Project & Presidential Awards: The Social, Economic, and Political Effects of the Affordable Care Act
This initiative is carried out in collaboration with and support from the Robert Wood Johnson Foundation.
The Affordable Care Act (ACA) of 2010 represents the most significant reform of the U.S. health care system in decades. It was enacted with the goals of increasing access to health insurance, enhancing the quality of care and moderating the growth in costs. The new law is likely to have far reaching effects, beyond the way health insurance markets operate and beyond its impact on population health outcomes. It is those other effects of the ACA that we seek to understand.
This Russell Sage Foundation initiative will support innovative social science research on the social, economic and political effects of the Affordable Care Act. We are especially interested in funding analyses that address important questions about the effects of the reform on outcomes such as financial security and family economic well-being, labor supply and demand, participation in other public programs, family and children’s outcomes, and differential effects by age, race, ethnicity, nativity, or disability status. We are also interested in research that examines the political effects of the implementation of the new law, including changes in views about government, support for future government policy changes, or the impact on policy development outside of health care. Funding is available for secondary analysis of data or for original data collection. We welcome projects that propose novel uses of existing data, as well as projects that propose to analyze newly available or underutilized data. We will not fund research on the effects of the ACA on health care delivery or health outcomes (e.g., barriers to implementation, changes in the quality of care and health status, or trends in enrollment and affordability); other funders already do that.
Examples of the kinds of topics and questions that are of interest include, but are not limited to, the following:
Financial Security and Family Economic Well-Being
The Affordable Care Act represents a significant transfer of resources to low and moderate income families, in the form of subsidized health insurance. In theory, this transfer should increase total resources for target households while reducing their exposure to the financial risks associated with high medical bills. Is there evidence that the coverage expansion reduces risk and improves material well-being among low and moderate-income families? Do these effects translate into improved credit scores, a reduction in material hardships or even a reduction in bankruptcy rates? Do increased coverage and new subsidies for previously insured families reduce their need for precautionary savings? Do the subsidies free up financial resources for other purposes, such as greater investments in child care or education or retirement savings?
Labor Market Outcomes
Given the links between health insurance and employment, the ACA may have significant effects on both labor supply and labor demand. Does the increased availability of affordable individually purchased insurance alleviate various forms of “job-lock”? Specifically, does the reform lead to an increase in early retirement or a shift toward voluntary part-time work? Does the ACA increase self-employment and entrepreneurship? How does the availability of coverage as a dependent until age 26 affect the labor market decisions of young adults? Do the implicit tax rates associated with means-tested subsidies reduce the labor supply of lower income workers? Does the availability of insurance increase the average duration of family leave tied either to the birth of a child or the illness of other family members?
On the demand side of the market, larger firms will be subject to penalties if they do not provide affordable coverage to all employees who work more than 30 hours per week. To what extent do employers shift low-wage workers to part-time schedules to avoid these penalties? Does the employer mandate cause firms to make less use of such workers altogether? Do workers who gain employer-sponsored insurance implicitly pay for this new coverage through reduced wages or reduced total compensation? Is there a shift to smaller enterprises to avoid the penalty that the law imposes on large firms that do not provide insurance? Do employers thin out their insurance offerings (for example, move to insurance plans with greater employee cost-sharing) to hold down costs or to avoid the “Cadillac tax” on high cost plans? Do employers cease to offer insurance coverage for dependents? Does the Cadillac tax change patterns of collective bargaining by private- or public-sector unions?
Public Program Participation
The ACA’s Medicaid expansion not only extends coverage to low-income adults who were previously ineligible, but will likely also increase coverage among people who were already eligible for Medicaid but were not enrolled. Will outreach efforts aimed at enrolling people in Medicaid lead to an increase in enrollment for other means-tested programs such as the Supplemental Nutrition Assistance Program or the Earned Income Tax Credit? How does the availability of Medicaid or subsidized private health insurance affect applications for the Social Security Disability (SSDI) program or Supplemental Security Income (SSI)?
How does it affect the likelihood that individuals on SSDI or SSI will leave these programs since they will now be able to obtain coverage without remaining on one of these programs? Will the availability of insurance coverage increase labor supply among those eligible for these programs?
