Inequalities in Young Adult Health Insurance Coverage Post-federal Health Reform

Abstract

Background: Uninsurance for young adults (YAs) was greatly reduced by the Affordable Care Act (ACA). However, reforms may not be equally beneficial for all YAs and certain policies may exacerbate, rather than resolve, pre-existing disparities.

Objective: To investigate inequalities in YAs' insurance coverage pre- (2000-2010) and post-federal health reforms (dependent coverage expansion, 2010-2013, and Medicaid/Marketplace expansions, 2014-2016), among a nationally representative sample.

Design: A difference-in-differences estimator (controlling for sociodemographics) was used to determine the effects of the ACA for young adults (ages 19-25) compared to adolescents (ages 13-18) and older YA (ages 26-30) counterparts; triple-difference estimators quantified differential policy effects by sociodemographics.

Participants: Three hundred eighty-seven thousand six hundred thirty-five participants in the 2000-2016 National Health Interview Survey.

Main measures: Respondents reported their health insurance coverage types during the last 12 months, reasons uninsured, and detailed sociodemographics.

Key results: An adjusted difference-in-differences estimator quantified a 12.3 percentage point increase (p < 0.0001) in full-year coverage post-ACA for YAs compared to older counterparts, driven by increases in employer-sponsored private insurance while younger and older youth saw larger gains in Medicaid coverage. Triple-difference estimators identified subgroups experiencing less beneficial dependent coverage expansion effects, including females, lower socioeconomic status, non-citizens, non-English speakers, and several racial/ethnic minority groups. Later ACA reforms (Marketplace/Medicaid expansions) mitigated many of these widening disparities.

Conclusion: While the ACA significantly impacted YA insurance coverage, these gains were not of equal magnitude for all YAs and disparities remain. As such, more work needs to be done to ensure optimal and equitable access to high-quality, affordable insurance for all YAs.

Keywords: National Health Policy; adolescence; health care disparities; insurance coverage; young adult.

Figure 1

a–c Health insurance coverage by age, 2000–2016. Points depict unadjusted prevalence of health insurance coverage by age group (ages 19–25 years in orange and ages 26–30 years in blue) during the study period (2000–2016). Full-year coverage; partial-year coverage; full-year uninsured; full-year private; full-year employer-sponsored insurance; full-year non-group market coverage, including coverage obtained on the health insurance exchanges; and full-year Medicaid coverage are shown.

Figure 1

a–c Health insurance coverage by age, 2000–2016. Points depict unadjusted prevalence of health insurance coverage by age group (ages 19–25 years in orange and ages 26–30 years in blue) during the study period (2000–2016). Full-year coverage; partial-year coverage; full-year uninsured; full-year private; full-year employer-sponsored insurance; full-year non-group market coverage, including coverage obtained on the health insurance exchanges; and full-year Medicaid coverage are shown.

Figure 2

a–d Magnitude of policy effects on full-year insurance by sociodemographics. Marginal predicted probabilities of full-year health insurance coverage for youth ages 19–25 years across reform periods were output from fully adjusted multivariate triple-difference models; adjusted probability (colored bar) and the associated 95% confidence intervals (error bars) for youth ages 19–25 overall and by selected sociodemographic characteristics are presented in the figure. The table below shows the absolute policy effects (difference in marginal probabilities) for ages 19–25 between the post-dependent coverage expansion (DCE) and pre-reform periods (DCE Effect), the post-all expansions (Exp+) and post-DCE periods (incremental Exp+ Effect), and post-Exp+ and pre-reform periods (Total Affordable Care Act, ACA, Effect). Additionally, period-specific inequities were calculated as the difference in marginal probabilities between each subgroup vs. the reference level (e.g., pre-reform inequity of − 7.03% in panel a describes that full-year insurance coverage was 7.03 percentage points lower for Mexican-Americans compared to their White, non-Hispanic counterparts, ages 19–25 years, during the pre-reform period). Inequities that diverge from zero (moving from pre- to post-reform) are increasing, while inequities that converge to zero are decreasing. AIAN, American Indian/Alaska Native.

Figure 2

a–d Magnitude of policy effects on full-year insurance by sociodemographics. Marginal predicted probabilities of full-year health insurance coverage for youth ages 19–25 years across reform periods were output from fully adjusted multivariate triple-difference models; adjusted probability (colored bar) and the associated 95% confidence intervals (error bars) for youth ages 19–25 overall and by selected sociodemographic characteristics are presented in the figure. The table below shows the absolute policy effects (difference in marginal probabilities) for ages 19–25 between the post-dependent coverage expansion (DCE) and pre-reform periods (DCE Effect), the post-all expansions (Exp+) and post-DCE periods (incremental Exp+ Effect), and post-Exp+ and pre-reform periods (Total Affordable Care Act, ACA, Effect). Additionally, period-specific inequities were calculated as the difference in marginal probabilities between each subgroup vs. the reference level (e.g., pre-reform inequity of − 7.03% in panel a describes that full-year insurance coverage was 7.03 percentage points lower for Mexican-Americans compared to their White, non-Hispanic counterparts, ages 19–25 years, during the pre-reform period). Inequities that diverge from zero (moving from pre- to post-reform) are increasing, while inequities that converge to zero are decreasing. AIAN, American Indian/Alaska Native.