Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act

Objectives. We examined preventive care use by nonelderly adults (aged 18–64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns.Methods. We used data from the 2005–2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income.Results. There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers.Conclusions. Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.The benefits of many preventive health care services are well-established.1 In the case of immunization, for instance, those who receive the recommended services are likely to avoid a variety of life-threatening diseases while promoting herd immunity and protecting individuals who are unable to be immunized.2 Those appropriately screened for cancer are likely to receive more timely diagnosis and treatment, which ultimately leads to better outcomes.3 Furthermore, early detection of heart disease, diabetes, and other chronic conditions can lead to the promotion of healthier lifestyles and better management of the diseases.4 Despite this evidence, many studies have shown the use of preventive services, including cholesterol checks, Papanicolaou (Pap) tests, mammograms, colon cancer screenings, and flu vaccines to be below recommended levels.5–9In recent years, the growing prevalence of obesity and chronic conditions and the evidence that modifiable behaviors are among the leading causes of death have led to a renewed emphasis on promoting health and wellness as opposed to treating disease.10,11 This emphasis on prevention was particularly evident in the national conversation leading up to the passage of the Affordable Care Act (ACA) in March 2010. Increasing access to preventive care was one motivation for expanding coverage to the uninsured, and was the explicit goal of an additional provision in the ACA requiring private insurers to cover recommended preventive services without any cost-sharing obligations to consumers. The effects of these ACA policies on preventive service use will depend on the extent to which preventive services are currently underused and whether expanding coverage will increase the receipt of these services.We examined the receipt of 8 preventive services by nonelderly adults in the years before the ACA (2005–2010), thus providing recent evidence on the extent of underuse of a variety of important services. Previous studies have found that lower rates of service use are generally associated with more limited education, low incomes, and a lack of insurance coverage12–14; we concentrated on the disparities in service use between the lower-income adults most likely to benefit from the ACA coverage expansion and their higher-income counterparts. Using a regression-based decomposition analysis, we identified the roles of insurance coverage, education, and other factors in explaining these income-related disparities. The results provide important insights on the potential of ACA efforts to increase the use of preventive care through coverage expansion as well as on the limitations of such efforts.Our conceptual framework relies on human capital models, which suggest that the demand for medical care is derived from the demand for health.15,16 According to such models, critical factors that are expected to affect the demand for health and medical care include age, health status, education, and rate of time preference. In some cases, the effects of these factors on demand for preventive care may be distinct from their effects on demand for treatment. In the case of age, for example, the demand for treatment, or curative care, is expected to increase with age as an individual’s health depreciates, whereas investment in preventive medical care is expected to decrease with age as the payoff period for avoiding future illness shortens.13,17 This reflects a more general distinction between investment and consumption considerations in the demand for preventive care, which is also relevant with respect to the role of health status. From a consumption perspective, those in poor health are more likely to use preventive services, but healthy individuals and those who are future-oriented are also more likely to invest in health and preventive care.18,19 Lastly, although the effect of education on the demand for health and health care is theoretically ambiguous,15 considerable empirical evidence finds a positive relationship between education and prevention activities.13,20–22Another critical consideration is the influence of insurance coverage on the demand for medical care. The direct effect of insurance is to lower the out-of-pocket cost of medical care and thus increase the demand for services. The RAND health insurance experiment provides the most rigorous evidence that this is the case,23 but many other studies provide empirical evidence that having health insurance is associated with increased utilization of medical care.24–27 The possibility exists, however, that because insurance coverage protects against the financial costs of adverse health events, it may reduce the incentive to invest in preventive care.17 Despite this potential for “ex ante moral hazard,” most empirical evidence finds that those with insurance coverage use more preventive care, including blood pressure screenings, mammograms, and other cancer screenings.28–30 Furthermore, those with more generous coverage and lower cost-sharing exhibit higher rates of preventive service use.31–33The ACA includes several components that expand coverage and reduce cost-sharing and thus have the potential to increase the receipt of recommended preventive care. The ACA includes an optional expansion of Medicaid for those with incomes less than 138% of the federal poverty level (FPL) and federal subsidies to purchase coverage in the new health insurance exchanges for those with incomes up to 400% of the FPL. The law also includes penalties for not having health insurance coverage and enhanced enrollment and outreach efforts. When fully implemented, the ACA is expected to significantly expand coverage, particularly among adults with incomes less than 400% of the FPL.34 Many of those becoming newly insured under the ACA are expected to experience improved access to recommended preventive services, given that these services will be included at no or low cost in exchange plans and under most Medicaid plans.In addition to the broader coverage expansions included in the ACA, the law includes new requirements for private health insurance coverage of a set preventive services rated “A” or “B” by the US Preventive Services Task Force.35 After September 2010, many private health plans were required to cover the specified services, and to do so at no cost to members. Although coverage for some of the ACA-mandated services is already relatively common, other services, such as diet and tobacco counseling, are likely to see expanded coverage under the law.36 Furthermore, with the notable exception of mammograms, few of the mandated services are currently required to be covered by private plans under state laws.37     

Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio's Medicaid Expansion Under the Affordable Care Act

BackgroundEnsuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio's Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum visit attendance, receipt of contraceptive counseling, and use of contraceptive methods.MethodsWe used Ohio's linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to December 2015) the ACA Medicaid expansion implementation period (N = 170,787 after exclusions). We categorized women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the association of the ACA expansion with their postpartum enrollment in Medicaid and use of services.ResultsWomen who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2 percentage point) increase in the likelihood of long-acting reversible contraceptive use.ConclusionsOhio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.     

Receipt of Preventive Health Services in Young Adults

PurposeTo examine self-reported rates and disparities in delivery of preventive services to young adults.MethodsA population-based cross-sectional analysis, of 3,670 and 3,621 young adults aged 18–26 years who responded to California Health Interview Survey (CHIS) in 2005 and CHIS 2007, respectively. The main outcome measures were self-reported receipt of flu vaccination, sexually transmitted disease (STD) screening, cholesterol screening, diet counseling, exercise counseling, and emotional health screening. Multivariate logistic regression was used to examine how age, gender, race/ethnicity, income, insurance, and usual source of care influence the receipt of preventive services.ResultsDelivery rates ranged from 16.7% (flu vaccine) to 50.6% (cholesterol screening). Being female and having a usual source of care significantly increased receipt of services, with female participants more likely to receive STD screening (p < .001), cholesterol screening (p < .01), emotional health screening (p < .001), diet counseling (p < .01), and exercise counseling (p < .05) than male participants after controlling for age, race/ethnicity, income, insurance, and usual source of care. Young adults with a usual source of care were more likely to receive a flu vaccine (p < .05), STD screening (p < .01), cholesterol screening (p < .001), diet counseling (p < .05), and exercise counseling (p < .05) than those without a usual source of care after adjusting for age, race/ethnicity, income, and insurance.ConclusionsRates of preventive services delivery are generally low. Greater efforts are needed to develop guidelines for young adults to increase the delivery of preventive care to this age-group, and to address the gender and ethnic/racial disparities in preventive services delivery.     

社区健康服务对儿童早期保健的影响

目的增强社区保健人员的儿童早期保健服务能力,提高儿童父母的育儿保健意识,促进儿童早期健康发展。方法通过社区健康干预为儿童提供早期保健服务,比较干预前后的社区医师的儿童早期保健专业技能、儿童父母的育儿知识、儿童父母对社区提供的儿童早期保健服务的认可度。结果通过儿童早期社区健康干预保健计划,社区医师的儿童早期保健专业技能有显著提高,儿童父母的育儿保健知识有所增加,儿童父母对社区提供的儿童早期保健服务的认可度有显著提升。结论儿童早期社区健康干预保健计划实施可提高社区儿童早期保健服务提供能力,增强儿童父母的儿童早期保健意识,有利于促进儿童早期健康发展。     

