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Differential Rates of Medicaid Uptake for Hispanic English Speakers and Hispanic Spanish Speakers under the Affordable Care Act

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Abstract

One provision of the Affordable Care Act was Medicaid expansion, which increased eligibility in two ways: it raised the income threshold from 100 to 138% of the poverty line, and removed categorical restrictions, such as being a pregnant woman, to include all low-income adults. We capitalize on this policy change to determine if eligible Hispanics and Spanish speakers are more or less likely than their non-Hispanic and English-speaking counterparts to enroll in Medicaid. We use National Health Interview Survey data and apply a theoretical framework of social capital acquisition. We find that Hispanic Spanish speakers and Hispanic English speakers are about twice as likely to have Medicaid after the ACA expansion. However, Spanish speakers are about 75% as likely to have enrolled in Medicaid than their English-speaking counterparts post-ACA. In the NHIS sample, about 28% of Hispanic Spanish speakers have Medicaid. We see considerable evidence that Hispanics who have more social capital are much more likely to enroll in Medicaid. Even though the ACA expansion reduced the uninsured gap for Hispanics, there is still a noteworthy disparity in rates of insurance coverage.

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Notes

  1. In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act restricted Medicaid coverage to citizens and long-term permanent residents who have lived in the USA for at least 5 years, however there are exceptions for refugees, veterans, asylum-seeker, and victims of domestic violence and sex trafficking. (NCSL 2018). Although Medicaid is a state-run program, states have autonomy in the provision of benefits to immigrants.

  2. We also include the results of linear probability model and a plot of the predicted values of the LPM in Appendix 2. Looking at the plot, we see a bit over 10% of the predicted values fall below 0. As such, the LPM makes predictions that are non-sensible for a significant number of observations. Thus, the logit model in Eq. 1 provides a more reasonable specification to determine marginal effects.

  3. For a complete discussion, see Ai and Norton’s 2003 Economics Letters article.

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Acknowledgments

The authors gratefully acknowledge help and guidance from Peter VanderHart, James Bland, participants of the Midwest Economic Association meeting, and three anonymous referees.

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Authors and Affiliations

  1. Department of Economics, Bowling Green State University, Bowling Green, OH, 43403, USA

    Alice Abboud & Amanda C. Cook

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  1. Alice Abboud
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  2. Amanda C. Cook
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Correspondence to Amanda C. Cook.

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Appendices

Appendix 1

We calculate odds ratios in our results section in Tables 2, 3, 4, 5, 6, 7, 8, and 9. However, since in Eq. 3, we have both interaction terms and non-interacted terms of interest, one cannot simply look at exponentiated coefficients on a single variable to determine the correct odds ratios

$$ {\displaystyle \begin{array}{l}\mathrm{Has}\ {\mathrm{Medicaid}}_i\\ {}\kern5em ={\beta}_0+{\beta}_1 Hispani{c}_i+{\beta}_2 Hispani{c}_i\ast post+{\beta}_3 PostACA+{\beta}_4 languag{e}_i\\ {}\kern5em +{\beta}_5 languag{e}_i\ast post+{\beta}_6 Hispani{c}_i\ast languag{e}_i+{\beta}_7\ast Hispani{c}_i\\ {}\kern5em \ast languag{e}_i\ast post+{\gamma}_R+{\gamma}_P+{\varepsilon}_i\end{array}} $$
(3)

For each of the below calculations, we calculate the ratio of the probabilities of the two groups having Medicaid. For example, in Table 2, we calculate the probability of a Hispanic person pre-ACA having Medicaid, the probability of a Hispanic person post-ACA having Medicaid, and take the ratio of those two probabilities. The result is an odds ratio.

Table 2: Odds ratios of Hispanic English speaker having Medicaid pre- and post-ACA

$$ \frac{\hat{Y} \mid H=1,L=0,P=0}{\hat{Y} \mid H=1,L=0,P=1}=\frac{e^{\beta_0+{\beta}_H}}{e^{\beta_0+{\beta}_H+{\beta}_P+{\beta}_{\left\{ HP\right\}}}}=\frac{1}{e^{\beta_P+{\beta}_{\left\{ HP\right\}}}} $$

Table 3: Odds ratios of Hispanic Spanish speakers having Medicaid pre- and post-ACA

$$ \frac{\hat{Y} \mid H=1,P=0,L=1}{\hat{Y} \mid \kern0.5em H=1,P=1,L=1}=\kern0.5em \frac{1}{e^{\beta_P+{\beta}_{HP}+{\beta}_{LP} LP}} $$

Table 4: Odds ratios pre-ACA of a Hispanic English speaker to a non-Hispanic English speaker having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=0}{\hat{Y} \mid H=0,P=0}=\frac{e^{\beta_0+{\beta}_H}}{e^{\beta_0}}={e}^{\beta_H} $$

Table 5: Odds ratios post-ACA of a Hispanic English speaker to a non-Hispanic English speaker having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=1}{\hat{Y} \mid H=0,P=1}=\frac{e^{\beta_0+{\beta}_H+{\beta}_P+{\beta}_{HP}}}{e^{\beta_0+{\beta}_P}}={e}^{\beta_P+{\beta}_{HP}} $$

