Marriage and the Obamacare Effect

Let’s put some recent ideas together.

Last month, we saw that drug overdose rates were rising particularly quickly for people in states that fully implemented the Affordable Care Act and accepted the Medicaid Expansion.

Medicaid and Holdout States Age Structure

Even since 2013, there was a faster increase in overdoses in the Medicaid expansion states.


Moreover, even if you controlled for some relevant economic and demographic characteristics of individual counties, counties in states that expanded Medicaid still had larger increases in overdose rates.

Percent Error

This pattern didn’t appear to be true of the other “deaths of despair“- alcohol-related deaths and suicides weren’t rising faster in ACA states, despite their increases for middle aged whites nationwide.


Nor was obesity– a corollary of general ill health and contributor to chronic pain- rising faster in ACA states.


Instead, insurance itself appeared to be closely connected with where overdose rates were rising.

decreaseversus2015expansiononly (1)prediction4

Earlier this week, however, we looked at another possible contributor to rising mortality (or perhaps simply an indicator of general economic and social stability in the community)- reduced marriage rates among middle aged women:

Averaged Change 2005 2010 to 2011 2015 2


Perhaps because they are more politically liberal, this is one characteristic in which the Medicaid expansion states differ dramatically from the Holdout states. Medicaid expansion states have significantly lower marriage rates, particularly for young white women:



For both Medicaid and non-Medicaid expansion states, the increase in drug-related deaths has also been concentrated among white women- if we reference to the rate within each age group in 2000, we can see a rapid increase for both types of states, with another jump since 2014 (ACA implementation) in Medicaid states (y axis shows percent of year 2000 value)ageovertimemedstatusrecentwhitefemaleaa

This same increase has not been duplicated for black women, for whom overdose rates have been generally stable since 2000 (y axis shows percent of year 2000 value):


You can summarize these graphs by looking at the average change for black and white women in overdose rates from 2005 to 2015 for holdouts and Medicaid Expansion states:


A reasonable question, therefore, is whether marriage is a “missing mediator” of the Obamacare effect– maybe we’re seeing not the direct effect of health care policy on overdose, but in part an effect of changing family and household structure, which is accelerated in more liberal states? Or, for that matter, since Obamacare creates larger disincentives to marry for people eligible for the exchanges or Medicaid (since marriage would involve losing a subsidy or Medicaid eligibility), could the way the ACA boosted overdose rates be partly by accelerating decreases in marriage rates? Contrariwise, if you don’t believe marriage drives anything directly, but you do think that political or culturally liberal tendencies are important, then controlling for levels and changes in marriage should help you isolate the true policy impact of the Affordable Care Act.

Looking cross-sectionally across all years for all states, an effect of marriage on overdose is at least plausible. Marriage rates within age groups, by state, are more closely associated with overdose rates within those age groups than they were with all-cause mortality:


Looking at changes over time within states and age groups appears less convincing, however.  For white women there is a slight negative association between change from 2005 in marriage rates and change in  overdose rates, particularly among  young white women in the ACA states. drugmarrchg5drugmarrchg4

For black women, there doesn’t appear to be any such association at all (although because the data tends to be censored for small values, we don’t see all the age groups for all the years):


It appears, then, that marriage continues to be an extremely strong predictor of the overall health of a community (spilling over into such indicators as overdose rates), for both black and white women, but that short-term changes in marriage rates do not have a measurable association with overdose rates.

In fact, in an OLS regression of state-level overdose rates among white women in 2015 on 2005 baseline characteristics, only the 2005 overdose rates and Medicaid expansion status were significant predictors of where overdose rates were higher in 2015.

OLS Regression White Female Overdose Rate 2015 White Female Overdose Rate 2015
White Female Overdose Rate (same state and age group) 2005 0.712*** 0.798***
(0.129) (0.118)
Percent with post-secondary education, 2005 -0.0514
Percent married, 2005 0.707
Percent with post-secondary education, 2015 -0.342
Percent married, 2015 -0.408
Did the State Expand Medicaid? 7.753*** 5.029**
(2.288) (2.049)
Average earned income, 2005 ($1000s) 0.612
Average earned income, 2015 ($1000s) -0.560
Constant 14.13 14.10***
(25.99) (2.825)
Observations 118 118
R-squared 0.426 0.298

Standard errors in parentheses

*** p<0.01, ** p<0.05, * p<0.1

It still looks to me like Obamacare made a difference.



Data files and Stata do file for additional analyses in this post here. (Warning, the individual-level American Community Survey data is pretty yuge.) MarriageAndObamacare

6 thoughts on “Marriage and the Obamacare Effect

  1. Have you heard of the Oregon Health Insurance Experiment? I think what you present here would explain why being on Medicaid “produced no statistically significant effects on physical health or labor market outcomes.”

    A RAND study from the 1970s-1980s had a similar result, but since RAND is pushing for the expansion of Medicaid, they are recasting the findings somewhat.


      1. Yes, exactly! All a wash I suspect. When I read that there are no changes in health for being on state aid vs. not, and I think of my family’s experience. For a few years in a rough patch my wife was on Medicaid while I was on my school’s student plan. A series of mis-diagnoses almost killed her until I took charge, read up on things, and managed to get her seen by a pair of specialist who figured out what was going on. Does this happen with gold plated medical? Yes, but there is a clear difference is the quality of care between being on the medical card and having other insurance. State aid is cattle car medicine, the kids got their shots and the simple stuff is dealt with, but anything that takes cognitive and bureaucratic effort is shunted aside unless you are willing to be a squeaky wheel.

        Liked by 1 person

      2. Interesting- we go to a pediatrician who is mainly a Medicaid provider and she’s great, but our first child was delivered at a hospital that’s mainly Medicaid and it was pretty awful (it’s subsequently been sold off.) I was in California recently and we were stopped at a gas station near Merced and I noticed a billboard that said,”51% of Merced County residents are on Medi-Cal”- it’s pretty remarkable that in some places it’s a de facto single payer system.


  2. California has about 40% of the nations welfare recipients, so your latter observation is no surprise. Considering the low reimbursement rates, medical providers make it up on volume. A community hospital in my hometown was going going through the steps to not take Medicare/Medicaid anymore, until the budget analysts noticed that they make it up on volume (something like half their business was medicare/medicaid) and they could continue to float from period to period because of the continued inflow of revenue while not all expenses were due at the same time. If you just looked at static revenues vs expenditures for one FY, they were losing money.

    I think the individual doctors (my kids’ pediatrician for example, and yours) tried, but mine was always harried and I ended up dealing with the nurses there more often than not. TANSTAAFL, so the trade off is quality of care.

    Liked by 1 person

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