The Five-Year Effect of Medicaid Expansion on Community Health Centers: Coverage,Quality of Care,and Service Volume

Our objective was to assess the five-year impact of Medicaid expansion on community health centers using nationally representative data on all US health centers, where 35% of the patient population was uninsured prior to expansion. We examined the impact of expansion on insurance coverage and type, quality of care, and utilization of services. Understanding longer term effects of expansion is critical given that some quality measures may take multiple years to be clinically affected while pent-up demand may also result in short-term effects on utilization. Using the 2011-2018 Uniform Data System, we conducted a difference-in-differences (DID) analysis with inverse probability of treatment weights (IPTWs), based on propensity scores, to compare outcomes in centers located in expansion versus nonexpansion states. Outcomes included insurance coverage type (none, Medicaid, private), 47 utilization measures (number of patient visits) for select categories of service and chronic conditions based on CPT and ICD codes, and 8 primary care quality measures that may be sensitive to Medicaid expansion. Propensity scores included 23 baseline covariates (patient demographics, health center organizational features, county-level characteristics). For each measure, using IPTWs, a difference-in-difference was calculated using generalized linear models. We included a treatment indicator, time in postperiod indicator, treatment*post-time interaction, vector of time-variant covariates, state and year fixed effects, and clustered errors at the center-level. 100% sample of US health centers (N = 1061 centers/year, or 24.5 million patients/year, after exclusions). By 2018, compared to centers in nonexpansion states, centers in expansion states experienced a 12.0 percentage-point decrease in the percent patients without health insurance (P < .001) and a 13.2 percentage-point increase in those with Medicaid coverage (P < .001). These gains were largely driven by coverage gains in 2014-2015. Medicaid expansion was associated with improved quality of care for 5 of 8 measures, though relative gains in quality dissipated over the five-year postperiod for some measures (eg, asthma treatment) while relative gains for other measures (eg, colorectal cancer screening, diabetes control) were not detected until several years postexpansion. For instance, by 2018, expansion was a 4.5 percentage-point relative increase in rates of HbA1c control among diabetics (95% CI 2.2-6.8) and a 3.5 percentage-point relative increase in colorectal cancer screening rates (95% CI 0.1-6.9); neither measure was statistically affected until 3 years postexpansion. By 2018, Medicaid expansion was associated with relative increases in 31 of 47 patient visit measures. Effect sizes in 2018 were greatest for visits for HIV testing (IRR = 2.02), hepatitis C testing (IRR = 1.88), mammograms (IRR = 1.45), alcohol disorder (IRR = 1.50), depression (IRR = 1.47), and other mental health (IRR = 1.77) (P < .01). The first five years of Medicaid expansion were associated with increases in insurance coverage, measured quality, and visit volume among health center patients, where effects on quality of care for measures such as diabetes control were not detected until three years into the postperiod. Findings highlight the longer term, significant role of Medicaid expansion in improving quality and in building capacity for health centers. This is particularly important in light of federal and state decisions about the future of Medicaid and extension of health center grant funding. Agency for Healthcare Research and Quality.     

Tuberculosis Elimination Efforts in the United States in the Era of Insurance Expansion and the Affordable Care Act