Family and Children’s Outcomes
Given the potentially large impact of the ACA’s coverage expansions on the financial well-being of lower income families, there may also be effects on union formation, divorce and fertility. Does the greater availability of affordable individual insurance options lead to an increase in divorce by reducing the need to remain in an unhappy marriage in order to maintain insurance coverage? Does the change in eligibility for Medicaid in states that expanded eligibility lead to an increase in marriage among women who were previously eligible for Medicaid only as single parents? To what extent do the new subsidized insurance options mitigate the negative economic consequences of divorce for women? How does increased access to effective contraception affect fertility outcomes?
To the extent that the expansion of insurance coverage improves financial well-being and reduces stress for affected families, are children in those families positively affected? For example, does reduced parental stress contribute to improved cognitive development or a reduction in problem behaviors for children? Does it improve educational outcomes?
The ACA will expand the coverage options for some, but not all, immigrant groups. Undocumented immigrants will not be allowed to enroll in Medicaid, nor will they be eligible to purchase coverage through the health insurance exchanges. Thus, most of the unauthorized foreign-born will likely remain uninsured. In addition, adult legalized permanent residents currently face a five-year waiting period to qualify for most public benefits, including health insurance coverage. What does this mean for the goals of immigrant integration? What are short- and long-term costs of excluding those whose legal status is not regularized from access to health care? How will differential enrollment policies affect social and economic outcomes for mixed-status families? Will differential enrollment policies affect immigrants understanding of, and attitudes towards, the new law?
Effects on Politics, Political Culture, and Public Policy
The U.S. has a long history of channeling public support through private sector mechanisms and the tax code. Measures of public opinion show that, when asked abstract questions, Americans oppose “big government” and any infringement on “individual liberties.” What explains disaffection for the ACA by both conservatives and many progressives? How much of this disaffection depends on knowledge of the law versus partisanship or ideology? How do Americans perceive the ACA–as a government program, as a system of private insurance, or otherwise? How might support for the ACA change over time? Do those who have personally benefited from ACA provisions feel differently about the law? What does the experience of states that have already implemented health exchanges suggest?
As implementation moves forward in an increasing number of states, how will Americans' personal experiences with the ACA affect their support for the law, their views of government generally, and their attitudes about future reform efforts? Does the availability of health insurance through the exchanges increase support for other reforms such as increasing the Medicare eligibility age? Will there be political pressure in non-Medicaid expansion states to expand Medicaid?
Outcomes for Underserved Groups
Homeless adults and former inmates stand to gain coverage via the expansion of Medicaid. Many of these adults have mental health and substance abuse problems that often go untreated. Prior to the ACA they were typically uninsured. Does the ACA's increased coverage for these treatments promote re-entry for ex-offenders and promote stability among the homeless? Does improved access to health care result in better employment and family outcomes and reduced recidivism?
Funding is available for secondary analysis of data or for original data collection. We are especially interested in novel uses of existing data, as well as analyses of new or under-utilized data. Proposals to conduct laboratory or field experiments, in-depth qualitative interviews, and ethnographies are also encouraged. Smaller projects might consist of exploratory fieldwork, a pilot study, or the analysis of existing data. The Foundation encourages methodological variety and inter-disciplinary collaboration. All proposed projects must have well-developed conceptual frameworks and research designs. Analytical models must be specified and research questions and hypotheses (where applicable) must be clearly stated.
Awards are available for research assistance, data acquisition, data analysis, and investigator time for conducting research and writing up results. Applications should limit budget requests to no more than a two-year period, with a maximum of $150,000 (including overhead) per project. Presidential Awards, with a maximum budget of $35,000 (no overhead allowed) are also available.
All applicants (both PIs and Co-PIs) must have a Ph.D. or comparable terminal degree, or a strong career background that establishes their ability to conduct high-level, peer-reviewed scholarly research. RSF particularly encourages early career scholars to apply for Presidential awards. All nationalities are eligible to apply and applicants do not have to reside in the U.S. RSF does not accept applications for Project and Presidential Awards from doctoral or other graduate students, unless specified in a special RFP.
Review Process and Award Decisions
The Foundation employs a rigorous multi-disciplinary review process at every stage of the application process. All letters of inquiry and proposals submitted to RSF are reviewed by program staff, external reviewers from multiple disciplines selected specifically for their expertise, members of one of the standing Advisory Committees, or some combination of these. In the case of Project Awards, final funding decisions are made by the Board of Trustees at our March, June and November Board meetings.