The effect of Medicaid expansion on crime reduction: Evidence from HIFA-waiver expansions☆
Introduction
Substance use and crime are two of the most intractable social ills facing the United States, and they are inextricably linked. A positive correlation between substance use and crime has been observed in arrestee drug test results and inmate drug reports. Among arrestees who were booked on violent or property crimes, one in every four tested positive for illicit drug use at the time of arrest (ONDCP, 2012). Moreover, among prison inmates charged with violent crimes, 52% reported being under the influence of alcohol or drugs when committing the crime, or committing the crime to acquire money to purchase drugs; among those charged with property crimes, this number is 39% (Miller et al., 2006).
To the extent that this observed correlation involves causality running from substance use to crime, interventions to reduce substance use should also reduce crime. Nonetheless, empirical evidence suggests that punitive approaches to substance control such as prohibition and the “war on drugs” have not led to significant crime reduction (Miron, 1999, Kuziemko and Levitt, 2004, Markowitz, 2005).1
In this paper we explore an area that has garnered relatively little attention in the economic literature on crime reduction, namely public health insurance policy. Using county-level panels of crime data between 2001 and 2008 across the United States, we examine the crime-reduction effect of state Medicaid expansions through Health Insurance Flexibility and Accountability (HIFA) waivers (CMS, 2001). The HIFA initiative provides states with federal matching funds to expand Medicaid to all low-income adults with family incomes up to 200% FPL in states. We also explore the extent that state HIFA-waiver expansions provide plausibly exogenous shocks for local SUD treatment rate, which serves as one of the potential pathways to substance use reduction and eventually leads to crime reduction. Our estimates reveal that state HIFA-waiver expansions are associated with an economically meaningful reduction in the rates of specific types of crimes for which theory suggests an increase in the SUD treatment rate should have an effect (i.e., robbery, aggravated assault and larceny theft). Our estimates also suggest that the effect of the HIFA-waiver expansions on increasing SUD treatment rate and reducing substance use prevalence is likely to be one of the driving forces behind the estimated crime-reduction effect.
This study has implications for both public health insurance policy and public safety policy. It provides previously undocumented evidence of significant reductions in crime rates arising from state Medicaid expansions. This has direct relevance to the current health care reform discussions surrounding insurance expansion and “mainstreaming” of SUD treatment. While the political sea change may lead to repeal of the Affordable Care Act (ACA), the effect of insurance expansion on social outcomes, such as crime reduction, may still be of interest for policy and research. We show that a set of state Medicaid expansions preceding the ACA benefitted people with SUDs by providing a cost-effective public health approach to crime reduction, partially through increasing their treatment use and reducing their substance use.
Previous studies of the economic benefits of SUD treatment have often emphasized the direct health returns on treatment through recovery from addiction and the related productivity gains (Belenko et al., 2005). We instead focus on the public finance aspects of SUD treatment and take a more comprehensive view of the cost of crime to the public sector, including direct, indirect and opportunity costs. Our instrumental variable (IV) estimates demonstrate a benefit-cost ratio of 1.8 to 3.2, that is, a 10 percent relative increase in the SUD treatment rate at an average cost of $1.6 billion yields a crime reduction benefit of $2.9 billion to $5.1 billion. This downstream benefit to public safety represents a sizable fraction of returns on SUD treatment. Specifically, as the U.S. criminal justice system scales back mandatory minimum sentences for low-level drug and other minor offenders who may also be substance users, replacing incarceration with better access to SUD treatment can be a cost-effective investment in public safety.
Section snippets
Theories of substance use, SUD treatment and crime
Contemporary criminological theories suggest that substance use is one of the root causes of crime. The most cited criminological theory on this causal relationship is Goldstein's (2003) tripartite model, in which three hypotheses are provided to explain how substance use causes violent and property crimes. First, the pharmacological hypothesis states that violence may occur as a direct result of the intoxication. Intoxication of certain substances may trigger aggression and lead to violent
Data
Our data consists of a panel of annual, county-level observations between 2001 and 2008. Data sources include the Uniform Crime Reports (UCR), the National Survey of Substance Abuse Treatment Services (N-SSATS), and other nationally representative datasets that provide supplementary information on important local-level socioeconomic and policy contextual measures (Table 1).
Estimating the main effect of HIFA-waiver expansions on crime rates
We used a two-way (i.e., county and year) fixed effects model to estimate the effect of state HIFA-waiver expansions on county crime rates to isolate the within-local variations over time: where c denotes county, s denotes state, t denotes year. ρc represents county fixed effects and τt represents year fixed effects. The two-way (i.e., county and year) fixed effects account for the time-invariant county heterogeneity and the national
Estimating the pathway effects of HIFA-waiver expansions on SUD treatment rate and of SUD treatment rate on crime rates
We first used a two-way fixed effects model to estimate the pathway effect of state HIFA-waiver expansions on county SUD treatment rate similar to the one used to estimate crime rates:
As in Eq. (11), we included in Eq. (12) ρc and τt to adjust for the time-invariant county heterogeneity and the national secular trend. We also included the full set of covariate vectors Xc,s,t and Xs,t to account for the time-varying county-level
Estimating the pathway effect of SUD treatment rate on substance use prevalence
We took one step further to explore the pathway effect of SUD treatment rate on substance use prevalence using a TSLS model similar to the one used to estimate the pathway effect of treatment rate on crime rates. The previous Eqs. (13), (14) capture the TSLS Stage I, and the following Eq. (16) captures the TSLS Stage II. Note that the level of aggregation here is substate region denoted by r. Our final sample includes a balanced panel of 347 substate regions over 8 years.
Discussion
Expanding public insurance coverage holds the potential to increase individual SUD treatment use, reduce substance use, and promote public safety through crime reduction. The main contribution of our study is that we uncovered a heretofore unrecognized relationship between the implementation of Medicaid expansions and the reduction in crime rates: we found that Medicaid expansions under HIFA-waiver reduced the rates of robbery, aggravated assault and larceny theft. Our study also contributes to
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We appreciate helpful comments on earlier drafts of this work from Joseph Doyle, Harold Pollack, Chad Meyerhoefer, Sara Markowitz, Alison Cuellar, as well as anonymous journal reviewers, participants at the 2014 ASHEcon Fifth Biennial Conference and the 2013 AcademyHealth's Annual Research Meeting, and seminar participants at Emory University. All errors are our own.