Job Market Paper

Saved by Medicaid: New Evidence on Health Insurance and Mortality from the Universe of Low-Income Adults (with Bruce D. Meyer; Job Market Paper)

Presented at: National Bureau of Economic Research (NBER) Summer Institute - Aging, Becker Friedman Institute (BFI) Health Economics Initiative, National Tax Association (NTA), Association for Public Policy Analysis & Management (APPAM)

Winner: 2024 JSM Best Student Paper Award, Business and Economics Section

We examine the causal effect of health insurance on mortality using the universe of low-income adults, a dataset of 37 million individuals identified by linking the 2010 Census to administrative tax data. Our methodology leverages state-level variation in the timing and adoption of Medicaid expansions under the Affordable Care Act (ACA) and earlier waivers and adheres to a pre-registered analysis plan, a novel approach in nonexperimental studies. We find that expansions increased Medicaid enrollment by 12 percentage points and reduced mortality of the low-income adult population by 2.5 percent, translating to a 21 percent reduction in the mortality hazard of new enrollees. These estimates are general to the low-income adult population targeted by recent Medicaid expansions, not limited to near-elderly or high-risk subgroups, and permit the most precise and comprehensive analysis to date of these policies’ life-saving effects. We find that benefits accrue not only to older age cohorts, but also to younger adults, who account for nearly half of life-years saved due to their longer lifespans and large share of the low-income adult population. Medicaid expansions also appear to be a cost-effective means of saving lives, with direct budgetary costs of $5.4 million per life saved and $179,000 per life-year saved, well below valuations commonly found in the literature. Our findings suggest that universal Medicaid enrollment would reduce the mortality gap between high- and low-income groups by about five to twenty percent. We contribute to a growing body of work showing that health insurance improves health and demonstrate that Medicaid’s life-saving effects extend across a much broader swath of the low-income population than previously understood.

Publications

The Size and Census Coverage of the U.S. Homeless Population (with Bruce D. Meyer and Kevin Corinth; Journal of Urban Economics)

Presented at: NBER Summer Institute - Urban, APPAM, American Economic Association and Allied Social Science Association (AEA/ASSA, poster), Society of Labor Economists (SOLE), American Statistical Association (ASA) Joint Statistical Meetings (JSM), ASA Women in Statistics and Data Science, U.S. Census Bureau, U.S. Department of Housing and Urban Development (HUD)

Media: VoxEU, 2023 AEA Poster Video

Fundamental questions about the size and characteristics of the homeless population are unresolved because it is unclear whether existing data are sufficiently complete and reliable. We examine these questions and the coverage of new microdata sources that are designed to be nationally representative. We compare two restricted data sources largely unused to study homelessness, the 2010 Census and American Community Survey (ACS), to restricted Homeless Management Information System (HMIS) data, HUD’s public-use point-in-time (PIT) estimates, and the Housing Inventory Count (HIC) at the national and individual level. We also develop a new approach to estimating the size of the sheltered homeless population using linked Census and HMIS microdata. Our analyses suggest that on a given night there are about 400,000 people experiencing homelessness in shelters in the U.S. and about 200,000 people sleeping on the streets, with this latter estimate subject to greater uncertainty. More than 90 percent of those in shelters appear to be counted in the Census, although many are classified as housed or in other group quarters, due largely to ambiguity in the definition of a homeless shelter. This paper lays the foundation for pathbreaking future work with these data on the U.S. homeless population.

Working Papers

Life and Death at the Margins of Society: The Mortality of the U.S. Homeless Population (with Bruce D. Meyer and Ilina Logani; NBER Working Paper)

Presented at: AEA/ASSA, SOLE (2024 planned)

Media: Wall Street Journal, KVTU News, San Francisco Chronicle)

This paper examines the relationship between extreme socioeconomic disadvantage and poor health by providing the first detailed and accurate picture of mortality patterns among people experiencing homelessness in the U.S. Our analyses center on 140,000 people who were sheltered or unsheltered homeless during the 2010 Census, by far the largest sample ever used to study this population and the only sample designed to be nationally representative. These individuals, along with housed comparison groups, are linked to Social Security Administration data on all-cause mortality from 2010-2022 to estimate the magnitude of health disparities associated with homelessness. We find that non-elderly people experiencing homelessness have 3.5 times the mortality risk of those who are housed, accounting for differences in demographic characteristics and geography, and that a 40-year-old homeless person faces a similar mortality risk to a housed person nearly twenty years older. Our results reveal notable patterns in relative mortality risk by age, race, gender, and Hispanic ethnicity and suggest that within the homeless population, employment, higher incomes, and more extensive observed family connections are associated with lower mortality. The mortality hazard of homeless individuals rose by 33 percent during the COVID-19 pandemic, an increase that, while similar in proportional terms to the increase for the housed population, affected a much larger share of the homeless population due to their substantially elevated baseline mortality rate. These findings elucidate the persistent hardships associated with homelessness and show that the well-documented gradient between health and poverty persists into the extreme lower tail of socioeconomic disadvantage.

