Policy Paper

April 13, 2016

 

Restoring KidsCare: Annual and Long-Term Benefits Far Exceed Cost to the State

 

By Dave Wells, Ph.D.

Research Director, Grand Canyon Institute

 

Executive Summary

Arizona is the only state in the country with an inactive Children’s Health Insurance Program (CHIP). A bill to reinstate the program, HB2309, has stalled in the Senate.  Arizona would be wise to revive its KidsCare program.  The state for FY2017 would actually come out ahead fiscally by reviving it.  Reinstating the program would yield approximately $40 million in direct economic benefits in FY2017 and total economic benefits of approximately $75 million, as the initial $40 million recirculates in the economy.  This added economic activity should bring in nearly $3 million in added state and local revenue, while the federal government would pay 100 percent of the cost of a program estimated to reach more than 30,000 children.

In addition, economic research estimates that KidsCare, besides improving health outcomes for children, leads to longer term benefits.  Longitudinal research has found expanded health insurance services for children including Medicaid and CHIP modestly reduce the high school dropout rate and increase the number of students graduating from college.  These future benefits, while realized over the working lifetimes of enrollees, amount in current dollars to more than $30 million annually in net fiscal benefits to the state, national and federal government.  As their earnings are higher, their taxes paid rise, and their use of assistance programs and criminal activity diminishes.

In addition, should the federal government draw back on its support for the CHIP program in FY2018, the state would have full budgetary control to limits its immediate fiscal impact and freeze enrollment.

Consequently, no reason exists to continue the freeze on KidsCare in Arizona.  The program should be restored immediately with whichever budgetary controls the legislature feels would be necessary.

 

Introduction

Michelle and Michael Wolfson had three children receiving public health insurance.  All three children had been enrolled in KidsCare before enrollment was frozen in 2010.  Since that time their youngest daughter, Alisa, who suffers from scoliosis as well as from Friedreich’s Ataxia, which is related to Muscular Dystrophy, was switched to the SSI Medicaid program. When their oldest daughter turned 18, they discovered their family size was reclassified as four and their income became too high to qualify for those health benefits.  Their income is still below 200 percent of the Federal Poverty Line (FPL), but, due to the KidsCare enrollment freeze, Alisa was not allowed to be placed back into the program.

Come June, Alisa will need a surgical procedure for scoliosis. After she lost her Medicaid coverage, the family switched Alisa to a high deductible plan, which means despite their modest income they face thousands of added health care costs.

If the Wolfson’s lived in any other state they wouldn’t face this challenge, as every other state has an active Children’s Health Insurance Program. In Arizona the program is called KidsCare, but new children have not been allowed to enroll since 2011 with a brief temporary inclusion of some children in 2013. As illustrated with Alisa, if they are removed from the program, they cannot re-enroll. Under KidsCare, children up to 200 percent of the FPL would also be covered by AHCCCS with enrollees, depending on income paying monthly premiums of up to $50 for one child and a maximum of $70 a family.[1] Unlike private insurance plans whether on the Exchange or through employers, KidsCare after the monthly premium pays all costs and provides comprehensive care, making it an ideal cost-effective choice to make healthcare accessible to lower income children.[2]

 

Federal Government Pays 100 Percent of the Cost. Worst case scenario costs $27 million

When CHIP was last renewed by Congress in 2015, the Federal match was increased by 23 percent. Prior to then, Arizona paid 23 percent of the program’s cost, but with the federal match for FY2016 through FY2019, the federal government pays 100 percent of the cost of the program in Arizona.[3]

While the Centers for Medicare and Medicaid Services (CMS) foresees ample funding with enough of the current funding even covering part of Federal FY2018, funding for CHIP has only been approved through Federal FY2017.[4] CHIP enjoys wide bipartisan support, so there’s little doubt that the program will be renewed for 2018. An expressed concern by Senate President Andy Biggs has been that the Federal government would cut future funding and the state would not be willing to close a program they just re-opened.

That fear is misplaced.

CHIP is funded by a match as noted above and is a capped program, meaning there is a budgetary limit. A global allotment is provided to Centers for Medicare and Medicaid Services (CMS) to administer the program. In recent years the cap has been more than adequate. In fact due to cost savings from other ACA areas, such as fewer subsidized health plans on the exchange, renewing the CHIP program for two years through FY2019 would only have a net budgetary impact of $3.1 billion according to the Department of Health and Human Services. At $13 billion for two years, excluding savings from other categories, KidsCare is a modest program.[5]

Presently, if Arizona exceeds its allotment, then it makes a request to CMS to increase the allotment. Due to ample funding, CMS has been forthcoming with those funds.