The Patient Protection and Affordable Care Act can enhance ongoing efforts to control tuberculosis (TB) in the United States by bringing millions of currently uninsured Americans into the health-care system. However, much of the legislative and financial framework that provides essential public health services necessary for effective TB control is outside the scope of the law. We identified three key issues that will still need to be addressed after full implementation of the Affordable Care Act: (1) essential TB-related public health functions will still be needed and will remain the responsibility of federal, state, and local health departments; (2) testing and treatment for latent TB infection (LTBI) is not covered explicitly as a recommended preventive service without cost sharing or copayment; and (3) remaining uninsured populations will disproportionately include groups at high risk for TB. To improve and continue TB control efforts, it is important that all populations at risk be tested and treated for LTBI and TB; that testing and treatment services be accessible and affordable; that essential federal, state, and local public health functions be maintained; that private-sector medical/public health linkages for diagnosis and treatment be developed; and that health-care providers be trained in conducting appropriate LTBI and TB clinical care.Most provisions of the Patient Protection and Affordable Care Act (hereinafter, Affordable Care Act) went into effect in January 2014.¹ Its principal intents are to increase access to and affordability of health insurance, prohibit denial of coverage based on preexisting conditions, make improvements in health insurance, curb health-care costs, and improve health-care quality and outcomes.² In 2012, 46% (55 million) of adults aged 19–64 years in the United States had no health insurance for some time, and another 25% (30 million) had coverage that provided inadequate protection for health-care costs.³ The Congressional Budget Office estimated that the Affordable Care Act will extend insurance to approximately 92% of nonelderly (,65 years of age) legal U.S. residents by 2017.⁴In 2013, 9,582 U.S. cases of tuberculosis (TB) were reported, a rate of 3.0 per 100,000 population, and the lowest rate in the nation''s history.⁵ The nation''s efforts to eliminate TB will require continued commitment of health-care resources. However, much of the legislative and financial framework that allows for effective TB control is outside the scope of the Affordable Care Act.Although preventable and treatable, TB remains one of the world''s deadliest diseases, with an estimated 9 million cases and 1.5 million deaths worldwide in 2013.⁶ TB is principally caused by respiratory spread of Mycobacterium tuberculosis (M. tuberculosis), which most often affects the lungs but can also affect the spine, bones, brain, and other organs. If untreated, infected people may progress to active disease (referred to hereinafter as TB) within weeks, or may remain asymptomatic indefinitely (referred to hereinafter as having latent TB infection [LTBI]). An estimated one-third of the world''s population has LTBI.In the United States, diagnosis of a TB case activates a local public health response that includes identification and evaluation of all people who have had close contact with the case to identify quickly and treat other people with TB and LTBI and break the chain of transmission. These contact investigations, especially in congregate settings, are complex and labor-intensive; they often require large, flexible workforces for weeks or months, and are not reimbursed by health insurance.⁷ Other public sector activities directed at limiting TB transmission include the systematic gathering and reporting of case-specific data (surveillance), provision of state and/or national reference laboratory support, and provision of directly observed treatment (DOT) (i.e., having a health-care worker or other designated individual watch the TB patient swallow every dose of prescribed drug to assure treatment adherence and prevent development of drug resistance).⁸ Most of these activities are not supported by health insurance.Outpatient medical costs of treating a drug-susceptible TB case (using the standard regimen of two months of isoniazid, rifampin, pyrazinamide, and ethambutol, followed by four months of isoniazid and rifampin) are substantial, estimated at $3,970 in 2004 ($5,000 in 2013 dollars).⁹ An estimated 49% of U.S. patients with TB are hospitalized, either as part of their initial diagnostic work-up or as part of their treatment, which (including the costs of physicians) would cost an additional estimated $27,900 in 2013 dollars per person hospitalized.^10,11 To increase adherence and treatment completion, the Centers for Disease Control and Prevention (CDC) recommends providing DOT to all people with TB,¹² to all people with LTBI who are <5 years of age, to all people with LTBI who are receiving intermittent dosing regimens,^13,14 and to all those who are at high risk for TB and/or have characteristics that make them unlikely to complete treatment.¹⁴ Unfortunately, patients under TB care in the private sector are less likely to receive DOT,¹⁵ are less likely to have documented culture conversion of sputum cultures from M. tuberculosis positive to negative,¹⁵ and have a higher risk of death.¹⁶Insurance expansions that are part of the Affordable Care Act can enhance efforts to control TB by bringing millions of uninsured Americans into the health-care system.^2,3 The closest model of an insurance expansion to the Affordable Care Act has been the subsidized health-care insurance experience in Massachusetts; in that setting, cost reductions have been observed even with increased access to and use of preventive services.¹⁷ Although the Affordable Care Act is focused on access to diagnosis, care, and prevention, controlling TB entails public health activities that are beyond the capacity of most private practitioners and that are not expected to be affected by the law. These public health activities include:

