Fee for service
When the Cost Curve Bent - Pre-Recession Moderation in Health Care Spending
Charles Roehrig et al.
New England Journal of Medicine, forthcoming
"Our analysis of monthly data on health care spending shows that the moderation in growth began well before the recession and has continued through May 2012 ... Excess growth decreased from more than 3% during 2003 to less than 1% starting in July 2005 and continuing, for the most part, until near the end of the recession in June 2009. Excess growth exceeded 1% during the post-recession period, until May 2011, when it again dropped below 1%, going negative during the latter part of that year."
----------------------
Leemore Dafny & Subramaniam Ramanarayanan
NBER Working Paper, August 2012
Abstract:
The majority of private health insurance in the U.S. is administered or issued by for-profit insurers, but little is known about how for-profit status affects outcomes. We find that plausibly exogenous increases in local for-profit market share induced by conversions of Blue Cross and Blue Shield affiliates in 11 states (and 28 distinct geographic markets) had no significant impact on average premiums, uninsurance rates, or medical loss ratios. However, we do find significant increases in Medicaid enrollment and a reallocation of medical spending toward rivals of BCBS. Moreover, in markets where the converting BCBS affiliate had substantial market share, fully-insured premiums for employer plans increased significantly. The results suggest that the welfare effects of subsidies for new not-for-profit insurers, such as those in the Affordable Care Act, are likely to depend on entrants' eventual market share.
----------------------
Karen Davis et al.
Health Affairs, August 2012, Pages 1866-1875
Abstract:
The experiences of people covered by Medicare and those with private employer insurance can help inform policy debates over the federal budget deficit, Medicare's affordability, and the expansion of private health insurance under the Affordable Care Act. This article provides evidence that people with employer-sponsored coverage were more likely than Medicare beneficiaries to forgo needed care, experience access problems due to cost, encounter medical bill problems, and be less satisfied with their coverage. Within the subset of beneficiaries who are age sixty-five or older, those enrolled in the private Medicare Advantage program were less likely than those in traditional Medicare to have premiums and out-of-pocket costs exceed 10 percent of their income. But they were also more likely than those in traditional Medicare to rate their insurance poorly and to report cost-related access problems. These results suggest that policy options to shift Medicare beneficiaries into private insurance would need to be attentive to potentially negative insurance experiences, problems obtaining needed care, and difficulties paying medical bills.
----------------------
Mandatory insurance coverage and hospital productivity in Massachusetts: Bending the curve?
Mark Thompson, Timothy Huerta & Eric Ford
Health Care Management Review, forthcoming
Objective: The aim of this study was to examine whether universal insurance coverage mandates lead to a more productive use of hospital resources.
Data Sources: The American Hospital Association's Annual Survey and the Centers for Medicare and Medicaid Services' case mix index for fiscal years 2005 through 2008 were used.
Study Design: A Malmquist approach was used to assess hospitals' productivity in the United States and Massachusetts over the sample period. Propensity score matching is used to "simulate" a randomized control group of hospitals from other markets to compare with Massachusetts. Comparisons are then made to examine if productivity differences are due to universal health insurance coverage mandate.
Principal Findings: In the early stages, Massachusetts' coverage mandates lead to a significant drop in hospitals' productivity relative to comparable facilities in other states. In 2008, Massachusetts functioned 3.53% below its 2005 level, whereas facilities across the United States have seen a 4.06% increase over the same period.
Conclusions: If the individual mandate is implemented nationwide, the Massachusetts' experience indicates that a near-term decrease in overall hospital productivity will occur. As such, current cost estimates of the Patient Protection and Affordable Care Act's impact on overall health spending are potentially understated.
