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Journal of General Internal Medicine

, Volume 34, Issue 1, pp 65–74 | Cite as

Inequalities in Young Adult Health Insurance Coverage Post-federal Health Reform

  • Lauren E. WiskEmail author
  • Niraj Sharma
Original Research

Abstract

Background

Uninsurance for young adults (YAs) was greatly reduced by the Affordable Care Act (ACA). However, reforms may not be equally beneficial for all YAs and certain policies may exacerbate, rather than resolve, pre-existing disparities.

Objective

To investigate inequalities in YAs’ insurance coverage pre- (2000–2010) and post-federal health reforms (dependent coverage expansion, 2010–2013, and Medicaid/Marketplace expansions, 2014–2016), among a nationally representative sample.

Design

A difference-in-differences estimator (controlling for sociodemographics) was used to determine the effects of the ACA for young adults (ages 19–25) compared to adolescents (ages 13–18) and older YA (ages 26–30) counterparts; triple-difference estimators quantified differential policy effects by sociodemographics.

Participants

Three hundred eighty-seven thousand six hundred thirty-five participants in the 2000–2016 National Health Interview Survey.

Main Measures

Respondents reported their health insurance coverage types during the last 12 months, reasons uninsured, and detailed sociodemographics.

Key Results

An adjusted difference-in-differences estimator quantified a 12.3 percentage point increase (p < 0.0001) in full-year coverage post-ACA for YAs compared to older counterparts, driven by increases in employer-sponsored private insurance while younger and older youth saw larger gains in Medicaid coverage. Triple-difference estimators identified subgroups experiencing less beneficial dependent coverage expansion effects, including females, lower socioeconomic status, non-citizens, non-English speakers, and several racial/ethnic minority groups. Later ACA reforms (Marketplace/Medicaid expansions) mitigated many of these widening disparities.

Conclusion

While the ACA significantly impacted YA insurance coverage, these gains were not of equal magnitude for all YAs and disparities remain. As such, more work needs to be done to ensure optimal and equitable access to high-quality, affordable insurance for all YAs.

KEY WORDS

insurance coverage National Health Policy health care disparities adolescence young adult 

Notes

Acknowledgments

We wish to thank the anonymous reviewers for their helpful comments which greatly improved the content of this paper. We presented earlier versions of the manuscript at the Society for General Internal Medicine meeting (Denver, 2018) and the Society for Adolescent Health and Medicine meeting (Seattle, 2018).

Support

This work was financially supported by the Office of Faculty Development (OFD)/Basic/Translational Executive Committee (BTREC)/Clinical and Translational Research Executive Committee (CTREC) Faculty Career Development Fellowship 400384 (PI: Wisk) and Agency for Healthcare Research and Quality K12HS022986 (PI: Finkelstein).

