Silvia Helena Barcellos

Preparedness of Americans for the Affordable Care Act.

Significance The ultimate success of the Affordable Care Act (ACA) depends on how well the health insurance exchanges can bring the benefits of private competition to individuals in the form of lower premiums. Doing so requires that individuals, when shopping for health insurance, correctly weigh the benefits and costs of various insurance options. Our work suggests that the overall population, and even more so those most likely affected by the ACA, is not well equipped to do so. We documented low levels of ACA and health insurance knowledge in the month preceding the introduction of the exchanges. We propose that simplified options, decision aids, and health insurance product design to address the limited understanding of health insurance contracts will be crucial for ACA’s success. This paper investigates whether individuals are sufficiently informed to make reasonable choices in the health insurance exchanges established by the Affordable Care Act (ACA). We document knowledge of health reform, health insurance literacy, and expected changes in healthcare using a nationally representative survey of the US population in the 5 wk before the introduction of the exchanges, with special attention to subgroups most likely to be affected by the ACA. Results suggest that a substantial share of the population is unprepared to navigate the new exchanges. One-half of the respondents did not know about the exchanges, and 42% could not correctly describe a deductible. Those earning 100–250% of federal poverty level (FPL) correctly answered, on average, 4 out of 11 questions about health reform and 4.6 out of 7 questions about health insurance. This compares with 6.1 and 5.9 correct answers, respectively, for those in the top income category (400% of FPL or more). Even after controlling for potential confounders, a low-income person is 31% less likely to score above the median on ACA knowledge questions, and 54% less likely to score above the median on health insurance knowledge than a person in the top income category. Uninsured respondents scored lower on health insurance knowledge, but their knowledge of ACA is similar to the overall population. We propose that simplified options, decision aids, and health insurance product design to address the limited understanding of health insurance contracts will be crucial for ACA’s success.

Legalization and the Economic Status of Immigrants

This paper investigates the impact of legalization on the economic outcomes of the legalized population. It uses a natural experiment caused by the 1986 Immigration Reform and Control Act (IRCA) which gave amnesty for undocumented immigrants who could prove continuous residence in the U.S. after January 1, 1982. The arbitrary cutoff date on the eligibility criteria causes a discontinuity in the relationship between the year of immigration and the probability of being legal. This paper uses this discontinuity to identify the causal impacts of legalization on immigrants’ outcomes. Regression discontinuity and difference-in-differences estimates show that immigrants eligible for the policy have a significantly higher probability of being naturalized citizens than those who were not. Legalization is also found to have a positive and significant effect on wages, a negative effect on the probability of working in a traditionally illegal occupation, and no significant effect on geographical mobility. The analysis for different demographic groups confirms such conclusions and shows that the estimated effects of legalization are larger for low-educated Latin American immigrants, the group that was disproportionably affected by the policy.

Knowledge as a Predictor of Insurance Coverage Under the Affordable Care Act

Background: The Affordable Care Act established policy mechanisms to increase health insurance coverage in the United States. While insurance coverage has increased, 10%–15% of the US population remains uninsured. Objectives: To assess whether health insurance literacy and financial literacy predict being uninsured, covered by Medicaid, or covered by Marketplace insurance, holding demographic characteristics, attitudes toward risk, and political affiliation constant. Research Design: Analysis of longitudinal data from fall 2013 and spring 2015 including financial and health insurance literacy and key covariates collected in 2013. Subjects: A total of 2742 US residents ages 18–64, 525 uninsured in fall 2013, participating in the RAND American Life Panel, a nationally representative internet panel. Measures: Self-reported health insurance status and type as of spring 2015. Results: Among the uninsured in 2013, higher financial and health insurance literacy were associated with greater probability of being insured in 2015. For a typical uninsured individual in 2013, the probability of being insured in 2015 was 8.3 percentage points higher with high compared with low financial literacy, and 9.2 percentage points higher with high compared with low health insurance literacy. For the general population, those with high financial and health insurance literacy were more likely to obtain insurance through Medicaid or the Marketplaces compared with being uninsured. The magnitude of coefficients for these predictors was similar to that of commonly used demographic covariates. Conclusions: A lack of understanding about health insurance concepts and financial illiteracy predict who remains uninsured. Outreach and consumer-education programs should consider these characteristics.

Education can Reduce Health Disparities Related to Genetic Risk of Obesity: Evidence from a British Reform

This paper investigates whether genetic makeup moderates the effects of education on health. Low statistical power and endogenous measures of environment have been obstacles to the credible estimation of such gene-by-environment interactions. We overcome these obstacles by combining a natural experiment that generated variation in secondary education with polygenic scores for a quarter million individuals. The additional schooling affected body size, lung function, and blood pressure in middle age. The improvements in body size and lung function were larger for individuals with high genetic predisposition to obesity. As a result, education reduced the gap in unhealthy body size between those with high and low genetic risk of obesity from 20 to 6 percentage points.

Education can reduce health differences related to genetic risk of obesity

Significance Educational policies may increase or decrease health differences, depending on whether they reinforce or counteract gene-related differences. We investigate whether one such policy affected health differently for people with different genetic backgrounds. We find that the additional education generated by the policy benefited those with higher genetic risk of obesity the most, reducing the gap in unhealthy body size between those in the top and bottom terciles of genetic risk of obesity from 20 to 6 percentage points. Our results challenge the notion of genetic determinism and underscore the role that social policy can have in mitigating possible health differences arising from genetic background. This work investigates whether genetic makeup moderates the effects of education on health. Low statistical power and endogenous measures of environment have been obstacles to the credible estimation of such gene-by-environment interactions. We overcome these obstacles by combining a natural experiment that generated variation in secondary education with polygenic scores for a quarter-million individuals. The additional schooling affected body size, lung function, and blood pressure in middle age. The improvements in body size and lung function were larger for individuals with high genetic predisposition to obesity. As a result, education reduced the gap in unhealthy body size between those in the top and bottom terciles of genetic risk of obesity from 20 to 6 percentage points.