Three general fiscal scenarios exist moving forward.

First, the enhanced 100 percent funding continues, and the allotment remains ample, in which case through FY2019 and perhaps longer, KidsCare would continue at no cost to the state.

Second, some Republican members of the U.S. House of Representatives would like to remove the 23 percent added match, so for Arizona this would return the Federal portion to 77 percent. The Arizona Health Care Cost Containment System (AHCCCS) estimates the total FY2018 cost of a reinstated KidsCare program at $89 million to serve approximately 35,000 enrollees. If Arizona had to pay 23 percent of that cost, reinstating KidsCare would still only cost Arizona $20 million a year.[6]

Finally, the allotment could be cut, so that Arizona exceeded it. The AHCCCS legislative committee presentation on February 6 effectively included this scenario, presuming the state’s allotment dropped by one-third from Arizona’s current FY2016 allotment and by 40 percent from the probable FY2017 allotment. Under this scenario, Arizona’s allotment would first be used to cover the KidsCare population and the remainder for Medicaid Children between 0 and 138 percent of the FPL. If expenditures exceed the allotment, then the Federal government would pay 68 percent of the remaining costs of the Medicaid children, leaving the state to pay 32 percent. Under that scenario, AHCCCS estimates reinstating KidsCare to cost an extra $27 million on top of a $30 million baseline budget cost to continue covering the children between 0 and 138 percent of the FPL in FY2018. Under the Affordable Care Act (ACA), Arizona is obliged to maintain coverage of these latter children through Federal FY2019 (September 2019). Under this worst case scenario, KidsCare restoration is still only $27 million and the overall impact is $57 million when children Arizona is required to cover are included.

Even with Arizona’s relatively tight fiscal situation, even the worst case scenario is highly manageable.

Because Arizona’s CHIP program had an enrollment freeze at the time the ACA was passed, Arizona has more flexibility than other states. States generally could not reduce existing programs under the ACA, but since Arizona had already done so, the baseline Federal expectation for Arizona is much lower. Consequently, Arizona has full control over the budgetary impact of KidsCare. Presuming that the state would not want to throw children off KidsCare, they could still freeze enrollment based on whatever cost threshold they desired.[7] In fact, language to that effect was added to HB2309.

 

 

 

Immediate Economic Benefits at least $60 million annually

Reinstating KidsCare will provide new federal funds to the state, which will have an immediate economic impact.

Children currently eligible for KidsCare, but not able to enroll, either have their families being forced to cover health care costs out of pocket or they are paying for the insurance through the exchange or they have no insurance at all.

There are two effects documented by the freeze on KidsCare. On the one hand, a study by Georgetown University’s Center for Children and Families and Children’s Action Alliance estimated that in calendar year 2014 that 16 percent of children between 138 and 200 percent of the FPL lack health insurance, which was the highest rate for that income range in the country.[8]  In addition, the most recent enrollment data shows that Arizona has slightly more than twice as many children enrolled in the health care exchanges than other states.[9]

AHCCCS projects for FY2017, a federal infusion of $76 million, rising to $89 million in FY2018, if the federal government pays 100 percent of the costs.  Including indirect economic benefits, and adjusting for the movement of some children from the federally subsidized exchange to KidsCare, the economic benefit of new federal dollars to the state should be at least $75 million annually.  This in turn would generate about $2.6 million for state and local government in added taxes.[10]

Under the worst case scenario with the Federal Government contributing $62 million and the net cost to the state being $27 million, then the total economic impact would still equal about  $60 million.  In this case at least $2.1 million in state and local government revenue would be gained.

 

 

 

Long-Term Economic Benefits exceed $50 million annually

In addition to direct immediate benefits, KidsCare will also generate long-term benefits by improving the health of children, leading to improved economic success and better lifetime earnings.

Since the 1980s publicly provided health insurance for children has grown increasingly available.  Research from Sarah Cohodes of Columbia University, Daniel Grossman of West Virginia University and Samuel Kleiner and Michael Lovenheim, both of whom are affiliated with Cornell University and the National Bureau of Economic Research, found that expanded eligibility for children’s health insurance program led to modest increases in educational attainment.[11]

They found that a ten percent increase in Public Health Insurance eligibility led to 0.39 percent decline in high school drop outs and a 0.66 percent increase in college graduates.  These estimates seem small, but they were statistically significant and of significant economic benefit.