Homelessness and the Persistence of Deprivation: Income, Employment, and Safety Net Participation (with Bruce D. Meyer, Gillian Meyer, Alexa Grunwaldt, and Derek Wu; NBER Working Paper )

Presented at: APPAM, SOLE, NTA, U.S. Census Bureau-IRS Income Measurement Workshop, Institute for Research on Poverty (IRP) Summer Research Workshop (2024 planned)

Homelessness is arguably the most extreme hardship associated with poverty in the United States, yet people experiencing homelessness are excluded from official poverty statistics and much of the extreme poverty literature. This paper provides the most detailed and accurate portrait to date of the level and persistence of material disadvantage faced by this population, including the first national estimates of income, employment, and safety net participation based on administrative data. Starting from the first large and nationally representative sample of adults recorded as sheltered and unsheltered homeless taken from the 2010 Census, we link restricted-use longitudinal tax records and administrative data on the Supplemental Nutrition Assistance Program (SNAP), Medicare, Medicaid, Disability Insurance (DI), Supplemental Security Income (SSI), veterans’ benefits, housing assistance, and mortality. Nearly half of these adults had formal employment in the year they were observed as homeless, and nearly all either worked or were reached by at least one safety net program. Nevertheless, their incomes remained low for the decade surrounding an observed period of homelessness, suggesting that homelessness tends to arise in the context of long-term, severe deprivation rather than large and sudden losses of income. People appear to experience homelessness because they are very poor despite being connected to the labor market and safety net, with low permanent incomes leaving them vulnerable to the loss of housing when met with even modest disruptions to life circumstances.

Learning About Homelessness Using Linked Survey and Administrative Data (with Bruce D. Meyer, Alexa Grunwaldt, Derek Wu, and Carla Medalia; NBER Working Paper)

Presented at: U.S. Census Bureau, ASA Symposium on Statistics and Data Science, Population Association of America (PAA, poster), ASA Practicum on Blended Data

Media: VoxEU

This paper examines the characteristics, labor market attachment, geographic mobility, earnings, and safety net utilization of the U.S. homeless population in order to understand their economic well-being. This paper is the first to examine these outcomes at the national level using administrative data on income and government program receipt. It is part of the Comprehensive Income Dataset project, which combines household survey data with administrative records to improve estimates of income and related statistics. Specifically, we use restricted microdata from the 2010 Decennial Census, which enumerates both sheltered and unsheltered homeless people, the 2006-2016 American Community Survey (ACS), which surveys sheltered homeless people, and longitudinal shelter-use data from several major U.S. cities. We link these data to longitudinal administrative tax records as well as administrative data on the Supplemental Nutrition Assistance Program (SNAP), veterans’ benefits, Medicare, Medicaid, housing assistance, and mortality. Our approach benefits from large samples that offer a guide to national homelessness patterns and allow us to compare estimates between data sources, including the Department of Housing and Urban Development (HUD)’s point-in-time (PIT) counts. By shedding light on issues of data linkage and survey coverage among homeless people, this paper contributes to efforts to better incorporate this hard-to-survey population into income and poverty estimates.

Works in Progress

The Limits of Public Health Insurance? Medicaid, Medicare, and the Mortality of Homeless Adults (with Bruce D. Meyer)

People who are homeless face nearly four times the mortality risk of those who are housed. We consider the potential for public health insurance to reduce this disparity. Our methodology leverages two natural experiments: (1) state-level variation in the timing and adoption of Medicaid eligibility expansions under the Affordable Care Act (ACA) and earlier waivers, and (2) the discontinuity in Medicare eligibility at age 65. Despite Medicaid expansions’ large causal effect on the enrollment of homeless adults, we find no evidence that the program reduced their mortality. We similarly find no evidence of a drop in mortality when homeless adults age into Medicare eligibility. These null findings contrast with prior work showing that Medicaid and Medicare reduce mortality risk in the housed population. Potential explanations center on the difficulty of maintaining continuity of care without stable housing and the limited amenability to health care of the hazards faced by homeless individuals.

Who Experiences Homelessness? Evidence from Nationally Representative Data (with Bruce D. Meyer)

Understanding who experiences homelessness is a crucial step towards understanding the causes of homelessness. We use restricted-use American Community Survey (ACS) data that randomly sample people in homeless shelters to provide new estimates of this population’s social and economics characteristics. We find that homeless adults are much more likely than the single housed poor to report difficulties remembering things and making decisions (23 vs 11.5 percent) and to have moved states in the preceding year (9 percent vs 3 percent). Older children residing in shelters were much less likely to be enrolled in school than their housed poor counterparts (69 vs 94 percent among 16- and 17-year-olds). We also document substantial aging of this population over time, with the share of homeless adults who are over 50 rising from 22 percent in 2006 to 35 percent in 2016. This paper provides the first detailed look at this population’s characteristics using nationally representative data in nearly three decades.