Association for Public Policy Analysis & Management

 Prior to implementation of the Affordable Care Act (ACA), nearly 34 percent of young adults aged 19-25 were uninsured.  Insurance coverage increased among young adults after the 2010 implementation of the ACA dependent-coverage provision and again after the 2014 implementation of additional ACA policies.  The objective of this paper is to assess and compare the effects of the 2010 and 2014 policy implementations on racial/ethnic disparities in health insurance coverage as well as access to care among young adults.  We use an interrupted time series analysis of changes in outcomes after each policy implementation along with data from the 2000-2014 National Health Interview Survey (NHIS).  Main outcome measures include health insurance coverage (any coverage, private coverage, Medicaid coverage), as well as several measure of access to or use of care (whether an individual has a usual source of medical care, at least one visit with a general practitioner, or at least one emergency room visit.)

We find that the dependent coverage and 2014 insurance expansions were associated with increases in the likelihood of having any insurance coverage of 5.6 percentage points (p<0.01) and 8.0 percentage points (p<0.01), respectively. Though the effect of the dependent coverage provision on insurance coverage and access to care did not differ significantly across racial/ethnic groups, the effect of the 2014 insurance expansion on the likelihood of having insurance was significantly larger for black (10.4 percentage points, p<0.01) and Hispanic (11.4 percentage points, p<0.01) relative to white young adults (6.0 percentage points, p<0.01). Similarly, the effect of the 2014 insurance expansion on the likelihood of having a usual source of medical care was significantly larger for black (9.3 percentage points, p<0.01) compared to white young adults (3.1 percentage points, p<0.05). 

To further explore changes in health insurance coverage in 2014, we compare states that did and did not implement the ACA Medicaid expansion.  The percentage of young adults with any source of insurance coverage increased by 9.6 percentage points (p<0.01) in expansion states compared to 5.8 percentage points (p<0.01) in non-expansion states, a significant difference of 3.9 percentage points (p<0.01).  The increase in any insurance coverage was significantly larger in expansion compared to non-expansion states among whites and Hispanics, with this difference positive but not significant among blacks and negative among Asian/other individuals.  The increase in insurance coverage in expansion states was significantly larger for blacks (12.0 percentage points, p<0.01) and Hispanics (13.3 percentage points, p<0.01) compared to whites (7.2 percentage points, p<0.01).  However, the relative increase in expansion compared to non-expansion states did not differ significantly by race/ethnicity.

Our results suggest that unlike the dependent coverage provision, which resulted in similar gains in insurance coverage across racial/ethnic groups, the 2014 insurance expansion was associated with larger gains in coverage among black and Hispanic relative to white young adults. Our estimates of changes in access and use of care measures after the 2014 insurance expansion were also larger for black and Hispanic individuals, a difference that was significantly different for blacks in some cases.