• Administration of DOT to all TB patients and to high-risk groups and children with LTBI;
• Controlling TB outbreaks and conducting contact investigations;
• Surveillance;
• Overseas screening and post-entry follow-up of immigrants and refugees for TB and LTBI;
• Epidemiologic, programmatic, laboratory, and clinical research to improve diagnosis, treatment, and prevention;
• Development, implementation, and evaluation of guidelines, policies, and protocols;
• Ensuring an uninterrupted supply of TB drugs and diagnostics;
• Providing regional and national TB laboratory services including diagnostic smears and culture of sputum and tissue, rapid molecular testing for diagnosis and drug-susceptibility testing, and genotyping of isolates;
• Providing free training for and expert consultation to public and private practitioners; and
• Legal actions (e.g., proceedings to ensure isolation, travel restriction, or detention of infectious people).¹⁸

     

Whether Health Departments Should Provide Clinical Services After the Implementation of the Affordable Care Act

I have described a decision support tool that may facilitate local decisions regarding the provision and billing of clinical services. I created a 2 by 2 matrix of health professional shortage and Medicaid expansion availability as of July 2015. I found that health departments in 93% of US counties may still need to provide clinical services despite the institution of the Affordable Care Act. Local context and market conditions should guide health departments’ decision to act as safety net providers.Because more individuals have health insurance coverage as a result of the Affordable Care Act, health departments grapple with the question of whether to continue to provide clinical services such as maternal and child health, oral health, and HIV/AIDS treatment and, if so, whether to seek reimbursement from third party payers.1 In fact, a 2012 Institute of Medicine report states,

As clinical care provision in a community no longer requires financing by public health departments, public health departments should work with other public and private providers to develop adequate alternative capacity in a community’s clinical care delivery.2^(p68)

The decision to provide clinical services and pursue reimbursement is complex,3 and that complexity will likely increase as reimbursement moves to new models such as accountable care organizations. Health departments must decide whether it makes sense to provide clinical services on the basis of local context and, if so, whether to seek reimbursement.4 As of 2013, a minority of local health departments provided clinical services such as maternal and child health, oral health, and HIV/AIDS treatment,5 although a 2014 report showed that, of those who do, the majority bill some form of third party payment.6 I tested a simple decision support tool that might be used to facilitate local decision-making.     

Health Care Utilization and Receipt of Preventive Care for Patients Seen at Federally Funded Health Centers Compared to Other Sites of Primary Care

Objective

To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings.

Data Sources

A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004–2008).

Study Design

HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients.

Principal Findings

Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients.

Conclusions

Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.     

Medicaid Primary Care Physician Fees and the Use of Preventive Services among Medicaid Enrollees

Objective

The Patient Protection and Affordable Care Act (ACA) increases Medicaid physician fees for preventive care up to Medicare rates for 2013 and 2014. The purpose of this paper was to model the relationship between Medicaid preventive care payment rates and the use of U.S. Preventive Services Task Force (USPSTF)–recommended preventive care use among Medicaid enrollees.

Data Sources/Study Session

We used data from the 2003 and 2008 Medical Expenditure Panel Survey (MEPS), a national probability sample of the U.S. civilian, noninstitutionalized population, linked to Kaiser state Medicaid benefits data, including the state Medicaid-to-Medicare physician fee ratio in 2003 and 2008.

