Did the Affordable Care Act's Dependent Coverage Expansion Affect Race/Ethnic Disparities in Health Insurance Coverage?
Ontology highlight
ABSTRACT: Objective
To test the impact of the dependent coverage expansion (DCE) on insurance disparities across race/ethnic groups.Data sources/study setting
Survey data from the National Survey of Drug Use and Health (NSDUH).Study design
Triple-difference (DDD) models were applied to repeated cross-sectional surveys of the U.S. adult population.Data collection/extraction methods
Data from 6 years (2008-2013) of the NSDUH were combined.Principal findings
Following the DCE, the relative odds of insurance increased 1.5 times (95 percent CI 1.1, 1.9) among whites compared to blacks and 1.4 times (95 percent CI 1.1, 1.8) among whites compared to Hispanics.Conclusions
Health reform efforts, such as the DCE, can have negative effects on race/ethnic disparities, despite positive impacts in the general population.
SUBMITTER: Breslau J
PROVIDER: S-EPMC5867154 | biostudies-literature | 2018 Apr
REPOSITORIES: biostudies-literature
Publications
Did the Affordable Care Act's Dependent Coverage Expansion Affect Race/Ethnic Disparities in Health Insurance Coverage?
Breslau Joshua J Han Bing B Stein Bradley D BD Burns Rachel M RM Yu Hao H
Health services research 20170608 2
<h4>Objective</h4>To test the impact of the dependent coverage expansion (DCE) on insurance disparities across race/ethnic groups.<h4>Data sources/study setting</h4>Survey data from the National Survey of Drug Use and Health (NSDUH).<h4>Study design</h4>Triple-difference (DDD) models were applied to repeated cross-sectional surveys of the U.S. adult population.<h4>Data collection/extraction methods</h4>Data from 6 years (2008-2013) of the NSDUH were combined.<h4>Principal findings</h4>Following ...[more]
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Project description:ContextThe Affordable Care Act (ACA) is predicted to expand health insurance to 25 million individuals. Since insurance reduces the price of medical care, the quantity of services demanded by these newly covered individuals is expected to rise. In this article I provide a comprehensive picture of the demographics, health status, and medical care utilization of the population targeted for the ACA's expansion of coverage, contrasted with that of other nonelderly, insured populations. In addition, I synthesize the current evidence regarding the causal impact of insurance on medical care demand, drawing heavily on recent evidence from Massachusetts and Oregon.MethodsUsing the 2008 to 2010 Medical Expenditure Panel Survey, I conducted bivariate and multivariate analyses to examine differences between the ACA target population and other insured groups. I used the results from the descriptive analysis and quasi-experimental literature to generate "back of the envelope" estimates of the potential impact of the coverage expansion on total medical care utilization by the noninstitutionalized US population.FindingsComparisons of the potential ACA target population with the privately and publicly insured reveal that the former is younger and more likely to be male. The ACA target population, and particularly the uninsured with incomes under 200% of the federal poverty line, reports lower rates of several medical conditions relative to those of the privately and publicly insured. Future changes in rates of inpatient hospitalization and ED use among the newly insured could vary widely, based on descriptive findings and inferences from the quasi-experimental literature. Results also suggest moderate increases in ambulatory care. Total increases in overall demand for medical care by the newly insured comprise a modest proportion of the aggregate utilization.ConclusionsWith the expected increases in utilization resulting from the coverage expansion, stakeholders will need to monitor local health care delivery system capacity and respond where needed with policy- and/or market-based innovations.