----------------------
Pharmaceutical Innovation and Longevity Growth in 30 Developing and High-income Countries, 2000-2009
Frank Lichtenberg
NBER Working Paper, July 2012
Abstract:
We examine the impact of pharmaceutical innovation, as measured by the vintage of prescription drugs used, on longevity, using longitudinal, country-level data on 30 developing and high-income countries during the period 2000-2009. We control for fixed country and year effects, real per capita income, the unemployment rate, mean years of schooling, the urbanization rate, real per capita health expenditure (public and private), the DPT immunization rate, HIV prevalence and tuberculosis incidence. Life expectancy at all ages and survival rates above age 25 increased faster in countries with larger increases in drug vintage. The increase in drug vintage was the only variable that was significantly related to all of these measures of longevity growth. Controlling for all of the other potential determinants of longevity did not reduce the vintage coefficient by more than 20%. Pharmaceutical innovation is estimated to have accounted for almost three-fourths of the 1.74-year increase in life expectancy at birth in the 30 countries in our sample between 2000 and 2009, and for about one third of the 9.1-year difference in life expectancy at birth in 2009 between the top 5 countries (ranked by drug vintage in 2009) and the bottom 5 countries (ranked by the same criterion).
----------------------
Mortality and Access to Care among Adults after State Medicaid Expansions
Benjamin Sommers, Katherine Baicker & Arnold Epstein
New England Journal of Medicine, forthcoming
Background: Several states have expanded Medicaid eligibility for adults in the past decade, and the Affordable Care Act allows states to expand Medicaid dramatically in 2014. Yet the effect of such changes on adults' health remains unclear. We examined whether Medicaid expansions were associated with changes in mortality and other health-related measures.
Methods: We compared three states that substantially expanded adult Medicaid eligibility since 2000 (New York, Maine, and Arizona) with neighboring states without expansions. The sample consisted of adults between the ages of 20 and 64 years who were observed 5 years before and after the expansions, from 1997 through 2007. The primary outcome was all-cause county-level mortality among 68,012 year- and county-specific observations in the Compressed Mortality File of the Centers for Disease Control and Prevention. Secondary outcomes were rates of insurance coverage, delayed care because of costs, and self-reported health among 169,124 persons in the Current Population Survey and 192,148 persons in the Behavioral Risk Factor Surveillance System.
Results: Medicaid expansions were associated with a significant reduction in adjusted all-cause mortality (by 19.6 deaths per 100,000 adults, for a relative reduction of 6.1%; P=0.001). Mortality reductions were greatest among older adults, nonwhites, and residents of poorer counties. Expansions increased Medicaid coverage (by 2.2 percentage points, for a relative increase of 24.7%; P=0.01), decreased rates of uninsurance (by 3.2 percentage points, for a relative reduction of 14.7%; P<0.001), decreased rates of delayed care because of costs (by 2.9 percentage points, for a relative reduction of 21.3%; P=0.002), and increased rates of self-reported health status of "excellent" or "very good" (by 2.2 percentage points, for a relative increase of 3.4%; P=0.04).
Conclusions: State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.
----------------------
Derek Ng et al.
Journal of General Internal Medicine, forthcoming
Background: It is unclear how lack of health insurance or otherwise being underinsured contributes to observed racial disparities in health outcomes related to cardiovascular disease.
Objective: To determine the relative risk of death associated with insurance and race after hospital admission for an acute cardiovascular event.
Design: Prospective cohort study in three hospitals in Maryland representing different demographics between 1993 and 2007.
Patients: Patients with an incident admission who were either white or black, and had either private insurance, state-based insurance or were uninsured. 4,908 patients were diagnosed with acute myocardial infarction, 6,759 with coronary atherosclerosis, and 1,293 with stroke.
Main Measures: Demographic and clinical patient-level data were collected from an administrative billing database and neighborhood household income was collected from the 2000 US Census. The outcome of all-cause mortality was collected from the Social Security Death Master File.
Key Results: In an analysis adjusted for race, disease severity, location, neighborhood household income among other confounders, being underinsured was associated with an increased risk of death after myocardial infarction (relative hazard, 1.31 [95 % CI: 1.09, 1.59]), coronary atherosclerosis (relative hazard, 1.50 [95 % CI: 1.26, 1.80]) or stroke (relative hazard, 1.25 [95 % CI: 0.91, 1.72]). Black race was not associated with an increased risk of death after myocardial infarction (relative hazard, 1.03 [95 % CI: 0.85, 1.24]), or after stroke (relative hazard, 1.18 [95 % CI: 0.86, 1.61]) and was associated with a decreased risk of death after coronary atherosclerosis (relative hazard, 0.82 [95 % CI: 0.69, 0.98]).