Compliance with Ethical Standards

Disclaimer

The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

References

  1. 1.
    Clarke TC, Norris T, Schiller JS. Early release of selected estimates based on data from the 2016 National Health Interview Survey. National Center for Health Statistics; 2017. Available at: https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201705.pdf. Accessed 27 Nov 2017.
  2. 2.
    Callahan ST, Cooper WO. Uninsurance and health care access among young adults in the United States. Pediatrics. 2005;116(1):88–95.CrossRefGoogle Scholar
  3. 3.
    Majerol M, Newkirk V, Garfield R. The uninsured: a primer – key facts about health insurance and the uninsured in America. Menlo Park: Kaiser Family Foundation; 2015.Google Scholar
  4. 4.
    Sommers BD, Kronick R. The Affordable Care Act and insurance coverage for young adults. JAMA. 2012;307(9):913–914.CrossRefGoogle Scholar
  5. 5.
    Wisk LE, Finkelstein JA, Toomey SL, Sawicki GS, Schuster MA, Galbraith AA. Impact of an individual mandate and other health reforms on dependent coverage for adolescents and young adults. Health Serv Res. 2018;53(3):1581–1599.CrossRefGoogle Scholar
  6. 6.
    McMorrow S, Kenney GM, Long SK, Anderson N. Uninsurance among young adults continues to decline, particularly in Medicaid expansion states. Health Aff. 2015;34(4):616–620.CrossRefGoogle Scholar
  7. 7.
    Buchmueller TC, Levinson ZM, Levy HG, Wolfe BL. Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage. Am J Pub Health. 2016;106(8):1416–1421.CrossRefGoogle Scholar
  8. 8.
    Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN. Racial and ethnic disparities in health care access and utilization under the affordable care act. Med Care. 2016;54(2):140–146.CrossRefGoogle Scholar
  9. 9.
    Gonzales S, Sommers BD. Intra-ethnic coverage disparities among latinos and the effects of health reform. Health Serv Res. 2018;53(3):1373–1386.CrossRefGoogle Scholar
  10. 10.
    Griffith K, Evans L, Bor J. The affordable care act reduced socioeconomic disparities in health care access. Health Aff. 2017.  https://doi.org/10.1377/hlthaff.2017.0083.
  11. 11.
    Hayes SL, Riley P, Radley DC, McCarthy D. Reducing racial and ethnic disparities in access to care: has the affordable care act made a difference?. Issue Brief (Commonw Fund). 2017;20171–14.Google Scholar
  12. 12.
    Kennedy J, Wood EG, Frieden L. Disparities in insurance coverage, health services use, and access following implementation of the affordable care act: a comparison of disabled and nondisabled working-age adults. Inquiry. 2017;54:46958017734031.PubMedGoogle Scholar
  13. 13.
    Look KA, Kim NH, Arora P. Effects of the affordable care act’s dependent coverage mandate on private health insurance coverage in urban and rural areas. J Rural Health. 2017;33(1):5–11.CrossRefGoogle Scholar
  14. 14.
    Lipton BJ, Decker SL, Sommers BD. The affordable care act appears to have narrowed racial and ethnic disparities in insurance coverage and access to care among young adults. Med Care Res Rev. 2017:1077558717706575.  https://doi.org/10.1177/1077558717706575.
  15. 15.
    Blewett LA, Drew JAR, Griffin R, King ML, Williams K. IPUMS Health Surveys: National Health Interview Survey, Version 6.2. Minneapolis: University of Minnesota; 2016.Google Scholar
  16. 16.
    United States Census Bureau. Current Population Survey (CPS) Health Insurance Definitions. Glossary. Available at: https://www.census.gov/topics/health/health-insurance/about/glossary.htmlf. Accessed 24 March 2016.
  17. 17.
    Buchmueller TC, Monheit AC. Employer-sponsored health insurance and the promise of health insurance reform. Inquiry. 2009;46(2):187–202.CrossRefGoogle Scholar
  18. 18.
    Wong CA, Asch DA, Vinoya CM, et al. The experience of young adults on HealthCare.gov: suggestions for improvement. Ann Intern Med. 2014;161(3):231–232.CrossRefGoogle Scholar
  19. 19.
    Busch SH, Golberstein E, Meara E. ACA dependent coverage provision reduced high out-of-pocket health care spending for young adults. Health Aff. 2014;33(8):1361–1366.CrossRefGoogle Scholar
  20. 20.
    Chen J, Vargas-Bustamante A, Novak P. Reducing young adults’ health care spending through the aca expansion of dependent coverage. Health Serv Res. 2017;52(5):1835–1857.CrossRefGoogle Scholar
  21. 21.
