate community
services system can be developed. The public health community
can add to that conversation by taking 12 key steps:
1. Educate state health reform policymakers about the
connections among homelessness, behavioral health, and the
criminal justice system.
2. Work with the criminal justice system to develop its
commitment to improving the health status of individuals who
are incarcerated and who are being released.
3. Develop new protocols for screening incoming detainees for
health insurance enrollment and ensuring connection to
community care at discharge.
4. Incorporate data links between community providers and jails
and detention centers to better coordinate health care and
reentry services.
5. Commit to adequately funding a wide range of behavioral
health programs and introduce greater service flexibility so that
treatment can be accessed on demand.
6. Develop a health care system and trained workforce that can
meet the needs of those with severe, multiple morbidities
(especially behavioral health).
7. Reduce the connection between homelessness and
incarceration by decriminalizing activities related to
homelessness, such as nuisance crime arrests.
8. Encourage states to suspend-not terminate-Medicaid benefits
for those who are incarcerated.

9. Ensure each state fully expands Medicaid to 133% of the
FPL.
10. Ensure jail and detention center administrators are aware of
policy changes and the potential financial implications for their
operations and are active in state decisions.
11. Track public health data related to these populations and tie
them to state health reform outcome measures.
12. Commit to the larger goal of ending homelessness by
investing in adequate housing, particularly for individuals after
release, so they are not released to the streets.
Criminal justice administrators and health care providers for the
homeless share goals related to reducing recidivism and
improving public health, especially for populations with high
rates of chronic and communicable disease, and are particularly
in need of ongoing behavioral health services. The
recommendations included in this article are intended to
increase awareness about the needs of a vulnerable group,
maximize outreach and Medicaid enrollment levels, and identify
opportunities for which stronger connections to care are
possible. Striking now while the proverbial iron is hot will help
ensure that system changes include provisions tailored to these
special populations. Not only will individual and community
health benefit from such an approach, but significant cost
savings are possible when investments in health care can offset
savings in the criminal justice system. Galvanizing these
changes will require a wide range of stakeholders who can see
across fences and walls-figuratively and literally-to the common
goals that are possible through effective Medicaid expansion
policies.
References
References
1. Patient Protection and Affordable Care Act, Pub. L. No. 111-
148, § 3502, 124 Stat. 119, 124(2010). Available at:
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-
detail.html. Accessed November 28, 2012.
2. Health Services and Resources Administration. 2012 Health

center data, homeless program grantee data plus additional
analysis on unpublished data. Available at:
http://bphc.hrsa.gov/uds/ datacenter.aspx?fd=ho&year=2012.
Accessed October 15, 2013.
3. Aron L, Honberg R, Duckworth K, et al. Grading the states
2009. Available at: http://
www.nami.org/Content/NavigationMenu/
Grading_the_States_2009/Full_Report1/ Full_Report.htm.
Accessed May 5, 2013.
4. Greenberg GA, Rosenheck RA. Jail incarceration,
homelessness, and mental health: a national study. Psychiatr
Serv. 2008;59(2):170-177.
5. Greenberg GA, Rosenheck RA. Homelessness in the state and
federal prison population. Crim Behav Ment Health.
2008;18(2):88-103.
6. Health Care for the Homeless, Inc. Still serving time:
struggling with incarceration and re-entry in Baltimore.
Available at: http://www.hchmd.org/research. shtml#reentry.
Accessed December 27, 2012.
7. Metraux S, Culhane D. Recent incarceration history among a
sheltered homeless population. Crime Delinq. 2006;52(3):504-
517.
8. Kenney GM, Dubay L, Zuckerman S, Huntress M. Opting out
of the Medicaid expansion under the ACA: how many uninsured
adults would not be eligible for Medicaid? 2012. Available at:
http:// www.urban.org/UploadedPDF/412607-Opting-Out-of-
the-Medicaid-Expansion-Under-the-ACA.pdf. Accessed
December 26, 2012.
9. Kaiser Family Foundation. A guide to the Supreme Court's
Affordable Care Act decision. Available at: http://www.kff.
org/healthreform/upload/8332.pdf. Accessed December 24,
2012.
10. Kenney GM, Dubay L, Zuckerman S, et al. Opting in to the
Medicaid expansion under the ACA: who are the uninsured
adults who could gain health insurance coverage? 2012.
Available at: http:// www.urban.org/UploadedPDF/412630-