Conclusions: Race was not associated with an increased risk of death, before or after adjustment. Being underinsured was strongly associated with death among those admitted with myocardial infarction, or a coronary atherosclerosis event. Our results support growing evidence implicating insurance status and socioeconomic factors as important drivers of health disparities, and potentially racial disparities.
----------------------
Stacey Fedewa et al.
American Journal of Public Health, September 2012, Pages 1782-1790
Objectives: We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years.
Methods: We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs).
Results: The proportion of late-stage disease increased with age: from 16.53% (21-34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients.
Conclusions: Screening should be encouraged for women at high risk for advanced-stage disease.
----------------------
Does Seeing the Doctor More Often Keep You Out of the Hospital?
Robert Kaestner & Anthony Lo Sasso
NBER Working Paper, July 2012
Abstract:
By exploiting a unique health insurance benefit design, we provide novel evidence on the causal association between outpatient and inpatient care. Our results indicate that greater outpatient spending was associated with more hospital admissions: a $100 increase in outpatient spending was associated with a 2.7% increase in the probability of having an inpatient event and a 4.6% increase in inpatient spending among enrollees in our sample. Moreover, we present evidence that the increase in hospital admissions associated with greater outpatient spending was for conditions in which it is plausible to argue that the physician and patient could exercise discretion.
----------------------
Joseph Ross et al.
Health Affairs, August 2012, Pages 1739-1748
Abstract:
Safety-net hospitals, which include urban hospitals serving large numbers of low-income, uninsured, and otherwise vulnerable populations, have historically faced greater financial strains than hospitals that serve more affluent populations. These strains can affect hospitals' quality of care, perhaps resulting in worse outcomes that are commonly used as indicators of care quality - mortality and readmission rates. We compared risk-standardized rates of both of these clinical outcomes among fee-for-service Medicare beneficiaries admitted for acute myocardial infarction, heart failure, or pneumonia. These beneficiaries were admitted to urban hospitals within Metropolitan Statistical Areas that contained at least one safety-net and at least one non-safety-net hospital. We found that outcomes varied across the urban areas for both safety-net and non-safety-net hospitals for all three conditions. However, mortality and readmission rates were broadly similar, with non-safety-net hospitals outperforming safety-net hospitals on average by less than one percentage point across most conditions. For heart failure mortality, there was no difference between safety-net and non-safety-net hospitals. These findings suggest that safety-net hospitals are performing better than many would have expected.
----------------------
Reforming the Tax Preference for Employer Health Insurance
Joseph Bankman et al.
Tax Policy and the Economy, 2012, Pages 43-58
Abstract:
The tax preference for employer-sponsored health insurance contributes to the very high level of health spending in the United States. In this paper, we consider the consequences for spending of one approach to reducing this preference: giving people with health insurance an additional deduction for their expected out-of-pocket spending, that is, an additional deduction that declines as the actuarial value of their insurance rises. We show that this approach would reduce health spending more and have a smaller budget cost than the deduction for actual out-of-pocket spending analyzed by Cogan, Hubbard, and Kessler by encouraging a shift to higher-copayment health insurance. We estimate that a deduction for expected out-of-pocket expenses would reduce private health spending by $86 billion in 2010 at a budget cost of approximately $5 billion. We conclude that, under reasonable assumptions about consumers' valuation of this incremental spending and the cost of public funds, such a deduction would be welfare improving.
----------------------
Andrew Rettenmaier
Journal of Public Economics, October 2012, Pages 760-772
Abstract:
The absence of individual level data linking earnings histories to the receipt of Medicare benefits has hampered the study of the program's distributional properties. Data developed by the Social Security Administration for an early cohort of Medicare beneficiaries includes both earnings records and Medicare payment records and thus overcomes this limitation. For this early cohort, lifetime benefits and taxes are found to rise with lifetime earnings, but taxes rise more rapidly resulting in redistribution from higher to lower earning beneficiaries. Lifetime benefits in the top decile of the earnings distribution are 19% higher than in the bottom decile, but taxes and premiums are four times higher in the top than in the bottom decile. Once taxes and premiums are subtracted, net benefits in the top decile are 79% of net benefits in the bottom decile.