Study Design

Probit models were used to estimate the probability that eligible individuals received one of five USPSF-recommended preventive services. A difference-in-difference model was used to separate out the effect of changes in the Medicaid payment rate and other factors.

Data Collection/Extraction Methods

Data were linked using state identifiers.

Principal Findings

Although Medicaid enrollees had a lower rate of use of the five preventive services in univariate analysis, neither Medicaid enrollment nor changes in Medicaid payment rates had statistically significant effects on meeting screening recommendations for the five screenings. The results were robust to a number of different sensitivity tests. Individual and state characteristics were significant.

Conclusions

Our results suggest that although temporary changes in primary care provider payments for preventive services for Medicaid enrollees may have other desirable effects, they are unlikely to substantially increase the use of these selected USPSTF-recommended preventive care services among Medicaid enrollees.     

Young Adult Preventive Healthcare: Changes in Receipt of Care Pre- to Post-Affordable Care Act

PurposeYoung adults have unique health and health care needs. Although morbidity and mortality stem largely from preventable factors, they lack a structured set of preventive care guidelines. The Affordable Care Act (ACA), enacted in 2010, increased young adult insurance coverage, prohibited copayments for preventive visits among privately insured and for many preventive services. The objectives were to evaluate pre- to post-ACA changes in young adults' past-year well visits and, among those using a past-year health care visit, the receipt of preventive services.MethodsWe used pooled Medical Expenditure Panel Survey data, comparing pre-ACA (2007–2009, N = 10,294) to post-ACA (2014–2016, N = 10,567) young adults aged 18–25 years. Bivariable and multivariable stratified logistic regression, adjusting for sociodemographic covariates, were conducted to determine differences in well visits and in preventive services among past-year health care utilizers: blood pressure and cholesterol checks, influenza immunization, and all three received.ResultsPast-year well visits increased from pre-ACA (28%) to post-ACA (32%), p < .001. Increases were noted for most demographic subgroups with greatest increases among males, Asian, and highest income subgroups. Larger pre- to post-ACA increases were found for most of the preventive services, p < .05, including the receipt of all three services (7% vs. 16%), p < .001, among past-year health care utilizers.ConclusionFollowing ACA implementation, young adults experienced modest increases in well visit rates and larger increases in most preventive services received. Overall rates of both remain low. Building on these improvements requires concerted efforts that account for young adults' unique combination of health care issues and challenges in navigating an adult health care system.     

Young Adults' Health Care Utilization and Expenditures Prior to the Affordable Care Act

PurposeTo examine young adults' health care utilization and expenditures prior to the Affordable Care Act.MethodsWe used 2009 Medical Expenditure Panel Survey to (1) compare young adults' health care utilization and expenditures of a full-spectrum of health services to children and adolescents and (2) identify disparities in young adults' utilization and expenditures, based on access (insurance and usual source of care) and other sociodemographic factors, including race/ethnicity and income.ResultsYoung adults had (1) significantly lower rates of overall utilization (72%) than other age groups (83%–88%, p < .001), (2) the lowest rate of office-based utilization (55% vs. 67%–77%, p < .001) and (3) higher rate of emergency room visits compared with adolescents (15% vs. 12%, p < .01). Uninsured young adults had high out-of-pocket expenses. Compared with the young adults with private insurance, the uninsured spent less than half on health care ($1,040 vs. $2,150/person, p < .001) but essentially the same out-of-pocket expenses ($403 vs. $380/person, p = .57). Among young adults, we identified significant disparities in utilization and expenditures based on the presence/absence of a usual source of care, race/ethnicity, home language, and sex.ConclusionsYoung adults may not be utilizing the health care system optimally by having low rates of office-based visits and high rates of emergency room visits. The Affordable Care Act provision of insurance for those previously uninsured or under-insured will likely increase their utilization and expenditures and lower their out-of-pocket expenses. Further effort is needed to address noninsurance barriers and ensure equal access to health services.