| S-EPMC3955378 | biostudies-literature
Project description:BACKGROUND:Disparities in trauma outcomes based on insurance and race are especially pronounced among young adults who have relatively high uninsured rates and incur a disproportionate share of trauma in the population. The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed young adults to remain on their parent's health insurance plans until age 26 years, leading to >3 million young adults gaining insurance. We investigated the impact of the DCP on racial disparities in coverage expansion among trauma patients. STUDY DESIGN:Using the 2007-2012 National Trauma Data Bank, we compared changes in coverage among 529,844 19- to 25-year-olds with 484,974 controls aged 27 to 34 years not affected by the DCP. Subgroup analyses were conducted by race and ethnicity and by census region. RESULTS:The pre-DCP uninsured rates among young adults were highest among black patients (48.1%) and Hispanic patients (44.3%), and significantly lower among non-Hispanic white patients (28.9%). However, non-Hispanic white young adults experienced a significantly greater absolute reduction in the uninsured rate (-4.9 percentage points) than black (-2.9; p = 0.01) and Hispanic (-1.7; p < 0.001) young adults. These absolute reductions correspond to a 17.0% relative reduction in the uninsured rate for white patients, 6.1% for black patients, and 3.7% for Hispanic patients. Racial disparities in the provision's impact on coverage among trauma patients were largest in the South and West census regions (p < 0.01). CONCLUSIONS:Although the DCP increased insurance coverage for young adult trauma patients of all races, both absolute and relative racial disparities in insurance coverage widened. The extent of these racial disparities also differed by geographic region. Although this policy produced overall progress toward greater coverage among young adults, its heterogeneous impact by race has important implications for future disparities research in trauma.
| S-EPMC4676942 | biostudies-literature
Project description:ImportanceDental coverage for adults is a state option in Medicaid, and despite significant gains in coverage after the Medicaid expansion under the Affordable Care Act (ACA), dental outcomes among adults in expansion states remain unexplored.ObjectiveTo explore the association of state coverage of dental benefits through Medicaid expansion with clinical dental outcomes.Design, setting, and participantsThis cross-sectional study analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2018. Included participants were low-income adults aged 19 to 64 years with income up to 138% of the federal poverty level. The study used a difference-in-differences analysis to compare changes from before to after ACA expansion in expansion states vs in control states. Changes were examined in the full sample and separately in states that did and did not provide Medicaid adult dental benefits. We defined a state as providing Medicaid adult dental benefits if it covered services beyond emergency dental benefits in 2014. Data were analyzed from November 2020 to March 2021.ExposuresMedicaid expansion under the ACA.Main outcomes and measuresRates of health coverage, having a dental visit, affordability of dental care in the past year, poor oral health, and teeth flossing were obtained from self-reported data. Mean number of missing teeth and prevalence of untreated decayed teeth, filled teeth, and functional dentition were obtained from clinical examination data.ResultsAmong 7637 low-income adults, the mean (SD) age was 37.8 (13.4) years and 4153 (weighted percentage, 54.5 %) were women. At baseline, 1732 low-income adults in nonexpansion states compared with 2520 low-income adults in expansion states were more likely, as shown by weighted percentage, to be Black (473 individuals [21.0%] vs 508 individuals [15.1%]) and US born (1281 individuals [76.7%] vs 1613 individuals [69.6%]). In the full sample, Medicaid expansion, compared with nonexpansion, was associated with an increased rate of seeing a dentist in the prior year (12.4 percentage points; 95% CI 4.6 to 20.2 percentage points; P = .003). In expansion states that provided dental benefits, compared with nonexpansion states that provided dental benefits, the expansion was associated with increases in rates of Medicaid coverage (8.2 percentage points; 95%CI 0.5 to 15.8 percentage points; P = .04) and having seen a dentist in the previous year (11.4 percentage points, 95% CI, 3.7 to 19.1 percentage points; P = .006) and decreases in the uninsured rate (-12.6 percentage points, 95% CI -18.9 to -6.4 percentage points; P < .001) and prevalence of untreated decayed teeth (-16.8 percentage points; 95% CI, -25.5 to -8.0 percentage points; P = .001). In states without Medicaid dental benefits, the expansion was associated with an increase in the mean number of missing teeth (1.3 teeth; 95% CI 0.1 to 2.5 percentage points; P = .04) and a decrease in the prevalence of functional dentition (-8.7 percentage points; 95% CI, -14.1 to -3.3 percentage points; P = .003) compared with nonexpansion states.Conclusions and relevanceThis study found that the combination of Medicaid expansion and coverage of Medicaid dental benefits was associated with improved oral health among low-income adults.