----------------------
Defensive Medicine and Obstetric Practices
Michael Frakes
Journal of Empirical Legal Studies, September 2012, Pages 457-481
Abstract:
Using data on physician behavior from the 1979-2005 National Hospital Discharge Surveys (NHDS), I estimate the relationship between malpractice pressure, as identified by the adoption of noneconomic damage caps and related tort reforms, and certain decisions faced by obstetricians during the delivery of a child. The NHDS data, supplemented with restricted geographic identifiers, provides inpatient discharge records from a broad enough span of states and covering a long enough period of time to allow for a defensive medicine analysis that draws on an extensive set of variations in relevant tort laws. Contrary to the conventional wisdom, I find no evidence to support the claim that malpractice pressure induces physicians to perform a substantially greater number of cesarean sections. Extending this analysis to certain additional measures, however, I do find some evidence consistent with positive defensive behavior among obstetricians. For instance, I estimate that the adoption of a noneconomic damage cap is associated with a reduction in the utilization of episiotomies during vaginal deliveries, without a corresponding change in observed neonatal outcomes.
----------------------
How Tort Reform Affects Insurance Markets
Martin Grace & Tyler Leverty
Journal of Law, Economics, and Organization, forthcoming
Abstract:
The impact of a statute that is currently in effect depends on expectations about its future constitutionality. We investigate the effect of tort reform by segmenting reforms into those that are eventually declared unconstitutional (temporary) and those that are unchallenged or upheld (permanent). We find permanent tort reforms lower medical malpractice insurance losses and premiums and increase insurer profitability. In contrast, the effects of temporary reforms are never statistically significant. Measures that combine temporary and permanent reforms, the norm in the literature, significantly misestimate the impact of tort reform. Our results suggest that examining the effect of a current law without accounting for its future treatment produces misleading results.
----------------------
Zirui Song et al.
Health Affairs, August 2012, Pages 1885-1894
Abstract:
Seven provider organizations in Massachusetts entered the Blue Cross Blue Shield Alternative Quality Contract in 2009, followed by four more organizations in 2010. This contract, based on a global budget and pay-for-performance for achieving certain quality benchmarks, places providers at risk for excessive spending and rewards them for quality, similar to the new Pioneer Accountable Care Organizations in Medicare. We analyzed changes in spending and quality associated with the Alternative Quality Contract and found that the rate of increase in spending slowed compared to control groups, more so in the second year than in the first. Overall, participation in the contract over two years led to savings of 2.8 percent (1.9 percent in year 1 and 3.3 percent in year 2) compared to spending in nonparticipating groups. Savings were accounted for by lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees, as well as reduced utilization among some groups. Quality of care also improved compared to control organizations, with chronic care management, adult preventive care, and pediatric care within the contracting groups improving more in year 2 than in year 1. These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care.
----------------------
Lenny López & Ashish Jha
Health Services Research, forthcoming
Objective: Hospital care for blacks is concentrated among a small number of hospitals and whether they have worse outcomes across common medical conditions is unknown.
Data Source: We used the 2007 100% Medicare file to calculate 30- and 90-day mortality rates for white and black patients admitted for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia.
Study Design: We ranked all hospitals in the country by their proportion of discharged black patients and identified the top 10 percent of these hospitals as black serving. We examined race-specific adjusted mortality rates and adjusted for differences in hospital characteristics.
Principal Findings: At 30 days, black-serving hospitals had, compared with nonblack-serving hospitals, similar mortality for AMI, lower mortality for CHF, and higher mortality for pneumonia. At 90 days, mortality was higher at black-serving hospitals for both AMI and pneumonia and comparable for CHF compared with nonblack-serving hospitals. White patients had worse outcomes at black-serving hospitals for two conditions at 30 days and all three conditions at 90 days. Blacks also had worse outcomes at black-serving hospitals.
Conclusions: Hospitals with a high proportion of black patients had worse outcomes than other hospitals for both their white and black elderly patients.
