Association for Public Policy Analysis & Management

Insurance gains under the Affordable Care Act (ACA) included low-income children already eligible for public insurance. Research has shown a link between ACA policies and children’s coverage, with parental eligibility and coverage playing a significant role.

In this paper we observe access to care, healthcare utilization, and financial burdens of health expenditures among low- to moderate-income children before and after 2014. Prior literature predicts access and utilization could increase among children due to increases seen in children’s own insurance coverage, in their parents’ insurance coverage, and in the percentage of children in families where both parent and child are eligible for Medicaid. Children’s exposure to each of these factors varies based on how policies affect their own eligibility, and their parents’ eligibility, for Medicaid, CHIP, or Marketplace subsidies. To date, we know of no studies that observe children’s access, utilization, and financial burden before and after 2014 and/or based on how eligibility for public and private health insurance affects families at both the child- and parent-level.

We use the Medical Expenditure Panel Survey (MEPS) in 2012-2015 to study non-disabled children ages 0-18 in families with incomes below 400% FPL. We identify separate effects based on a child’s eligibility for Medicaid, CHIP, and Marketplace subsidies. To exploit policy effects at the family level, we categorize children into six subgroups: Medicaid/CHIP eligible children (1) with newly Medicaid-eligible parents (via ACA adult expansion), (2) with pre-ACA Medicaid-eligible parents, (3) with Marketplace subsidy-eligible parents, and (4) with parents ineligible for Medicaid and Marketplace subsidies, and children ineligible for Medicaid/CHIP (5) with Marketplace subsidy-eligible parents and (6) with parents ineligible for Marketplace subsidies.

Access and utilization are measured by usual source of care, any well-child visit during the year, any well-dental visit during the year, and compliance ratios for well visits during the year (using age-appropriate recommendations for medical and dental well visits). Burden is measured as percent of family income spent on out-of-pocket medical expenditures and premiums.

Preliminary results based on children’s eligibility suggest that gains for any well-child visit and well-child compliance ratios under the ACA were limited to Medicaid-eligible children. Burdens did not vary over time, but varied widely by policy. The largest burdens were found among children who were ineligible for public coverage. In particular, premium burdens were significantly higher for these families (even in the post-ACA period), indicating the availability of public coverage for children was associated with lower costs for low-income families.

When taking parental eligibility into account, we find that increases for any well-child visit and for well-child compliance ratios were largest among Medicaid-eligible children whose parent gained Marketplace subsidy eligibility. Notably, parents in these families were the only subgroup to experience an increase in usual source of care. In the post-ACA period, we find that burdens remained highest among families where the child was ineligible for public coverage. Among Medicaid-/CHIP-eligible children, we observed larger burdens in families where parents were ineligible for both Medicaid and Marketplace subsidies.