Because KidsCare expands Medicaid eligibility to 200 percent of the FPL, their estimates can be used to estimate long-term economic benefits of recipients.  However, because these families may have already begun to benefit from the subsidized premiums available on the Exchange, estimates need to account for that.  So this analysis takes a restrictive assumption of only attributing lifetime gains to those joining KidsCare who previously were likely uninsured.  This analysis presumes that unfreezing KidsCare will reduce the uninsured rate by 3.3 percent among those between 138-200 percent of the FPL by FY2018, meaning about one-third of those enrolling in KidsCare would have been previously uninsured. Quantitatively this represents reducing the number of uninsured children by about 35 percent as much as the first year of the Expanded Medicaid under the Affordable Care did in Arizona.[12]  Figure 1 illustrates the insurance status of those expected to enroll in KidsCare, if the program is fully reinstated.

 

 

Figure 1

While expanding access to KidsCare should have health outcome benefits, this analysis does not evaluate those benefits except to the degree that they impact later educational attainment and subsequent earnings.  Table 1 summarizes those results.

Table 1

KidsCare Lifetime Benefits for Enrollees

	AnnualKidsCare Effect	Growth in Lifetime Earnings		Improved Lifetime Net Fiscal Contribution(Taxes Paid less Direct Assistance and Criminal Justice Use)
		Per Person	Total	Per Person	Total
High School Drop Outs	-33	$500,000	$16 Million	$300,000	$10 Million
College Graduates	+55	$700,000	$38 Million	$400,000	$22 Million

 

The size of KidsCare relative to Medicaid enrollment for children will be small, as nearly 600,000 children age 0-17 currently receive Medicaid services under AHCCCCS.[13] By contrast AHCCCS projects KidsCare enrollment to be 34, 260 by June of 2018.  This analysis estimates not quite one-third of them, just over 10,000 will move from not having insurance to having insurance.[14]

So for purposes of applying the longitudinal study’s estimates to Arizona the 10,000 is taken relative to the 600,000, yielding a 1.7 percent gain in public insurance eligibility for purposes of estimating the long-term economic gains. This seems to be the most reasonable, conservative estimate to make, given the added insurance options provided to families above 138 percent of the FPL under the Affordable Care Act.

A 1.7 percent improvement in pubic insurance eligibility leads to the number of drop outs reducing by 0.72 percent and the number of college graduates increasing by 0.43 percent among those under 200 percent of the Federal Poverty Line using the estimates of Cohodes, Grossman, Kleiner and Lovenheim.  This translates into 32 fewer students dropping out in a given year and instead graduating from high school and 55 more graduating from college on average each year rather than just attending some college without earning a degree.  While this impact may sound small, they translate into significant gains.

Based on estimates from the Center from Labor Market Studies at Northeastern University those with a high school degree can expect to earn $500,000 more over a lifetime than someone who drops out of high school.  This yields a $16 million lifetime benefit across 32 students.[15]

Likewise, the New York Federal Reserve published estimates that those with a college degree earn about $700,000 more over a lifetime over someone who had only attended college at some point but did not have a four-year degree. This results in a $38 million improvement across 55 students.[16]

High School drops outs are also far more likely to be unemployed, have low incomes, inconsistent labor force participation, and are more susceptible to criminal activity.  Consequently, they consume more social services, criminal justice costs and income supports than they pay in taxes. Someone with a high school degree The Center for Labor Market Studies estimates does about $300,000 better in his or her net lifetime fiscal contribution than a high school dropout.   Collectively that is a $10 million gain to local, state and national government.  Likewise as taxes go up with earnings, those with a college degree have a net fiscal benefit that exceeds those with only some college by about $400,000, a $22 million annual gain across 55 students.[17]

The total of these impacts are shown in Figure 2.

Figure 2

 

These gains would be realized by each graduating cohort.  There are 18 years of potential KidsCare eligibility, so these estimates were based on just looking at one-eighteenth of those under 200 percent of FPL.  KidsCare access assures greater continuity of quality healthcare during a child’s growing years.

 

Conclusion

Fiscal, health and economic impacts all indicate the state and residents of Arizona are better off if KidsCare is reinstated.

