Racial/Ethnic Variation in the Impact of the Affordable Care Act on Insurance Coverage and Access Among Young Adults

All of the authors are affiliated with the Health Management and Policy Program, College of Public Health and Human Sciences, Oregon State University, Corvallis.

Correspondence should be sent to Aurora VanGarde, MPH, PhD Candidate, College of Public Health and Human Sciences, Oregon State University, Waldo 401, Corvallis, OR 97331-5151 (e-mail: ude.etatsnogero@edragnav.aroruA). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

A. VanGarde led statistical analyses and the drafting of the article. All authors were involved in the conceptualization and design of the work, contributed to the analysis, and made critical revisions to the article.

Abstract

Objectives. To examine the impact of the Affordable Care Act’s (ACA’s) 2010 parental insurance coverage extension to young adults aged 19 to 25 years on health insurance coverage and access to care, including racial/ethnic disparities.

Methods. We pooled data from the Behavioral Risk Factor Surveillance System for the periods 2007 to 2009 and 2011 to 2013 (n = 402 777). We constructed quasiexperimental difference-in-differences models in which adults aged 26 to 35 years served as a control group. Multivariable statistical models controlled for covariates guided by the Andersen model for health care utilization.

Conclusions. The ACA’s expansion had a significant positive effect for young adults acquiring health insurance and reducing cost-related barriers to accessing health care. However, racial/ethnic disparities in coverage and access persist.

Public Health Implications. Policies not dependent on parental insurance could further increase access and reduce disparities.

In 2010, young adults aged 19 to 25 years had a higher uninsured rate (30%) than did any other age group in the United States and lower rates of access to employer-based insurance than did adults aged 26 to 64 years. 1,2 Although young adults are generally healthier than are older populations, it has been well documented that underinsured and uninsured individuals are less likely to engage in preventive health services or seek necessary treatment. 3 Moreover, young adults are more likely to delay needed health care because of cost issues than are their insured counterparts. 4,5

As of September 23, 2010, the Patient Protection and Affordable Care Act (ACA) 6 allowed young adults (aged 19–25 years) to stay on their parent’s or guardian’s health plan until aged 26 years. This ACA coverage extension reduced young adults’ likelihood of being uninsured and delaying medical care. 7 Within the first year after this extension came into effect, approximately 3 million young adults gained insurance coverage. 8

The ACA relies on existing parental insurance plans to extend insurance coverage to young adults. However, people of color are at a disproportionate risk of being uninsured and of lower income. 9 Research has shown that Hispanics have lower rates of health insurance coverage than do non-Hispanic Blacks and non-Hispanic Whites. 10 In 2009, Hispanic and Black individuals aged 18 to 24 years were less likely to be insured than were White individuals of the same age. 11 Despite an overall decrease in the uninsured rate for young adults after the ACA coverage extension, it is unclear what impact the ACA has had on racial/ethnic disparities in health insurance coverage and on cost issues preventing service utilization among young adults.

We examined these disparities among those aged 19 to 25 years before and after ACA implementation. We measured the impact of ACA implementation on the outcomes of health insurance coverage and deterring necessary health care visits because of costs, and we quantified the variation in these impacts across racial/ethnic groups.

METHODS

We retrieved data from the Behavioral Risk Factor Surveillance System Annual Surveys (BRFSS) for the periods 2007 to 2009 and 2011 to 2013 for all 50 US states and the District of Columbia. 12 BRFSS provided data on health insurance and access to health care as well as health behaviors and population health outcomes. We excluded data from 2010 to allow a lag to capture policy impact.

The analytic sample contained 402 777 observations, including a policy group of young adults aged 19 to 25 years who were affected by the ACA coverage extension (n = 121 523) and a comparison group of adults aged 26 to 35 years who were unaffected (n = 281 254) and comparable to the policy group ( Table 1 ).

TABLE 1—

Characteristics of Young Adults (19–25 Years) and Adults (26–35 Years) Before (2007–2009) and After (2011–2013) the ACA Coverage Extension: United States

Note. ACA = Affordable Care Act. Covariates in our multivariable regression models also included marital status, children, and metropolitan statistical area status. Full results are available from the authors on request.

We employed a multivariable difference-in-differences approach in which we compared a change in an outcome before and after the coverage extension for the policy group with a change in the same outcome for the comparison group. Main outcomes were indicators of having health insurance coverage and avoiding necessary health care services because of cost issues. The main independent variables were the policy group indicator (1 for adults aged 19–25 years) to control for differences intrinsic to the policy and comparison group, the post-ACA period indicator (1 for 2011–2013) to control for secular trends during the pre- and post-ACA periods, and the interaction term of the policy group and post-ACA period indicators. Importantly, the interaction term was the variable of main interest and measured changes in the outcomes attributable to the coverage extension.

We selected covariates on the basis of the Andersen model for health care utilization. 13–15 Predisposing factors included gender, age, marital status, education, race/ethnicity, number of children, and employment. Enabling factors included income and geographic location. We measured need by variables of preexisting conditions/diagnoses, perceived health, and duration without health care.