opting-in-medicaid.pdf. Accessed December 26, 2012.
11. Congressional Budget Office. CBO's February 2013 estimate
of the effects of the Affordable Care Act on health insurance
coverage. Available at: http://www.cbo.gov/
sites/default/files/cbofiles/attachments/
43900_ACAInsuranceCoverageEffects.pdf. Accessed May 13,
2013.
12. Buettgens M, Hall MA. Who will be uninsured after health
insurance reform? 2011. Available at: http://www.urban.
org/UploadedPDF/1001520-Uninsured-After-Health-Insurance-
Reform.pdf. Accessed December 23, 2012.
13. Patient Protection and Affordable Care Act, Pub. L. 111-148
and 111-152, § 2201, Enrollment and simplification and
coordination with state health insurance exchanges; amends
USC Title 19 of the Social Security Act, § 1943.
14. US Department of Housing and Urban Development. The
2011 annual homeless assessment report to Congress. 2012.
Available at: https://www.onecpd.info/resources/
documents/2011AHAR_FinalReport.pdf. Accessed May 13,
2013.
15. Wang EA, White MC, Jamison R, Goldenson J, Estes M,
Tulsky J. Discharge planning and continuity of health care:
findings from the San Francisco county jail. Am J Public
Health. 2008;98 (12):2182-2184.
16. James DJ. Bureau of Justice Statistics special report: profile
of jail inmates, 2002. 2004. Available at: http://bjs.ojp.
usdoj.gov/content/pub/pdf/pji02.pdf. Accessed December 13,
2012.
17. US Department of Justice, National Institute of Corrections.
Solicitation for a cooperative agreement-evaluating early access
to Medicaid as a reentry strategy. Fed Regist. 2011;76(129):
39438-39443.
18. US Department of Health and Human Services, Center for
Medicaid and State Operations, Disabled and Elderly Health
Programs Group. Ending chronic homelessness: letter from
Glenn Stanton, acting director, to state Medicaid directors.

Available at: http://jfs.ohio.gov/ohp/bcps/
OHMedAdvComm/documents/
ENDING_CHRONIC_HOMELESSNESS. PDF. Accessed
December 27, 2012.
19. Minton TD. Jail inmates at midyear 2010-statistical tables.
2011. Available at: http://bjs.ojp.usdoj.gov/content/pub/
pdf/jim10st.pdf. Accessed December 10, 2012.
20. Guerino P, Harrison PM, Sabol W. Prisoners in 2010. 2011.
Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/ p10.pdf.
21. Cuellar AE, Cheema J. As roughly 700,000 prisoners are
released annually, about half will gain health coverage and care
under federal laws. Health Aff(Millwood). 2011;31(5):931-938.
22. US Department of Justice, Office of Justice Programs,
Bureau of Justice Statistics. Community corrections (parole and
probation). Available at: http://bjs.
ojp.usdoj.gov/index.cfm?ty=tp&tid=15. Accessed December 10,
2012.
23. Manatt Health
Solution
s. Overview of the final Medicaid eligibility regulation.
Available at: http://www.hca.wa.gov/
hcr/documents/Medicaid_Eligibility_ Final_Rule_Overview.pdf.
24. Veysey BM. The intersection of public health and public
safety in US jails: implications and opportunities of federal
health care reform. 2011. Available at: http://
www.cochs.org/files/Rutgers%20Final. pdf. Accessed December