The Fiscal Cost for FY2017 is zero, as the federal government would inject around $40 million directly with a $75 million economic impact. In future years, the federal government may continue to pay the full cost of the program, but, even if it did not, Arizona’s expected cost would not be expected to exceed $27 million and the state would retain full abilities to freeze enrollment or terminate the program in the future.

In addition, besides the health benefits of the comprehensive care KidsCare offers, this analysis finds that KidsCare would have small but significant impacts in lowering the number of high school drop outs and raising the number of recipients eventually graduating from college.  These outcomes lead to higher lifetime earnings and much improved net fiscal contributions over their lifetimes as they pay higher taxes and need less help from assistance programs and are less likely to engage in crime.

Each year KidsCare would generate an estimated $55 million in lifetime earnings improvements and more than $30 million in gains in lifetime net fiscal contributions to local, state and federal government.

These gains far exceed the state’s investment, even under a worst case scenario.

 

 

 

 

 

Dave Wells holds a doctorate in Political Economy and Public Policy and is the Research Director for the Grand Canyon Institute.  He can be reached at DWells@azgci.org or contact the Grand Canyon Institute at (602) 595-1025.

 

 

 

The Grand Canyon Institute, a 501(c) 3 nonprofit organization, founded in 2011, is a centrist think tank led by a bipartisan group of former state lawmakers, economists, community leaders and academicians. The Grand Canyon Institute serves as an independent voice reflecting a pragmatic approach to addressing economic, fiscal, budgetary and taxation issues confronting Arizona.

Grand Canyon Institute

P.O. Box 1008

Phoenix, Arizona 85001-1008

APPENDIX

To estimate the number of uninsured children, three data sources were used. First, the American Action Forum, a center-right think tank, did an analysis of Survey of Income and Program Participation data from April 2013, at the cusp of the enactment of the ACA, and broke down the CHIP eligible population as follows:[18]

6 million children enrolled in CHIP (Dec. 2013)

9.1 million children CHIP eligible

5.1 million would be eligible for insurance under the health exchange marketplace

1.3 million have access to employer-provided health insurance (not family glitch)

2.7 million uninsured or at risk of being uninsured, broken out as

1.6 million in CHIP fall under the ACA family glitch

645,000 uninsured fall under the ACA family glitch

460,000 covered by CHIP funded Medicaid expansion under the ACA

The family glitch is an issue whereby an employee is offered affordable insurance via an employer.  However, the definition of affordable excludes what the costs are to cover the rest of the family, which may be exorbitant. But as currently in force, the ACA does not permit any of the other family members from qualifying for a health plan through the exchange if the employer-sponsored one is deemed “affordable.”[19] However, the children could qualify for CHIP.

Arizona has already expanded Medicaid, so by this estimate 1.6 million divided by 6 million less the 460,000 covered by Medicaid expansion leads to about 30 percent of actual likely CHIP participants falling into the Family Glitch.

That creates a base for current uninsured of 30 percent of those who might enroll in KidsCare.  To the degree some of the children who weren’t insured previously become insured, then the figure could be higher. Arizona has a significantly higher percentage of uninsured children than the country as a whole historically, though most recent data comes from 2014, so precise current estimates are more difficult since that was also the first year of Medicaid expansion. But it seems reasonable to suspect a slightly higher percent of KidsCare enrollees would have not had insurance.

The January 2016 report from the Georgetown Center for Children and Family and the Children’s Action Alliance, noted that in 2014, Arizona had a higher uninsured rate.[20]  The gap between Arizona and the nation for those up to 138 percent of the FPL was 4.8 percent, while it jumped to 7.5 percent for the KidsCare group of 138 to 200 percent of the FPL.   If KidsCare reinstatement were to reduce the gaps so that they were roughly equivalent, then that would mean a 2.7 percent reduction in the uninsured.  Alternatively, if KidCare reinstatement were to lead to similar rates of uninsured for the 138 to 200 percent as those under 138 percent of the FPL, then using the 2014 estimates, KidCare reinstatement would lead to a 3.9 percent reduction in the uninsured.   The average of the two would be a 3.3 percent reduction in the uninsured.

Using a 3.3 percent reduction in the uninsured or that 30 percent of those enrolling would have been uninsured both suggest a bit more than 10,000 of the KidsCare enrollees would likely lack health insurance.

These two measures come out quite similarly and are consistent with also estimating what reducing the added children in the exchanges to those of Nevada would be—assuming the rest moved to KidsCare.