| S-EPMC8485174 | biostudies-literature
Project description:OBJECTIVE:To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on disparities in insurance coverage after three years. DATA SOURCE:The 2011-2016 waves of the American Community Survey (ACS), with the sample restricted to nonelderly adults. DESIGN:We estimate a difference-in-difference-in-differences model to separately identify the effects of the nationwide and Medicaid expansion portions of the ACA using the methodology developed in the recent ACA literature. The differences come from time, state Medicaid expansion status, and local area pre-ACA uninsured rates. In order to focus on access disparities, we stratify our sample separately by income, race/ethnicity, marital status, age, gender, and geography. PRINCIPAL FINDINGS:After three years, the fully implemented ACA eliminated 43% of the coverage gap across income groups, with the Medicaid expansion accounting for this entire reduction. The ACA also reduced coverage disparities across racial groups by 23%, across marital status by 46%, and across age-groups by 36%, with these changes being partly attributable to both the Medicaid expansion and nationwide components of the law. CONCLUSIONS:The fully implemented ACA has been successful in reducing coverage disparities across multiple groups.
| S-EPMC6341207 | biostudies-literature
Project description:In order to gain insights into how the effects of the uneven adoption of Medicaid expansion varies across the rural/urban spectrum and between racial/ethnic groups in the United States, this research used the fertility question in the 2011-2015 American Community Survey to link infants' records to their mothers' household health insurance status. This preliminary exploration of the Medicaid expansion used logistic regression to examine the probability that an infant will be born without health insurance coverage. Overall, the states that adopted Medicaid expansion improved the health insurance coverage for households with infants. However, rural households with infants report lower percentages of coverage than urban households with infants. Furthermore, the rural/urban gap in health insurance coverage is wider in states that adopted the Medicaid expansion. Additionally, Hispanic infants remain significantly less likely to have health insurance coverage compared to Non-Hispanic White infants. Understanding infant health insurance coverage across ethnic/racial groups and the rural/urban spectrum will become increasingly important as the U.S. population transitions to a minority-majority and also becomes more urban. Although not a perfect solution, our findings showed that the Medicaid expansion of health insurance coverage had a mainly overall positive effect on the percentage of U.S. households with infants who have health insurance coverage.
| S-EPMC6980480 | biostudies-literature
Project description:BackgroundOral health problems are the leading chronic conditions among children and younger adults. Lack of dental coverage is thought to be an important barrier to care but little empirical evidence exists on the causal effect of private dental coverage on use of dental services. We explore the relationship between dental coverage and dental services utilization with an analysis of a natural experiment of increasing private dental coverage stemming from the Affordable Care Act's (ACA)-dependent coverage mandate.ObjectivesTo evaluate whether increased private dental insurance due to the spillover effect of the ACA-dependent coverage health insurance mandate affected utilization of dental services among a group of affected young adults.Data2006-2013 Medical Expenditure Panel Surveys.Study designWe used a difference-in-difference regression approach comparing changes in dental care utilization for 25-year olds affected by the policy to unaffected 27-year olds. We evaluate effects on dental treatments and preventive services RESULTS:: Compared to 27-year olds, 25-year olds were 8 percentage points more likely to have private dental coverage in the 3 years following the mandate. We do not find compelling evidence that young adults increased their use of preventive dental services in response to gaining insurance. We do find a nearly 5 percentage point increase in the likelihood of dental treatments among 25-year olds following the mandate, an effect that appears concentrated among women.ConclusionsIncreases in private dental coverage due to the ACA's-dependent coverage mandate do not appear to be driving significant changes in overall preventive dental services utilization but there is evidence of an increase in restorative care.
| S-EPMC5568688 | biostudies-literature
Project description:ObjectiveTo examine the impact of the Affordable Care Act on dental care use among poor adults ages 21-64 in 2014.Data2010-2014 Gallup-Healthways Wellbeing Index Survey.Study designAmong poor adults with income at or below 138% of the Federal Poverty Level, a differences-in-differences analysis was used to compare the changes in dental care use in states with different Medicaid expansion and adult dental policies.Principal findingsRelative to the pre-reform period and other states, in Medicaid expansion states with adult dental benefits, dental care use increased between 2 and 6 percent points in the second half of 2014, but most of these changes were not statistically significant.ConclusionsEarly evidence suggests that the Affordable Care Act may either not be having a substantial impact on dental care use or it is too early to assess the impact.
