Association of Medicaid expansion with health insurance coverage by marital status and sex

Autoři: Jim P. Stimpson aff001;  Jessie Kemmick Pintor aff001;  Fernando A. Wilson aff002
Působiště autorů: Drexel University, Dornsife School of Public Health, Philadelphia, PA, United States of America aff001;  University of Utah, Matheson Center for Health Care Studies, Salt Lake City, UT, United States of America aff002
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article



To determine the association of Medicaid expansion with health insurance coverage by marital status and sex.


A population-based, quasi-experimental policy analysis was undertaken of the implementation of the Patient Protection and Affordable Care Act’s (ACA) Medicaid expansion provision on or after January 1, 2014. The 2010–16 American Community Survey provided data on 3,874,432 Medicaid-eligible adults aged 19–64 with incomes up to 138% of the federal poverty level. The outcome measures were no health insurance coverage and Medicaid coverage. The predictor variables were marital status and sex, with controls for family size, poverty status, race/ethnicity, education, employment status, immigration status, and metropolitan residence.


In 2016, the uninsured rate for married men and women in a Medicaid expansion state was 21.2% and 17.1%, respectively, compared to 37.4% for married men and 35.8% for married women in a non-expansion state. The Medicaid coverage rate grew between 14.8% to 19.3% in Medicaid expansion states, which contrasts with less than a 5% growth in non-expansion states. Triple differences analysis suggests that, for women of all age groups, Medicaid expansion resulted in a 1.6 percentage point lower uninsured rate for married women compared to unmarried women. For men, there was not a statistically significant difference in the uninsured rate for married compared to unmarried men. For women of all age groups, there was a 2.6 percentage point higher Medicaid coverage rate for married compared to unmarried women. For men, there was a 1.8 percentage point higher Medicaid coverage rate for married compared to unmarried men.


Medicaid expansion under the ACA differentially lowered uninsurance and improved Medicaid coverage for married persons, especially married women, more than unmarried persons.

Klíčová slova:

Age groups – Census – Employment – Health insurance – Obstetrics and gynecology – Socioeconomic aspects of health – Surveys – Women's health


1. Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).

2. Mazurenko O, Balio CP, Agarwal R, Carroll AE, Menachemi N. The effects Of Medicaid expansion under the ACA: a systematic review. Health Aff. 2018;37:944–950.

3. Antonisse L, Garfield R, Rudowitz R, Artiga S. The effects of Medicaid expansion under the ACA: updated findings from a literature review [Internet]. San Francisco (CA): Henry J. Kaiser Family Foundation; 2018 Mar 28 [cited 2018 December]. Available from:

4. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA. 2015;314(4):366–74. doi: 10.1001/jama.2015.8421 26219054

5. Simon K, Soni A, Cawley J. The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. J Policy Anal Manage. 2017;36(2):390–417. 28378959

6. Wherry LR, Miller S. Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: a quasi-experimental study. Ann Intern Med. 2016;164:795–803. doi: 10.7326/M15-2234 27088438

7. Frean M, Gruber J, Sommers BD. Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act. J Health Econ. 2017;53:72–86. doi: 10.1016/j.jhealeco.2017.02.004 28319791

8. Sommers BD. State Medicaid expansions and mortality, revisited: a cost-benefit analysis. Am J Health Econ. 2017;3(3):392–421.

9. Alcalá HE, Roby DH, Grande DT, McKenna RM, Ortega AN. Insurance type and access to health care providers and appointments under the Affordable Care Act. Med Care. 2018;56(2):186–192. doi: 10.1097/MLR.0000000000000855 29271819

10. Shartzer A, Long SK, Anderson N. Access to care and affordability have improved following Affordable Care Act implementation: problems remain. Health Aff. 2016;35:161–168.

11. Torres H, Poorman E, Tadepalli U, Schoettler C, Fung CH, Mushero N, et al. Coverage and access for Americans with chronic disease under the Affordable Care Act: a quasi-experimental study. Ann Intern Med. 2017;166:472–479. doi: 10.7326/M16-1256 28114684

12. Yue D, Rasmussen PW, Ponce NA. Racial/ethnic differential effects of Medicaid expansion on health care access. Health Serv Res. 2018;53:3640–56. doi: 10.1111/1475-6773.12834 29468669

13. Stimpson JP, Wilson FA. Medicaid expansion improved health insurance coverage for immigrants but disparities persist. Health Affairs. 2018;37(10):1656–1662. doi: 10.1377/hlthaff.2018.0181 30273021

14. Courtemanche C, Marton J, Ukert B, Yelowitz A, Zapata D, Fazlul I. The three-year impact of the Affordable Care Act on disparities in insurance coverage. Health Serv Res. 2019 Feb;54 Suppl 1:307–316. doi: 10.1111/1475-6773.13077 30378119

15. Sommers BD, Gruber J. Federal funding insulated state budgets from increased spending related to Medicaid expansion. Health Aff. 2017;36:5:938–944.