Nevada is demographically similar to Arizona and in the same region.  They have an existing CHIP program with a premium for enrollees and a similar income limit.  Nevada has also expanded Medicaid under the ACA.  Relative to population, Nevada and Arizona are also fairly comparable with the portion of residents using the health insurance marketplace.

For the 2016 enrollment period, 14 percent of Nevada’s enrollees in the exchange were under 19, whereas for Arizona it was 23 percent.[21]  If Arizona were to have 14 percent of its enrollees under 19 that would mean approximately 20,000 would have enrolled in KidsCare.

Gathered together these numbers are consistent with the 30,000 to 35,000 enrollment projections of AHCCCS if KidsCare is restored.

To estimate the lifetime gains from those uninsured. The American Community Survey population for Arizona for 2014 was used along with 24.1 percent, which is the portion of those under 18.[22] Half of those have been found to be under 200 percent of the FPL.[23] That number divided by 18 for each year of KidsCare eligibility was the cohort size used to estimate lifetime economic benefits.  To get 2014 population up to 2018, the analysis assumes an annual population growth rate of 1.4 percent, which is what the Joint Legislative Budget Committee has been using to estimate student population growth.  So the one-year cohort of those children under 200 percent of the FPL is about 48,000 for 2018.

That figure is multiplied by the high school dropout rate from Cohodes, Grossman, Kleiner and Lovenheim  economic study of 9.4 percent to get a number of likely drop outs and that number is multiplied by -0.72 percent to yield the 32 fewer students dropping out due to KidsCare.   Likewise, for college graduates the 48,000 is multiplied by 26.5 percent, the college graduation portion, and that figure is multiplied by 0.43 percent to yield the 55 additional college graduates due to KidsCare.[24]

[1] Arizona Health Care Cost Containment System, “KidsCare Arizona’s Children’s Health Insurance Program (CHIP),” https://www.azahcccs.gov/Members/GetCovered/Categories/KidsCare.html.

[2] Brooks, Tricia, Martha Heberlein, and Joseph Fu (2014), “Dismantling CHIP in Arizona: How Losing CHIP Impacts a Child’s Healthcare Costs,” Georgetown University Center for Children and Families and Children’s Action Alliance, May, http://ccf.georgetown.edu/wp-content/uploads/2014/05/Dismantling-CHIP-in-Arizona.pdf.

[3] Whitener, Kelly (2016), “CCF Research Helps Inform Debate Over Reinstating Arizona KidsCare,” Georgetown University Center for Children and Families, February 17, http://ccf.georgetown.edu/all/informing-debate-over-arizona-kidscare-chip-freeze/.

[4] Spitalnic, Paul (2015), “Estimated Effects of the Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2),” Centers for Medicare and Medicaid Services, April 9, https://www.cms.gov/research-statistics-data-and-systems/research/actuarialstudies/downloads/2015hr2a.pdf.

[5] U.S. Dept. of Health and Human Services, “HHS FY2017 Budget in Brief—CMS—CHIP,” http://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/chip/index.html.

[6] Arizona Health Care Cost Containment System (2016), “Fiscal Impact of KidsCare Restoration,” January (prepared for House Committee hearing at Legislature) and Alker, Joan (2016), “Breaking News: U.S. House Energy and Commerce Committee Moves to Cut CHIP Funding, Georgetown  University Center for Children and Families, March 14, http://ccf.georgetown.edu/all/breaking-news-u-s-house-energy-commerce-committee-moves-cut-chip-funding/.

[7] Email correspondence with Kelly Whitener of Georgetown University Center for Children and Families.

[8] Burak, Elisabeth Wright and Joseph Fu (2016), “Children’s Health Coverage in Arizona: How are Children Doing without KidsCare?” Georgetown University Center for Children and Families and Children’s Action Alliance, January, http://ccf.georgetown.edu/ccf-resources/childrens-health-care-coverage-in-arizona-without-kidscare/.

[9] Office of the Assistant Secretary for Planning and Evaluation (2016), “Addendum to the Health Insurance Marketplaces 2016 Open Enrollment Period: Final Enrollment Report,” U.S. Department of Health and Human Services, March 11, https://aspe.hhs.gov/sites/default/files/pdf/188026/MarketPlaceAddendumFinal2016.pdf.