Table 6: Odds ratios pre-ACA of a Hispanic Spanish speaker to a non-Hispanic English speaker having Medicaid

$$ \frac{\hat{Y} \mid \kern0.5em H=1,P=0,L=1}{\hat{Y} \mid H=0,P=0,L=0}=\frac{e^{\beta_0+{\beta}_H+{\beta}_{HL}}}{e^{\beta_0}}={e}^{\beta_H+{\beta}_{HL}} $$

Table 7: Odds ratios post-ACA of a Hispanic Spanish speaker to a non-Hispanic English speaker having Medicaid

$$ \frac{\hat{Y} \mid \kern0.5em H=1,P=1,L=1}{\hat{Y} \mid \kern0.75em H=0,P=1,L=0}=\frac{e^{\beta_0+{\beta}_H+{\beta}_{HL}+{\beta}_P+{\beta}_{HL P}}}{e^{\beta_0+{\beta}_P}}={e}^{\beta_H+{\beta}_{HP}+{\beta}_{HL}+{\beta}_{HL P}} $$

Table 8: Odds ratios pre-ACA of a Hispanic Spanish speaker to a Hispanic English speaker having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=0,L=1}{\hat{Y} \mid H=1,P=0,L=0}=\frac{e^{\beta_0+{\beta}_h+{\beta}_{\left\{ HL\right\}}}}{e^{\beta_0+{\beta}_h}}={e}^{\beta_{\left\{ HL\right\}}} $$

Table 9: Odds ratios post-ACA of a Hispanic Spanish speaker to a Hispanic English speaker having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=1,L=1}{\hat{Y} \mid H=1,\kern0.5em P=1,L=0}=\frac{e^{\beta_0+{\beta}_P+{\beta}_H+{\beta}_{HP}+{\beta}_{HL P}}}{e^{\beta_0+{\beta}_P+{\beta}_H+{\beta}_{\left\{ HP\right\}}}}={e}^{\beta_{HL}+{\beta}_{HL P}} $$

For the enhanced measure of social capital involving neighborhood characteristics, responding that you agree, you trust (count on/are close with/help) your neighbors is coded as N (neighbor) = 1. In Eq. (4), we interact with the neighborhood dummy variables to determine if there is a differential effect of an increased social network on Medicaid uptake. Because of the numerous interaction terms, we again look at odds ratios.

$$ {\displaystyle \begin{array}{l} Has\ Medicai{d}_i\\ {}={\beta}_0+{\beta}_1 Hispani{c}_i+{\beta}_2 Hispani{c}_i\ast Post+{\beta}_3 PostACA+{\beta}_4 Languag{e}_i\\ {}+{\beta}_5 Languag{e}_i\ast Post+{\beta}_6 Hispani{c}_i\\ {}\ast Languag{e}_i+{\beta}_7 Hispani{c}_i\ast Languag{e}_i\ast Post+{\beta}_8 Hispani{c}_i\ast Neighbor+{\beta}_9 Hispani{c}_i\ast Post\\ {}\ast Neighbor+{\beta}_{10} PostACA\ast Neighbor+{\beta}_{11} Languag{e}_i\ast Neighbor\\ {}+{\beta}_{12} Languag{e}_i\ast Post\ast Neighbor+{\beta}_{13} Hispani{c}_i\ast Languag{e}_i\\ {}\ast Neighbor+{\beta}_{14}\ast Hispani{c}_i\ast Languag{e}_i\ast Post\ast Neighbor\\ {}+{\beta}_{15} Neighbo{r}_i+{\gamma}_R+{\gamma}_P+{\varepsilon}_i\end{array}} $$
(4)

Tables 10, 11, 12, and 13 each show the response to one of the neighborhood questions for 4 different groups. In each table, column (1) is the odds ratios post-ACA of a Hispanic Spanish speaker who trusts (counts on/is close with/helps) their neighbor to a Hispanic Spanish speaker who does not trust their neighbor having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=1,L=1\ N=1}{\hat{Y} \mid H=1,\kern0.5em P=1,L=1\ N=0}=\frac{e^{\beta_0+{\beta}_L+{\beta}_P+{\beta}_N+{\beta}_{LP}+{\beta}_H+{\beta}_{HP}+{\beta}_{HL}+{\beta}_{HN}+{\beta}_{HL P}+{\beta}_{LN}+{\beta}_{PN}+{\beta}_{LP N}+{\beta}_{HL N}+{\beta}_{HP N}+{\beta}_{HL P N}}}{e^{\beta_0+{\beta}_L+{\beta}_P+{\beta}_{LP}+{\beta}_H+{\beta}_{HP}+{\beta}_{HL}+{\beta}_{HL P}+{\beta}_{HN}}}={e}^{\beta_N+{\beta}_{PN}+{\beta}_{LN}+{\beta}_{HN}+{\beta}_{LP N}+{\beta}_{HP N}+{\beta}_{HL N}+{\beta}_{HL P N}} $$