To examine racial/ethnic disparities in changes in the main outcomes attributable to the ACA coverage extension, we augmented our statistical models by multiplying the interaction term by race/ethnicity categories. Whites served as the reference category, and therefore coefficients on these triple interaction terms captured differences in the impact of the ACA between a particular racial/ethnic group and Whites. We computed marginal effects separately for each racial/ethnic group as a linear combination of coefficients.

We estimated a linear probability model because its coefficients directly measure the magnitude of a change in the outcome, rather than simply the direction of a change. All predicted probabilities were contained within the 0 to 1 range. In our preliminary analysis, we also checked that our main results were qualitatively consistent with those from a logistic regression. We survey-weighted all estimates and adjusted SEs for clustering and stratification in BRFSS. We conducted analyses using Stata 12 SE (StataCorp LP, College Station, TX).

RESULTS

As shown in Table 1 , health insurance for young adults aged 19 to 25 years increased by approximately 5% in the post-ACA period, whereas it decreased by nearly 3% for adults aged 26 to 35 years in the same period. Skipping health care services because of cost decreased for young adults in the post-ACA period but increased slightly for adults.

The young adult and the adult groups were comparable on many dimensions relevant to the study, including racial/ethnic composition. Differences between the groups for characteristics such as employment status, number of children, marital status, education levels, and income reflect the evolution of general life patterns with age. For example, young adults were more likely to be single and less likely to be divorced than were those in the adult comparison group.

TABLE 2—

Impact of ACA’s Coverage Extension on Health Insurance Coverage and Avoided Health Care Services Because of Cost Issues Among Young Adults (19–25 Years): United States, 2007–2009 to 2011–2013

Note. ACA = Affordable Care Act. We survey-weighted estimates and adjusted SEs for a complex survey design of the Behavioral Risk Factor Surveillance System Annual Surveys. We did not detect any multicollinearity. The regression models also include marital status, children, and metropolitan statistical area status. Full results are available from the authors on request.

Table 3 quantifies the impact of the ACA’s 2010 coverage extension on young adults by racial/ethnic group. The second column shows that rates of health insurance coverage increased for all young adults, but the improvement varied across racial/ethnic groups. Coverage rates increased most for American Indians/Alaska Natives (8.4 percentage points; P < .001), non-Hispanic Whites (7.05 percentage points; P < .001), and Hispanics (6.1 percentage points; P < .001). Increases were smaller for other racial/ethnic groups and lowest of all for non-Hispanic Blacks (1.2 percentage points; P < .05).

TABLE 3—

Impact of ACA’s Dependent Coverage Extension on Young Adults’ Health Insurance Coverage and Avoided Health Care Services Because of Cost Issues, by Race/Ethnicity: United States, 2007–2009 to 2011–2013

Note. ACA = Affordable Care Act. We survey-weighted estimates and adjusted SEs for a complex survey design of the Behavioral Risk Factor Surveillance System Annual Surveys. We included all covariates. Results are from an augmented model that included additional triple interaction terms of the policy group indicator, post-ACA period indicator, and race/ethnicity category (Table A, available as a supplement to the online version of this article at http://www.ajph.org). We computed the marginal effect presented for each racial/ethnic subpopulation as the linear combination of coefficients for the reference group plus the interaction term coefficient for that racial/ethnic category. Table A shows a significant P value for the interaction term for each racial/ethnic group. We conducted Wald tests for the joint significance of all interaction terms: F = 2394.74; P < .001 for change in health insurance coverage; F = 1322.25; P < .001 for change in avoid health care services because of cost.

The third column of Table 3 shows that, after ACA implementation, young adults in most racial/ethnic groups became less likely to skip physician visits because of cost issues. These improvements were greatest for members of Hawaiian/Pacific Islander (3.3 percentage points; P < .001), non-Hispanic White (3.2 percentage points; P < .001), and multiple races (3.1 percentage points; P < .001) groups. Improvements were more modest for most other groups and not significant for non-Hispanic Blacks.

DISCUSSION

Our analyses suggest that the 2010 ACA extension of parental insurance coverage increased rates of health insurance coverage for young adults aged 19 to 25 years compared with a control group of adults aged 26 to 35 years. After the 2010 ACA implementation, young adults were also less likely to skip necessary physician visits because of cost issues. However, the magnitude of improvements in young adults’ insurance coverage and access to physician visits did vary widely across racial/ethnic groups.

Several studies have documented the increase in young adults’ insurance coverage because of the ACA. 8,16–18 These studies demonstrated the impact of the ACA on young adult insurance coverage, at times touching on covariates affecting insurance uptake, but did not focus on racial/ethnic disparities in access to insurance and care. Nevertheless, it is important to understand racial/ethnic variation in health insurance coverage and access to health care to identify potential disparities that future policy implementations could address.

We observed a 6.12 percentage point decrease in uninsurance among young adults after implementation of the 2010 ACA extension of parental insurance coverage, a reduction of approximately one fifth compared with the 30% rate of uninsurance among this group before the ACA. Nevertheless, the impact of age on insurance coverage persists, with young adults’ insurance rates remaining lower than adults in both the pre- and post-ACA periods.