[10] Calculation assumes based on the Dept. of Health and Human Services estimates that funding for CHIP displaces about half as much of a cost of subsidies through the Exchange.  The same 1.85 health care in state multiplier is used as was employed in the Grand Canyon Institute’s 2012 study on Medicaid Expansion.  So for $80 million x ½ x 1.85 = $74 million.  This represents the impact of an additional $40 million into Arizona beyond what is currently coming in via the Health Care Exchanges.

[11] Cohodes, Sarah, Daniel Grossman, Samuel Kleiner, and Michael Lovenheim (2015), “The Effect of Child Health Insurance Access on Schooling: Evidence from Public Health Insurance Expansions,” June 8, http://scholar.harvard.edu/files/cohodes/files/medicaid_edu_june2015.pdf (earlier version of paper available from National Bureau of Economic Research).

[12] For changes from 2013 to 2014 in healthcare coverage see Alker, Joan and Alisa Chester (2015), “Children’s Health Insurance Rates in 2014: ACA Results in Significant Improvements,” Georgetown University Center for Children and Families, October, http://ccf.georgetown.edu/ccf-resources/childrens-uninsured-rate-2014-affordable-care-act/.

[13] Arizona Health Care Cost Containment System, “AHCCCS Population Statistics,” https://www.azahcccs.gov/Resources/Reports/population.html. Population demographics accessed for April 1, 2016 when 592,000 children 0-17 were reported enrolled in AHCCCS acute excluding FES.

[14] See Appendix for derivation of this estimate.

[15] Sum, Andrew, Ishwar Khatiwada, Joseph McLaughlin, and Sheila Palma (2011), “High School Dropouts in Chicago and Illinois: The Growing Labor Market, Income, Civic, Social and Fiscal Costs of Dropping Out of High School,” Center for Labor Market Studies, Northeastern University, 2011, http://www.northeastern.edu/clms/wp-content/uploads/November-2011-High-School-Dropout-Paper.pdf.

[16] Abel, Jaison R. and Richard Deitz (2014), “Do the Benefits of College Still Outweigh the Costs?” Current Issues in Economics and Finance, Federal Reserve Bank of New York, Volume 20, Number 3, https://www.newyorkfed.org/medialibrary/media/research/current_issues/ci20-3.pdf.

[17] Sum, Andrew, Ishwar Khatiwada, Joseph McLaughlin, and Sheila Palma (2011), “High School Dropouts in Chicago and Illinois: The Growing Labor Market, Income, Civic, Social and Fiscal Costs of Dropping Out of High School,” Center for Labor Market Studies, Northeastern University, 2011, http://www.northeastern.edu/clms/wp-content/uploads/November-2011-High-School-Dropout-Paper.pdf.

[18] Ryan, Conor (2014), “Who Still Needs CHIP?” American Action Forum, Weekly Check-Up, September 15, http://www.americanactionforum.org/weekly-checkup/who-still-needs-chip/.

[19] Hiltzik, Michael (2016), “Yes Obamacare is in dire need of fixing: here’s a guide to the best options,” Los Angeles Times, January 4, http://www.latimes.com/business/hiltzik/la-fi-mh-yes-obamacare-is-in-desperate-need-of-fixing-here-s-a-guide-20160104-column.html.

[20] Burak, Elisabeth Wright and Joseph Fu (2016), “Children’s Health Coverage in Arizona: How are Children Doing without KidsCare?” Georgetown University Center for Children and Families and Children’s Action Alliance, January, http://ccf.georgetown.edu/ccf-resources/childrens-health-care-coverage-in-arizona-without-kidscare/.

[21] Office of the Assistant Secretary for Planning and Evaluation (2016), “Addendum to the Health Insurance Marketplaces 2016 Open Enrollment Period: Final Enrollment Report,” U.S. Department of Health and Human Services, March 11, https://aspe.hhs.gov/sites/default/files/pdf/188026/MarketPlaceAddendumFinal2016.pdf.

[22] American Community Survey, Arizona, Bureau of the Census, http://www.census.gov/quickfacts/table/PST045214/04.

[23] National Center for Children in Poverty, “Children in Arizona by Income Level, 2013,” http://www.nccp.org/profiles/AZ_profile_6.html.

[24] Cohodes, Sarah, Daniel Grossman, Samuel Kleiner, and Michael Lovenheim (2015), “The Effect of Child Health Insurance Access on Schooling: Evidence from Public Health Insurance Expansions,” June 8, http://scholar.harvard.edu/files/cohodes/files/medicaid_edu_june2015.pdf (earlier version of paper available from National Bureau of Economic Research).