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.     

Reducing Ex-offender Health Disparities through the Affordable Care Act: Fostering Improved Health Care Access and Linkages to Integrated Care

Despite steadily declining incarceration rates overall, racial and ethnic minorities, namely African Americans, Latinos, and American Indians and Alaska Natives, continue to be disproportionately represented in the justice system. Ex-offenders commonly reenter communities with pressing health conditions but encounter obstacles to accessing care and remaining in care. The lack of health insurance coverage and medical treatment emerge as the some of the most reported reentry health needs and may contribute to observed health disparities. Linking ex-offenders to care and services upon release increases the likelihood that they will remain in care and practice successful disease management. The Affordable Care Act (ACA) offers opportunities to address health disparities experienced by the reentry population that places them at risk for negative health outcomes and recidivism. Coordinated efforts to link ex-offenders with these newly available opportunities may result in a trajectory for positive health and overall well-being as they reintegrate into society.     

Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

Research Objective

To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent''s private health plan. Nearly one-in-three young adults lacked coverage before the ACA.

Study Design, Methods, and Data

Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.

Principal Findings

This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.

Conclusions and Implications

ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.     

Immigrants and the Affordable Care Act: Changes in Coverage and Access to Care by Documentation Status

Little is known about the effects of the ACA’s coverage expansion among immigrant groups of differing immigration status. Using data from the California Health Interview Survey (2003–2016), we compare changes in health coverage and access to care among immigrants in California before and after implementation of the ACA. We find that the ACA has led to major gains in coverage for lawful permanent residents in California, similar in scope to changes among citizens. However, unauthorized immigrants have experienced only modest increases in coverage, with the result disparity in uninsured rates for this group relative to citizens and permanent residents widening considerably since 2014. Findings indicate a significant increase in having a usual source of care across all groups, but without a significant change in disparities for this outcome. Our results have important implications for the intersection of health policy, immigration, and health equity.

     

Health insurance reform and retirement: Evidence from the Affordable Care Act

The Affordable Care Act (ACA) has provided millions of Americans with medical insurance but may have led to an increase in retirement among older individuals who are utilizing the newly available coverage options as a substitute for employer‐provided insurance. Using data from the American Community Survey from 2009–2016, this hypothesis is tested by estimating the effect of the premium subsidies and Medicaid expansions of the ACA on retirement transitions for the non‐Medicare eligible cohort of older Americans aged 55–64. Research results indicate a 2% and 8% decrease in labor force participation resulting from the premium subsidies and Medicaid expansions, respectively. Slightly larger estimates are found among a subgroup of adult couples. The study also finds suggestive evidence of crowd‐out of employer‐sponsored insurance by subsidized marketplace plans but finds no such effects from the Medicaid expansions.     

Access to Health Insurance and Utilization of Substance Use Disorder Treatment: Evidence from the Affordable Care Act Dependent Coverage Provision

The relationship between insurance coverage and use of specialty substance use disorder (SUD) treatment is not well understood. In this study, we add to the literature by examining changes in admissions to SUD treatment following the implementation of a 2010 Affordable Care Act provision requiring health insurers to offer dependent coverage to young adult children of their beneficiaries under age 26. We use national administrative data on admissions to specialty SUD treatment and apply a difference‐in‐differences design to study effects of the expansion on the rate of treatment utilization among young adults and, among those in treatment, changes in insurance status and payment source. We find that admissions to treatment declined by 11% after the expansion. However, the share of young adults covered by private insurance increased by 5.4 percentage points and the share with private insurance as the payment source increased by 3.7 percentage points. This increase was largely offset by decreased payment from government sources. Copyright © 2017 John Wiley & Sons, Ltd.     

Providing Health Information to Latino Farmworkers: The Case of the Affordable Care Act

Objective: Providing health program information to vulnerable communities, such as Latino farmworkers, is difficult. This analysis describes the manner in which farmworkers receive information about the Affordable Care Act, comparing farmworkers with other Latinos. Methods: Interviews were conducted with 100 Latino farmworkers and 100 urban Latino North Carolina residents in 2015. Results: Most farmworkers had received health information from a community organization. Trusted sources for health information were health care providers and community organizations. Sources that would influence decisions to enroll were Latino nurses and doctors, religious leaders, and family members. Traditional media, including oral presentation and printed material at the doctor’s office, were preferred by the majority of farmworkers and non-farmworkers. Farmworkers used traditional electronic media: radio, television, and telephone. More non-farmworkers used current electronic media: e-mail and Internet. Conclusions: Latino farmworkers and non-farmworkers prefer traditional media in the context of a health care setting. They are willing to try contemporary electronic media for this information.     

An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act

The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.     

How the Affordable Care Act and Mental Health Parity and Addiction Equity Act Greatly Expand Coverage of Behavioral Health Care

The Patient Protection and Affordable Care Act (ACA) will expand coverage of mental health and substance use disorder benefits and federal parity protections to over 60 million Americans. The key to this expansion is the essential health benefit provision in the ACA that requires coverage of mental health and substance use disorder services at parity with general medical benefits. Other ACA provisions that should improve access to treatment include requirements on network adequacy, dependent coverage up to age 26, preventive services, and prohibitions on annual and lifetime limits and preexisting exclusions. The ACA offers states flexibility in expanding Medicaid (primarily to childless adults, not generally eligible previously) to cover supportive services needed by those with significant behavioral health conditions in addition to basic benefits at parity. Through these various new requirements, the ACA in conjunction with Mental Health Parity and Addiction Equity Act (MHPAEA) will expand coverage of behavioral health care by historic proportions.     

Barriers to Contraceptive Access after Health Care Reform: Experiences of Young Adults in Massachusetts

ObjectiveTo explore how Massachusetts' 2006 health insurance reforms affected access to sexual and reproductive health (SRH) services for young adults.Study DesignWe conducted 11 focus group discussions across Massachusetts with 89 women and men aged 18 to 26 in 2009.ResultsMost young adults' primary interaction with the health system was for contraceptive and other SRH services, although they knew little about these services. Overall, health insurance literacy was low. Parents were primary decision makers in health insurance choices or assisted their adult children in choosing a plan. Ten percent of our sample was uninsured at the time of the discussion; a lack of knowledge about provisions in Chapter 58 rather than calculated risk analysis characterized periods of uninsurance. The dynamics of being transitionally uninsured, moving between health plans, and moving from a location defined by insurance companies as the coverage area limited consistent access to contraception. Notably, staying on parents' insurance through extended dependency, a provision unique to the post-reform context, had implications for confidentiality and access.ConclusionsYoung adults' access to and utilization of contraceptive services in the post-reform period were challenged by unanticipated barriers related to information and privacy. The experience in Massachusetts offers instructive lessons for the implementation of national health care reform. Young adult-targeted efforts should address the challenges of health service utilization unique to this population.     

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