| S-EPMC5682155 | biostudies-literature
Project description:Insurance coverage for young adults has increased since 2010, when the Affordable Care Act (ACA) required insurers to permit children to remain on parental policies until age 26 as dependents. This study estimated the association between the dependent coverage provision and changes in young adults' use of hospital-based services for substance use disorders and non-substance use psychiatric disorders.The authors conducted a quasi-experimental comparison of a national sample of non-childbirth-related inpatient admissions to general hospitals (a total of 2,670,463 admissions, 430,583 of which had primary psychiatric diagnoses) and California emergency department visits with psychiatric diagnoses (N=11,139,689), using data spanning 2005 to 2011. Analyses compared young adults who were targeted by the ACA dependent coverage provision (19- to 25-year-olds) and those who were not (26- to 29-year-olds), estimating changes in utilization before and after implementation of the dependent coverage provision. Primary outcome measures included quarterly inpatient admissions for primary diagnoses of any psychiatric disorder per 1,000 population; emergency department visits with any psychiatric diagnosis per 1,000 population; and payer source.Dependent coverage expansion was associated with 0.14 more inpatient admissions for psychiatric diagnoses per 1,000 for 19- to 25-year-olds (targeted by the ACA) than for 26- to 29-year-olds (not targeted by the ACA). The coverage expansion was associated with 0.45 fewer psychiatric emergency department visits per 1,000 in California. The probability that inpatient admissions nationally and emergency department visits in California were uninsured decreased significantly.ACA dependent coverage provisions produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adults nationally. Lower rates of emergency department visits were observed in California.
| S-EPMC4314328 | biostudies-literature
Project description:ObjectiveTo examine the effect of Medicare Part D on racial/ethnic disparities in having any drug coverage and in sources of payment for drug expenditure.MethodsWe used nationally representative data on whites, African-Americans, and Hispanics aged 55 and older from the 2002-2009 Medical Expenditure Panel Survey to analyze disparities in having any drug coverage and in sources of coverage for individuals aged 65 and older as compared with those for adults aged 55-63 without Medicare.ResultsThere was no disparity in the probability of drug coverage for African-American or Hispanic compared to white Medicare beneficiaries, before or after 2006. There were, however, differences in the sources of coverage. African-Americans and Hispanics over the age of 65 had lower rates of private coverage than whites. This disparity in private coverage was completely offset by minorities' higher rates of drug coverage through Medicaid before 2006 and through Part D since 2006. In contrast, among individuals aged 55-63, there are large and persistent disparities in the probability of having drug coverage throughout the period.DiscussionPronounced racial/ethnic disparities in drug coverage in the years just before Medicare eligibility are eliminated by access to public coverage at age 65. This was true even before the introduction of Part D.
| S-EPMC6372055 | biostudies-literature
Project description:ObjectiveTo estimate whether racial/ethnic behavioral health service disparities are likely to be reduced through insurance expansion coverage expected through the Affordable Health Care Act.Data sourcesPooled data from the nationally representative NIMH Collaborative Psychiatric Epidemiological Studies (2001-2003).Study designWe employ a novel reweighting method to estimate service disparities in the presence and absence of insurance coverage.Data collectionAccess to care was assessed by whether any behavioral health treatment was received in the past year. Need was determined by presence of prior year psychiatric disorder, psychiatric diagnoses, physical comorbidities, gender, and age.Principal findingsImproving patient education and availability of community clinics, combined with insurance coverage reduces service disparities across racial/ethnic groups.However, even with expanded insurance coverage, approximately 10 percent fewer African Americans with need for behavioral health services are likely to receive services compared to non-Latino whites while Latinos show no measurable disparity.ConclusionsExpansion of insurance coverage might have different effects for racial/ethnic groups, requiring additional interventions to reduce disparities for all groups.
| S-EPMC3418830 | biostudies-literature