----------------------
Yaa Akosa Antwi, Asako Moriya & Kosali Simon
NBER Working Paper, June 2012
Abstract:
We study the impact of the recent Affordable Care Act (ACA) provision that required private health insurers to allow older child dependents to stay on parental policies until age 26 using data from the Survey of Income Program Participation (SIPP) spanning August 2008 to November 2011. By comparing outcomes for targeted young adults aged 19-25 to those who are slightly older and slightly younger, before and after the law, we find the ACA substantially reduced uninsurance among young adults. Young adults were 30 percent more likely to be on their parents' employer policies on average after the staggered implementation commenced in September 2010, compared to before the enactment of the law. This increase in dependent coverage drew from both the uninsured and the otherwise insured. We also find evidence consistent with greater take-up among those with higher marginal benefits and lower marginal costs of obtaining dependent coverage, such as those whose parents already had family employer health insurance policies prior to the law. Dependent coverage increases are also greater for Whites relative to non-Whites, for single individuals relative to married individuals, and for non-students relative to students. We find no statistically significant difference in the impact of the provision on young adults who reside in states with and without some form of prior state dependent coverage mandate.
----------------------
The Effect of Medicaid Eligibility on Coverage, Utilization, and Children's Health
Dolores De La Mata
Health Economics, September 2012, Pages 1061-1079
Abstract:
I estimate the causal impact of Medicaid eligibility on take up, private health insurance coverage, healthcare utilization, and children's health by using a regression discontinuity design. In contrast to a standard regression discontinuity design, identification exploits multiple thresholds that arise from variation across states in income eligibility rules. Using data from the Panel Study of Income Dynamics and its Child Development Study supplement, I find that Medicaid eligibility increases take up by 10-13 percentage points on average, rising to 24-29 percentage points at lower income eligibility thresholds. There are significant crowding out effects of the same magnitude as those on take up rates. Medicaid eligibility increases the use of preventive health care by 11-14 percentage points but only at low income thresholds. Finally, I find that Medicaid eligibility has no significant effects on health outcomes in the short and medium run.
----------------------
David Lee & Frank Levy
Health Affairs, August 2012, Pages 1876-1884
Abstract:
The growth in the use of advanced imaging for Medicare beneficiaries decelerated in 2006 and 2007, ending a decade of growth that had exceeded 6 percent annually. The slowdown raises three questions. Did the slowdown in growth of imaging under Medicare persist and extend to the non-Medicare insured? What factors caused the slowdown? Was the slowdown good or bad for patients? Using claims file data and interviews with health care professionals, we found that the growth of imaging use among both Medicare beneficiaries and the non-Medicare insured slowed to 1-3 percent per year through 2009. One by-product of this deceleration in imaging growth was a weaker market for radiologists, who until recently could demand top salaries. The expansion of prior authorization, increased cost sharing, and other policies appear to have contributed to the slowdown. A meaningful fraction of the reduction in use involved imaging studies previously identified as having unproven medical value. What has occurred in the imaging field suggests incentive-based cost control measures can be a useful complement to comparative effectiveness research when a procedure's ultimate clinical benefit is uncertain.
----------------------
Dhaval Dave & Jose Fernandez
NBER Working Paper, July 2012
Abstract:
Autism is a developmental disorder characterized by impairments in social interaction, communication, and restricted or repetitive behaviors. This previously rare condition has dramatically increased in prevalence from 0.5 in 1000 children during the 1970s to 11.3 in 1000 children in 2008. Using data from the California Department of Developmental Services, we study how changes in the number of autism cases at each of the 21 regional development centers affected local wages and quantity of auxiliary health providers. We focus on this subset of health providers because, unlike physicians and psychologists who can diagnose autism, these workers cannot induce their own demand. If the incidence of autism is increasing independently of other mental disorders, then the demand for auxiliary health providers should increase, leading to higher wages and an increase in the number of these providers over time, else the increase in autism diagnosis is merely displacing other mental disorders. Using wages and provider counts from the American Community Survey, we find a 100% increase in the number of autism cases increases the wage of auxiliary health workers over non-autism health occupations by 8 to 11 percent and the number of providers by 7 to 15 percent the following year. Further, we find that four additional autism cases reduces the number of mild mental retardation cases by one, but is not found to have a statistically significant effect on the level of cerebral palsy or epilepsy.
