Health Care Reform, Insurance Coverage, and Use of Health Care among Young Adults by Race/Ethnicity

Prior to implementation of the Affordable Care Act (ACA), young adults aged 19-25 were the age group most likely to be uninsured, with near 34 percent uninsured in 2009.  Insurance coverage increased among young adults after the September 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 in access to and use of health care among young adults.  We use an interrupted time series analysis of changes in each outcome after the 2010 and 2014 policy implementations along with data from the 2000-2014 National Health Interview Survey (NHIS).   Main outcome measures consist of measures related to 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).  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.