Expanding Medicaid coverage for adults also helps to cover children, according to a new study by researchers at Columbia University Mailman School of Public Health, the University of Chicago, and MIT. The study examined Oregon’s 2008 Medicaid lottery and found that for every nine adults who gained healthcare coverage, one additional child also enrolled. The research describes the impact of expanded adult Medicaid eligibility on the enrollment of already-eligible children.

The findings of the paper, “Out of the Woodwork: Enrollment Spillovers in the Oregon Health Insurance Experiment,” are published in the August 2022 issue of American Economic Journal: Economic Policy.

In the lottery, some low income uninsured adult enrollees were randomly selected to be allowed to apply for Medicaid. Winning or losing the lottery did not change whether their children were eligible for coverage. The researchers asked whether expanding eligibility for one group, adults, helped to bring another group, their children, into coverage. Prior studies have referred to this phenomenon as the “woodwork effect” or the “welcome mat effect”.

“Our study shows that expanding Medicaid eligibility can improve insurance coverage rates for people who weren’t even the target of the expansion,” said Adam Sacarny, PhD, the study’s first author and an assistant professor of health policy and management at Columbia Public Health. “In this case, when adults signed up for Medicaid, their children gained coverage, too.”

Medicaid provides health insurance coverage to 81 million people in the U.S., including 34 million children. About 7 percent of children who are eligible for Medicaid haven’t signed up for coverage and are still uninsured. The paper adds to the existing literature about the barriers to enrolling in health insurance and other social programs. It also sheds new light on the policies of the 2010 Affordable Care Act, which included an expansion Medicaid to cover low-income people. The researchers studied an earlier, randomized expansion of Medicaid for adults that took place in 2008 in Oregon.

“This research highlights the value of conducting further secondary studies of randomized trials,” said Sacarny. “When you link trials with additional administrative data, you can use them to study additional, potentially really important questions for economic and social policy.”
 
The study also provides a new perspective on the broader impacts of Medicaid coverage expansions. “We found evidence of these woodwork effects,” said co-author Amy Finkelstein, PhD, a professor in MIT’s Department of Economics. “We reject the hypothesis that these types of spillovers don’t occur. On the other hand, relative to claims in the media and in some previous work about potentially large woodwork effects, in excess of half of the direct effect, our effects are quantitatively much smaller than what was conjectured.”
 
While the researchers found meaningful woodwork effects, they also found that the effects were short-lived. They showed that children of lottery winners saw an immediate jump in coverage as their parents signed up, but children of lottery losers eventually gained coverage, too.

“Therefore, our results suggest that woodwork effects mainly to encourage earlier enrollment for children who would have otherwise gained coverage later,” observed Sacarny.
 
The results point to two reasons there is incomplete coverage among people who are eligible for Medicaid, according to Sacarny. First, Medicaid’s eligibility rules can be complicated and some families may not be aware of them. In this experiment, when adults “won” the opportunity for to enroll in Medicaid, they may have learned about their children’s eligibility. Second, applying for Medicaid can be burdensome: at the time in Oregon, the application packet was 46 pages long with up to 19 pages of fill-in prompts. However, since the application was for an entire household, an adult signing up could easily include their children. 

“Incomplete enrollment in social insurance programs is pervasive including in the Medicaid program,” said Sacarny. “The present study demonstrates the many ways that randomized trials, like Oregon’s, can be used to generate further findings. Given a valid experiment, scholars can think creatively about how to identify its effects, and keep leveraging that experiment to produce rigorous results.”

Katherine Baicker, professor and dean at the University of Chicago Harris School of Public Policy, is a co-author.

The study was supported by the National Institute on Aging.

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The Affordable Care Act (ACA) Medicaid expansion increased preconception and postpartum Medicaid coverage and led to significant declines in uninsurance and insurance churn, according to a study conducted at Columbia University Mailman School of Public Health. There was limited evidence, however, that Medicaid expansion increased perinatal health care use or improved infant birth outcomes overall. The findings are published in the January 2022 issue of the journal Health Affairs.

“In earlier research before the ACA, we found high rates of uninsurance among reproductive-aged women,” said Jamie Daw, PhD, Columbia Mailman School assistant professor of health policy and management, and senior author. “In addition, insurance churn—moving between insurance and uninsurance or switching insurers—was common around pregnancy, and high rates of coverage instability may have contributed to lower access to care and poorer maternal and child health outcomes. The result disproportionately impacted low-income people and members of racial and ethnic minority groups who qualify for pregnancy Medicaid coverage.”

Drawing on original, peer-reviewed quantitative research studies, Daw and colleagues systematically analyzed data published between January 2014 and April 2021. They examined the effect of the ACA state Medicaid expansions on insurance coverage, health care use, and health outcomes measured between one month prior to conception through one year postpartum, and neonatal outcomes within twenty-seven days of birth. The researchers identified 35 unique studies that met their screening criteria.

Increases in Medicaid coverage were greater during the preconception and postpartum periods than at delivery since pregnant people already qualified for Medicaid from conception to sixty days after birth before the ACA.

“Despite large coverage increases before and after pregnancy, we found limited evidence that the ACA Medicaid expansion improved overall perinatal health care use or health outcomes in the first few years after implementation,” noted Meghan Bellerose, ’21 MPH, a PhD student at Brown University School of Public Health and first author. “However, one study found that the ACA Medicaid expansion was associated with reduced racial disparities in birth outcomes such as preterm birth, and another found a reduction in overall maternal mortality. These results are promising and merit further exploration as the U.S. continues to pursue strategies to reduce racial disparities in maternal mortality and morbidity.”

“Our findings indicate that Medicaid expansion to low-income adults is a very effective approach to increase preconception and postpartum health insurance coverage,” said Daw. “Our ability to observe corresponding changes in health care use and outcomes is partly related to a lack of data collection on preconception and postpartum outcomes in the U.S.  Our results are highly relevant to the recent maternal healthcare call to action from the White House  and the postpartum Medicaid provisions within the Build Back Better Act, suggesting that these provisions will result in large coverage gains, but more data will be needed for rigorous evaluation of the impact of Medicaid policy changes on maternal health disparities.”
 
A co-author is Lauren Collin of Columbia Mailman School.

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