16. Ayanian JZ, Ehrlich GM, Grimes DR, Levy H. Economic effects of Medicaid expansion in Michigan. N Engl J Med. 2017;376:407–410. doi: 10.1056/NEJMp1613981 28051917

17. Camilleri S. The ACA Medicaid expansion, disproportionate share hospitals, and uncompensated care. Health Serv Res. 2018;53:1562–1580. doi: 10.1111/1475-6773.12702 28480593

18. Lindrooth RC, Perraillon MC, Hardy RY, Tung GJ. Understanding the relationship between Medicaid expansions and hospital closures. Health Aff. 2018;37:111–120.

19. Carr D, Springer KW. Advances in Families and Health Research in the 21st Century. Journal of Marriage and Family. 2010;72:743–61.

20. Bernstein AB, Cohen RA, Brett KM, Bush MA. Marital status is associated with health insurance coverage for working-age women at all income levels, 2007. NCHS Data Brief. 2008 Dec;(11):1–8. 19389316

21. Simpson JL, Cohen RA. The Association of Marital Status and Offers of Employer-based Health Insurance for Employed Women Aged 27–64: United States, 2014–2015. NCHS Data Brief. 2017 Jan;(268):1–8. 28135187

22. Peters HE, Simon K, Taber JR. Marital disruption and health insurance. Demography. 2014 Aug;51(4):1397–421. doi: 10.1007/s13524-014-0317-6 25012788

23. Zimmer DM. Asymmetric effects of marital separation on health insurance among men and women. Contemporary Economic Policy. 2007;25:92–106.

24. Lavelle B, Smock PJ. Divorce and women's risk of health insurance loss. J Health Soc Behav. 2012;53(4):413–31. doi: 10.1177/0022146512465758 23147653

25. Williams K, Umberson D. Marital Status, Marital Transitions, and Health: A Gendered Life Course Perspective. J Health Soc Behav. 2004;45:81–98. doi: 10.1177/002214650404500106 15179909

26. Patchias EM, Waxman J. Women and health coverage: the affordability gap. Issue Brief (Commonw Fund). 2007 Apr;25:1–12.

27. National Center for Health Statistics. Health, United States, 2017: With special feature on mortality. Hyattsville, MD. 2018.

28. Jones RK, Sonfield A. Health insurance coverage among women of reproductive age before and after implementation of the affordable care act. Contraception. 2016 May;93(5):386–91. doi: 10.1016/j.contraception.2016.01.003 26802569

29. Johnston EM, Strahan AE, Joski P, Dunlop AL, Adams EK. Impacts of the Affordable Care Act's Medicaid Expansion on Women of Reproductive Age: Differences by Parental Status and State Policies. Womens Health Issues. 2018 Mar—Apr;28(2):122–129. doi: 10.1016/j.whi.2017.11.005 29275063

30. Ranji U, Salganicoff A. Medicaid and Women's Health Coverage Two Years into the Affordable Care Act. Womens Health Issues. 2015 Nov-Dec;25(6):604–7. doi: 10.1016/j.whi.2015.08.008 26432345

31. State Health Access Data Assistance Center. Defining “family” for studies of health insurance coverage. Issue Brief #27. Minneapolis, MN: University of Minnesota. March 2012. Available at:

32. Ruggles S, Genadek K, Goeken R, Grover J, Sobek M. Integrated Public Use Microdata Series: Version 7.0 [dataset]. Minneapolis, MN: University of Minnesota, 2018.

33. Kaiser Family Foundation. State Health Facts. 2019. Available from

34. Noon JM, Fernandez LE, Porter SR. Response error and the Medicaid undercount in the current population survey. Health Serv Res. 2019;54:34–43. doi: 10.1111/1475-6773.13058 30270431

35. Claxton G, Levitt L, Brodie M, Garfield R, Damico A. Meauring changes in insurance coverage under the Affordable Care Act. Henry J. Kaiser Family Foundation. Published April 30, 2014. Available from

36. Frean M, Gruber J, Sommers BD. Disentangling the ACA's coverage effects-lessons for policymakers. N Engl J Med. 2016;375:1605–1608. doi: 10.1056/NEJMp1609016 27653467

37. Bergeron CD, Friedman DB, Sisson DC, Tanner A, Kornegay VL, Owens OL, Weis MA, Patterson LL. Awareness, perceptions, and communication needs about the Affordable Care Act across the life span. American Journal of Health Education. 2016;47(2):108–16.

38. Sommers BD, Kenney GM, Epstein AM. New Evidence On The Affordable Care Act: Coverage Impacts Of Early Medicaid Expansions. Health Aff. 2014;33(1): 78–87.

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2019 Číslo 10
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