10, 2012.
25. National Reentry Resource Center. Frequently asked
questions: health, mental health and substance use disorders.
Available at: http://csgjusticecenter.org/ reentry/frequently-
asked-questions/ #FAQ2. Accessed December 18, 2012.
26. Maruschak LM. Bureau of Justice Statistics special report:
medical problems of jail inmates. 2006. Available at: http://
bjs.ojp.usdoj.gov/content/pub/pdf/mpji. pdf. Accessed
December 18, 2012.
27. Solomon L, Flynn C, Muck K, Vertefeuille J. Prevalence of
HIV, syphilis, hepatitis B and hepatitis C among entrants to
Maryland correctional facilities. J Urban Health. 2004;81(1):25-
37.
28. Conklin TJ, Lincoln T, Wilson R. A public health manual
for correctional health care. Ludlow, MA: Hampden County
Sheriff's Department; 2002.
29. James DJ, Glaze LE. Mental health problems of prison and
jail inmates. 2006. Available at: http://bjs.ojp.usdoj.
gov/content/pub/pdf/mhppji.pdf. Accessed December 21, 2012.
30. Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S.
Prevalence of serious mental illness among jail inmates.
Psychiatr Serv. 2009;60(6):761-765.
31. Lamb HR, Weinberger LE. Persons with severe mental
illness in jails and prisons: a review. Psychiatr Serv. 1998;49
(4):483-492.

32. Jemelka RP, Rahman S, Trupin EW. Prison mental health:
an overview. In: Steadman HJ, Cocozza JJ, eds. Mental Illness
in America's Prisons. Seattle, WA: National Coalition for the
Mentally Ill in the Criminal Justice System; 1993:9-23.
33. Rothbard AB, Wald H, Zubritsky C, Jaquette N, Chhatre S.
Effectiveness of a jail-based treatment program for individuals
with co-occurring disorders. Behav Sci Law. 2009;27(4):643-
654.
34. Center for Mental Health Services GAINS Center. The
prevalence of co-occurring mental illness and substance use
disorders in jails. Available at: http://
gainscenter.samhsa.gov/pdfs/disorders/ gainsjailprev.pdf.
35. Edens JF, Peters RH, Hills HA. Treating prison inmates
with co-occurring disorders: an integrative review of existing
programs. Behav Sci Law. 1997;15 (4):439-457.
36. Mancuso D, Felver B. Providing chemical dependency
treatment to lowincome adults results in significant public
safety benefits. 2009. Available at: http://
www.dshs.wa.gov/pdf/ms/rda/research/ 11/140.pdf. Accessed
December 17, 2010.
37. Shah MF, Mancuso D, Yakup S, Felver B. The persistent
benefits of providing chemical dependency treatment to low-
income adults. 2009. Available at:
http://www.dshs.wa.gov//pdf/ms/rda/ research/4/80.pdf.

AuthorAffiliation
Barbara DiPietro, PhD, and Lisa Klingenmaier, MPH, MSW
AuthorAffiliation
About the Authors
Barbara DiPietro is with the National Health Care for the
Homeless Council, Nashville, TN, and Health Care for the
Homeless of Maryland, Baltimore. At the time of the study, Lisa
Klingenmaier was with Health Care for the Homeless of
Maryland.
Correspondence should be sent to Barbara DiPietro, PhD,
Health Care for the Homeless, 421 Fallsway, Baltimore, MD
21202 (e-mail: [email protected]). Reprints can be ordered at
http://www.ajph.org by clicking the "Reprints" link.
This commentary was accepted June 1, 2013.
Contributors
B. DiPietro provided overall direction and was the primary
author of and researcher for the article. L. Klingenmaier
provided secondary writing and research assistance. Both
authors contributed to the content and design of the final
article.
Acknowledgments
The authors would like to thank the National Health Care for
the Homeless Council as well as Health Care for the Homeless
of Maryland for their unswerving dedication to the needs of

