Asset Transfers among those Accessing the Medicaid Program: Are Wealthy Older Adults Gaming the System?

Medicaid is the largest payer of long-term services and supports and millions of older Americans rely on the means-tested program for health care coverage. There has been longstanding concern that wealthy older adults are taking advantage of the program by divesting assets in order to qualify for coverage. The existing research on the issue is somewhat dated, does not focus on the question of asset transfer, and often lacks a significant longitudinal view. Thus, questions remain about whether states need to tighten asset eligibility rules to prevent the wealthier older adults from accessing the program. This analysis explores longitudinal data from the Health and Retirement Study (1998 to 2016) to determine the extent to which wealthier Americans age 50 and older engage in asset transfer to access Medicaid. Our findings demonstrate that this may occur among a relatively small proportion of wealthy older adults, and that tightening Medicaid eligibility criteria would likely have a small to modest impact on the financial status of the program.

The Line Between Medicaid and Marketplace: Coverage Effects from Wisconsin’s Partial Expansion

Context: States have sought to experiment with the income eligibility threshold between Medicaid coverage and access to subsidized Marketplace plans in an effort to increase coverage for low-income adults while meeting other state priorities, particularly a balanced budget. In 2014, Wisconsin opted against adoption of an ACA Medicaid expansion, instead setting the Medicaid eligibility threshold at 100% of the poverty level—a state-funded partial expansion. Childless adults gained new eligibility, while parents and caregivers with incomes between 101–200% of poverty lost existing eligibility. Methods: We use Wisconsin’s all-payer claims database to assess health insurance gains, losses, and transitions among low-income adults affected by this partial expansion. Findings: We find that less than one third of adults who lost Medicaid eligibility definitely took up commercial coverage, and many returned to Medicaid. Among those newly Medicaid eligible, there was little evidence of crowd-out. Both groups experienced limited continuity of coverage. Overall, new Medicaid enrollment of childless adults was offset by coverage losses among parents and caregivers, rendering Wisconsin’s overall coverage gains similar to non-expansion states. Conclusions: Wisconsin’s experience demonstrates the difficulty in relying on the Marketplace to cover the near poor and suggests that full Medicaid expansion more effectively increases coverage.

The Long-Run Effects of Childhood Insurance Coverage: Medicaid Implementation, Adult Health, and Labor Market Outcomes

This paper estimates the long-run effects of childhood Medicaid eligibility on adult health and economic outcomes using the program’s original introduction ( 1966–1970) and its mandated coverage of welfare recipients. The design compares cohorts born in different years relative to Medicaid implementation, in states with different preexisting welfare-based eligibility. Early childhood Medicaid eligibility reduces mortality and disability, increases employment, and reduces receipt of disability transfer programs up to 50 years later. Medicaid has saved the government more than its original cost and saved more than 10 million quality adjusted life years. (JEL H51, I12, I18, I32, I38, J13)

Medicaid Expansion and Medical Debt: Evidence From Louisiana, 2014–2019

Objectives. To identify the association between Medicaid eligibility expansion and medical debt. Methods. We used difference-in-differences design to compare changes in medical debt for those gaining coverage through Louisiana’s Medicaid expansion with those in nonexpansion states. We matched individuals gaining Medicaid coverage because of Louisiana’s Medicaid expansion (n=196 556) to credit report data on medical debt and compared them with randomly selected credit reports of those living in Southern nonexpansion state zip codes with high rates of uninsurance (n=973 674). The study spanned July 2014 through July 2019. Results. One year after Louisiana Medicaid expansion, medical collections briefly rose before declining by 8.1 percentage points (95% confidence interval [CI]=–0.107, –0.055; P≤.001), or 13.5%, by the third postexpansion year. Balances also briefly rose before falling by 0.621 log points (95% CI=–0.817, –0.426; P≤.001), or 46.3%. Conclusions. Louisiana’s Medicaid expansion was associated with a reduction in the medical debt load for those gaining coverage. These results suggest that future Medicaid eligibility expansions may be associated with similar improvements in the financial well-being of enrollees. (Am J Public Health. Published online ahead of print July 2, 2021: e1–e7. https://doi.org/10.2105/AJPH.2021.306316 )