Our results are similar to those of previous studies that found a 2.8% increase of private insurance in the first year of the ACA. 16 Our study indicates that subsequent years of ACA implementation continued to have a positive effect on the insurance rates of young adults. Other studies 17,19,20 noted higher rates of uninsurance among racial/ethnic minority young adults over longer periods, but these were not the primary focus of the research.

After ACA implementation, young adults had a significant decrease in avoided health care visits because of cost issues, a noticeable reduction compared with the pre-ACA period. It is also interesting to note that students were more likely to be insured and less likely to skip visits than were employed persons. This may reflect student insurance plans and parental plans carried over from the pre-ACA period that allowed students to remain on parental insurance with a typical age cutoff of 22 years. 21

Our findings revealed that after the 2010 ACA extension of parental insurance coverage, insurance coverage increased significantly for young adults of all racial/ethnic groups. However, the ACA only partially mitigated the disparities in insurance coverage that existed before the ACA. 9 Asians had the highest rates of insurance coverage before the ACA, 22 and their increase in insurance after ACA implementation was smaller than was that for several other groups. Non-Hispanic Whites had the second highest rates of insurance before the ACA and the second highest increase in coverage rates after its implementation. Hispanics, American Indians/Alaska Natives, and Hawaiian/Pacific Islanders had lower than average rates of insurance before the ACA, but these disparities were somewhat mitigated by relatively large increases in coverage after ACA implementation.

Access to health care services improved for young adults in most racial/ethnic groups after ACA implementation, but there was less mitigation of disparities among groups than for insurance coverage. Hawaiian/Pacific Islanders and non-Hispanic Whites had the greatest improvements in access. Improvements were somewhat smaller for Asians and American Indians/Alaska Natives and even smaller for Hispanics. Most disturbingly, the post-ACA changes were smallest for non-Hispanic Black young adults. They had by far the smallest increase in insurance coverage after ACA implementation and no significant improvement in access to physician visits.

The observed contribution of covariates to variation in our outcomes was generally consistent with previous research. As expected, we found that persons who were employed, 9 had higher income, 23–25 or had more education 26,27 were more likely to be insured and less likely to skip visits because of cost issues. Married persons were also more likely to be insured and less likely to skip visits because of cost. Women and individuals who had children were more likely to be insured. However, insurance coverage did not automatically increase access to care for these groups; they were more likely to skip visits because of cost issues.

Finally, we observed some disparities in insurance coverage and access to care on the basis of health. Persons who had fair or poor health status or who had asthma or diabetes were more likely to skip visits because of cost. However, these people can derive the greatest potential benefit from access to necessary health care services.

Limitations

Some limitations in our analysis are noteworthy. In 2011, BRFSS introduced a change to its survey methodology, adding cellular phones and using “raking” to adjust sample weights to be more representative of the population. 28 This change increased the proportion of interviews with respondents reporting lower incomes, lower educational levels, and younger age groups. As a result, prevalence estimates for fair or poor health or negative health behaviors could have increased, 28 potentially leading to slight imprecisions in some of our descriptive statistics. Nonetheless, the new survey methodology should not have influenced statistical inference from our multivariable models because it likely affected the policy and control groups similarly.

The identified impact of the ACA on young adults might vary by state because of state variation in health insurance market regulations, which may interact with federal policy. For example, 1 study found that uninsured rates for adults varied immensely by state: from 18% uninsured adults in Vermont to nearly 50% uninsured in Florida, Nevada, New Mexico, and Texas. 29 Unfortunately, BRFSS data do not include a geographic identifier, which prevented us from exploring this possible state heterogeneity. This is an important item for our future research.

Policy Implications and Future Research

Our findings have some implications for current and future policy debates. First, policies that increase or decrease overall adult insurance rates also affect young adults via parental insurance coverage. Weakening ACA provisions that increased insurance coverage, such as guaranteed issue to persons with preexisting conditions or mandates for employee health insurance, would further reduce young adults’ insurance availability. Second, targeted outreach to individual racial/ethnic groups could help to reduce the disparities in insurance coverage and access that remain even after ACA implementation.

Future research should examine the impacts of 2014 ACA implementations, which included individual health insurance marketplaces with premium and cost-sharing subsidies, increased insurance plan options for small businesses, and the expansion of Medicaid for low-income families. 30 Specifically, analyses can evaluate whether the resulting coverage expansions mitigated any of the racial/ethnic disparities in health insurance coverage and health care access we observed.

Public Health Implications

The 2010 ACA extension of parental insurance significantly increased the number of young adults with health insurance, but racial/ethnic disparities persisted. Our findings suggest that mitigating racial/ethnic disparities should be an explicit consideration when developing national health insurance reform policy.

ACKNOWLEDGMENTS

This research was presented at the 2017 Academy Health Annual Research Meeting and was awarded “best abstract.”

The authors would like to thank Michael Stewart for his helpful comments on earlier drafts of the article.

HUMAN PARTICIPANT PROTECTION

No protocol approval was necessary because no human participants were involved in this study.

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