people experiencing homelessness and commitment to
progressive public policies aimed at preventing and ending
homelessness.
Word count: 4159
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Copyright American Public Health Association Dec 2013
Indexing (details)
Cite
Subject
Health insurance;
Patient Protection & Affordable Care Act 2010-US;
Health care policy;
Public health;
Medicaid;
Uninsured people;
Expansion;
Health services;
Population;
Imprisonment;
Cost control;
Health facilities;
Patients;
Recidivism;
Patient safety
Location
United States--US
Company / organization
Name:
Health Care for the Homeless

NAICS:
621111
Title
Achieving Public Health Goals Through Medicaid Expansion:
Opportunities in Criminal Justice, Homelessness, and
Behavioral Health With the Patient Protection and Affordable
Care Act
Author
DiPietro, Barbara, PhD; Klingenmaier, Lisa, MPH, MSW
Publication title
American Journal of Public Health
Volume
103
Issue
2
Supplement
Supplement
Pages
E25-E29
Number of pages
5
Publication year
2013
Publication date
Dec 2013

Year
2013
Section
COMMENTARY
Publisher
American Public Health Association
Washington
United States
Publication subject
Public Health And Safety, Medical Sciences
ISSN
00900036
CODEN
AJPHDS
Source type
Scholarly Journals
English
Document type
Feature
Document feature
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Quiz 3 - The Rogerian Proposal " for ENGL102 B008 Win 14
The purpose of this proposal is to let me know your plan for the
Rogerian essay. Prior to completing this proposal, please make
sure to review the Rogerian assignment directions carefully.
These directions can be found in the classroom. The assignment
directions are also given below.
There is no time or submission limit for this proposal
assignment. Please take your time in completing this quiz.
The Rogerian assignment directions are as follows:
This essay should be between 900 and 1000 words. First, you
will choose a topic of interest that has two opposing sides.
Then, you need to research that topic in order to specify the

topic’s scope, so it can be easily discussed in a shorter, 1000
word essay.
The following overused topics may not be used in your essay:
gun control, abortion, capital punishment, gay marriage, gays in
the military, mandatory drug testing, euthanasia, childhood
obesity, women in the military, diets (including the Palio diet),
workout regiments (including CrossFit), underage drinking, and
the legalization of marijuana.
This essay must include a minimum of five sources. Three
should peer-reviewed sources preferably from the APUS
databases. You may use eBooks; however, as discussed earlier
this semester, books generally are not as current as peer-
reviewed articles. You may also use primary sources
(interviews, statistics, etc); however, these primary sources
should be obtained from experts within that field. If you cannot
find strong sources for your chosen topic, then change your
topic. If you have a question about the validity of a source,
please email me, or post your question to the open forum.
Make sure to include the following sections in your essay:
introduction and claim, background, body, and conclusion.
Within the body of your Rogerian essay, make sure to include
the following in any order: the background for your chosen

topic, the opposition, the strengths and weaknesses of your
opponents claim, scholarly research, your claim, discuss the
warrants for your claim and the opposition in order to find the
common ground, and show the common ground between your
opponents claim and your claim.
After you have written your essay, please make sure to revise
the content of your essay. Lastly, be sure to edit your essay by
checking grammar, format, and smaller technical details. Please
make sure your essay is written in third person.
Question 1 of 5
10.0 Points
Please state your proposed topic for the Rogerian essay and
briefly explain what the issue is with the topic. Please also state
your stance on this issue.
Question 2 of 5
10.0 Points
State your proposed thesis statement for this topic. Remember,
your thesis statement is a complete sentence.
Question 3 of 5
10.0 Points
List a peer-reviewed source that you plan to use in this essay.
You must show both an in-text and a works cited citation for
this source. *Note: To receive credit for this question, the
source must be peer-reviewed and correctly cited (a hanging

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