    Chua KP, Sommers BD. Changes in health and medical spending among young adults under health reform. JAMA. 2014;311(23):2437–2439.CrossRefGoogle Scholar
  22. 22.
    Mulcahy A, Harris K, Finegold K, Kellermann A, Edelman L, Sommers BD. Insurance coverage of emergency care for young adults under health reform. N Engl J Med. 2013;368(22):2105–2112.CrossRefGoogle Scholar
  23. 23.
    Akosa Antwi Y, Moriya AS, Simon K, Sommers BD. Changes in emergency department use among young adults after the patient protection and affordable care act's dependent coverage provision. Ann Emerg Med. 2015;65(6):664–672 e662.CrossRefGoogle Scholar
  24. 24.
    Barbaresco S, Courtemanche CJ, Qi Y. Impacts of the Affordable Care Act dependent coverage provision on health-related outcomes of young adults. J Health Econ. 2015;40:54–68.CrossRefGoogle Scholar
  25. 25.
    Blum AB, Kleinman LC, Starfield B, Ross JS. Impact of state laws that extend eligibility for parents' health insurance coverage to young adults. Pediatrics. 2012;129(3):426–432.CrossRefGoogle Scholar
  26. 26.
    Han X, Yabroff KR, Robbins AS, Zheng Z, Jemal A. Dependent coverage and use of preventive care under the Affordable Care Act. N Engl J Med. 2014;371(24):2341–2342.CrossRefGoogle Scholar
  27. 27.
    Lipton BJ, Decker SL. ACA provisions associated with increase in percentage of young adult women initiating and completing The HPV vaccine. Health Aff. 2015;34(5):757–764.CrossRefGoogle Scholar
  28. 28.
    Robbins AS, Han X, Ward EM, Simard EP, Zheng Z, Jemal A. Association between the Affordable Care Act dependent coverage expansion and cervical cancer stage and treatment in young women. JAMA. 2015;314(20):2189–2191.CrossRefGoogle Scholar
  29. 29.
    Sommers BD, Buchmueller T, Decker SL, Carey C, Kronick R. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. Health Aff. 2013;32(1):165–174.CrossRefGoogle Scholar
  30. 30.
    Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization and health among low-income adults after medicaid expansion or expanded private insurance. JAMA Intern Med. 2016;176(10):1501–1509.CrossRefGoogle Scholar
  31. 31.
    Galbraith AA, Wong ST, Kim SE, Newacheck PW. Out-of-pocket financial burden for low-income families with children: socioeconomic disparities and effects of insurance. Health Serv Res. 2005;40(6 Pt 1):1722–1736.CrossRefGoogle Scholar
  32. 32.
    Wisk LE, Gangnon R, Vanness DJ, Galbraith AA, Mullahy J, Witt WP. Development of a novel, objective measure of health care-related financial burden for U.S. families with children. Health Serv Res. 2014;49(6):1852–1874.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Wisk LE, Witt WP. Predictors of delayed or forgone needed health care for families with children. Pediatrics. 2012;130(6):1027–1037.CrossRefGoogle Scholar
  34. 34.
    Harris SK, Aalsma MC, Weitzman ER, et al. Research on clinical preventive services for adolescents and young adults: where are we and where do we need to go?. J Adolesc Health. 2017;60(3):249–260.CrossRefGoogle Scholar
  35. 35.
    Wisk LE, Finkelstein JA, Sawicki GS, et al. Predictors of timing of transfer from pediatric- to adult-focused primary care. JAMA Pediatr. 2015;169(6):e150951.CrossRefGoogle Scholar
  36. 36.
    Pande AH, Ross-Degnan D, Zaslavsky AM, Salomon JA. Effects of healthcare reforms on coverage, access, and disparities: quasi-experimental analysis of evidence from Massachusetts: Am J Prev Med. 2011;41(1):1–8.CrossRefGoogle Scholar
  37. 37.
    Grace AM, Horn I, Hall R, Cheng TL. Children, families, and disparities: pediatric provisions in the Affordable Care Act: Pediatr Clin N Am. 2015;62(5):1297–1311.CrossRefGoogle Scholar
  38. 38.
    Castor ML, Smyser MS, Taualii MM, Park AN, Lawson SA, Forquera RA. A nationwide population-based study identifying health disparities between American Indians/Alaska Natives and the general populations living in select urban counties. Am J Public Health. 2006;96(8):1478–1484.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  1. 1.Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital and Department of PediatricsHarvard Medical SchoolBostonUSA
  2. 2.Division of General Medicine, Department of MedicineBrigham and Women’s HospitalBostonUSA
  3. 3.Division of General Pediatrics, Department of PediatricsBoston Children’s HospitalBostonUSA
  4. 4.Harvard Medical SchoolBostonUSA

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