Column (2) odds ratios post-ACA of a Hispanic Spanish speaker who trusts (counts on/is close with/helps) their neighbor to a non-Hispanic English speaker who trusts their neighbor having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=1,L=1\ N=1}{\hat{Y} \mid H=0,\kern0.5em P=1,L=0\ N=1}=\frac{e^{\beta_0+{\beta}_L+{\beta}_P+{\beta}_N+{\beta}_{LP}+{\beta}_H+{\beta}_{HP}+{\beta}_{HL}+{\beta}_{HN}+{\beta}_{HL P}+{\beta}_{LN}+{\beta}_{PN}+{\beta}_{LP N}+{\beta}_{HL N}+{\beta}_{HP N}+{\beta}_{HL P N}}}{e^{\beta_0+{\beta}_P+{\beta}_N+{\beta}_{NP}}}={e}^{\beta_L+{\beta}_{LP}+{\beta}_H+{\beta}_{HP}+{\beta}_{HL}+{\beta}_{HN}+{\beta}_{HL P}+{\beta}_{LN}+{\beta}_{LP N}+{\beta}_{HL N}+{\beta}_{HP N}+{\beta}_{HL P N}} $$

Column (3) odds ratios post-ACA of a Hispanic Spanish speaker who trusts (counts on/is close with/helps) their neighbor to a non-Hispanic Spanish speaker who does trust their neighbor having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=1,L=1\ N=1}{\hat{Y} \mid H=0,\kern0.5em P=1,L=1\ N=1}=\frac{e^{\beta_0+{\beta}_L+{\beta}_P+{\beta}_N+{\beta}_{LP}+{\beta}_H+{\beta}_{HP}+{\beta}_{HL}+{\beta}_{HN}+{\beta}_{HL P}+{\beta}_{LN}+{\beta}_{PN}+{\beta}_{LP N}+{\beta}_{HL N}+{\beta}_{HP N}+{\beta}_{HL P N}}}{e^{\beta_0+{\beta}_L+{\beta}_P+{\beta}_N+{\beta}_{LP}+{\beta}_{LN}+{\beta}_{PN}+{\beta}_{LP N}}}={e}^{\beta_H+{\beta}_{HN}+{\beta}_{HL}+{\beta}_{HP}+{\beta}_{HP N}+{\beta}_{HL N}+{\beta}_{HL P}+{\beta}_{HL P N}} $$

Column (4) odds ratios post-ACA of a Hispanic Spanish speaker who trusts (counts on/is close with/helps) their neighbor to a Hispanic English speaker who does trust their neighbor having Medicaid

$$ \frac{\hat{Y} \mid H=1,P=1,L=1\ N=1}{\hat{Y} \mid H=1,\kern0.5em P=1,L=0\ N=1}=\frac{e^{\beta_0+{\beta}_L+{\beta}_P+{\beta}_N+{\beta}_{LP}+{\beta}_H+{\beta}_{HP}+{\beta}_{HL}+{\beta}_{HN}+{\beta}_{HL P}+{\beta}_{LN}+{\beta}_{PN}+{\beta}_{LP N}+{\beta}_{HL N}+{\beta}_{HP N}+{\beta}_{HL P N}}}{e^{\beta_0+{\beta}_P+{\beta}_H+{\beta}_N+{\beta}_{HP}+{\beta}_{PN}+{\beta}_{HN}+{\beta}_{HP N}}}={e}^{\beta_L+{\beta}_{LP}+{\beta}_{HL}+{\beta}_{LP N}+{\beta}_{LN}+{\beta}_{LP N}+{\beta}_{HL P}+{\beta}_{HL P N}} $$

Tables 11, 12, 14 and 13 have the same 4 columns for each of the subsequent neighborhood characteristic questions.

Linear Probability Model

Table 14 Linear probability model of having Medicaid pre- and post-ACA
Full size table
Fig. 2
figure 2

Predicted values from the LPM. About 10% of the fitted values are below 0

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Summary Statistics for English and Spanish Hispanics

Table 15 Summary demographic statistics for Hispanic Spanish speakers and Hispanic English speakers
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Changes in Medicaid Enrollment by Region

What we observe in Table 16 is that there were substantial differences in Medicaid uptake by region. In the West, for example, the number of people in the sample on Medicaid increased dramatically, from 5078 to 8022. While the data does not have a more granular geographic identifier than region, California comprises a significant portion of the Western region. Similarly, there was limited expansion in the South, from 6814 to 7990 individuals covered by Medicaid. As Texas makes up a significant portion of the South region, it is reasonable to think the low increases were due to Texas not expanding income eligibility.

Table 16 Having Medicaid pre- and post-reform by region of residence
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Abboud, A., Cook, A.C. Differential Rates of Medicaid Uptake for Hispanic English Speakers and Hispanic Spanish Speakers under the Affordable Care Act. J Econ Race Policy 3, 159–174 (2020). https://doi.org/10.1007/s41996-019-00036-y

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