----------------------
Hyungsoo Kim, Wonah Yoon & Karen Zurlo
Journal of Consumer Affairs, forthcoming
Abstract:
We examine two important issues related to health and financial burden in middle-aged and older Americans: (1) whether or not new health events affect a consumer's unsecured debt, and (2) to what extent the associated out-of-pocket medical expenses (OOP) contribute to unsecured debt. We use six biennial waves (1998, 2000, 2002, 2004, 2006 and 2008) from the Health and Retirement Study (HRS). We estimated fixed effects models and conducted mediation analyses. We find that new health events affect the accumulation of unsecured debt. Our estimates suggest that new health events increase unsecured debt by 6.3% ($230) to 9.3 % ($339); approximately 20% of the increase in unsecured consumer debt comes from OOP when experiencing new health events. New severe health events increase debt for the 50-64 age group, but do not increase it for the 65+ group.
----------------------
Sandra Decker
Health Affairs, August 2012, Pages 1673-1679
Abstract:
When fully implemented, the Affordable Care Act will expand the number of people with health insurance. This raises questions about the capacity of the health care workforce to meet increased demand. I used data on office-based physicians from the 2011 National Ambulatory Medical Care Survey Electronic Medical Records Supplement to summarize the percentage of physicians currently accepting any new patients. Although 96 percent of physicians accepted new patients in 2011, rates varied by payment source: 31 percent of physicians were unwilling to accept any new Medicaid patients; 17 percent would not accept new Medicare patients; and 18 percent of physicians would not accept new privately insured patients. Physicians in smaller practices and those in metropolitan areas were less likely than others to accept new Medicaid patients. Higher state Medicaid-to-Medicare fee ratios were correlated with greater acceptance of new Medicaid patients. The findings serve as a useful baseline from which to measure the anticipated impact of Affordable Care Act provisions that could boost Medicaid payment rates to primary care physicians in some states while increasing the number of people with health care coverage.
----------------------
Joel Cantor et al.
NBER Working Paper, July 2012
Abstract:
This paper evaluates one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA) which permits young adults up to age 26 to enroll as dependents on a parent's private health plan. The paper also considers how the interaction between prior state laws expanding dependent coverage to young adults and the ACA affected young adult coverage. Using data from the Current Population Survey for calendar years 2004-2010, we apply a difference-in-differences framework to estimate how these provisions affected coverage of eligible young adults compared to slightly older adults. Our findings indicate that controlling for state laws, early implementation of the ACA increased young adult dependent coverage by 5.3 percentage points and resulted in a 3.5 percentage point decline in their uninsured rate. The interaction between state laws and the ACA suggests that the increase in dependent coverage and decline in the uninsured rate may have been greater among young adults who were targeted by both the ACA and state laws.
----------------------
Stephen Patrick, Hwajung Choi & Matthew Davis
Health Affairs, August 2012, Pages 1796-1802
Abstract:
As the number of children living in poverty has increased steadily over the past decade, Medicaid and the Children's Health Insurance Program (CHIP) have enrolled millions of additional youths. Federal and state governments jointly finance both programs, with the federal portion determined by the Federal Medical Assistance Percentage, commonly known as the "federal match." The federal government has used intermittent increases in the federal match as a way to provide fiscal relief to states during economic downturns. The most recent broad increase ended in June 2011, but the precise impact on Medicaid and CHIP enrollment for children is not known. No previous study has evaluated the association of the federal match with children's enrollment in state Medicaid or CHIP programs in the context of other state factors. To shed light on the degree to which public coverage for children varies with differences in the federal match, we examined publicly available data from all fifty states from 1999 to 2009. We found that a ten-percentage-point increase in the federal match was associated with a 1.9 percent increase in Medicaid and CHIP enrollment, equivalent to approximately 500,000 children. This association persisted when adjusted for multiple state-level factors, including the proportion of children living in poverty. This analysis underscores the central role of the federal match in supporting expansion of Medicaid and CHIP coverage for children.