Large-Scale Impact of the Dependent Care Coverage Expansion to Age 26

Research Objective:  One of the first provisions of the Affordable Care Act to take effect was an expansion of insurance coverage for young adults up to 26 years of age whose parents have employer sponsored or individual health insurance. Under this provision, adult children up to 26 years of age whose parents have employer-sponsored or individual health insurance are eligible for insurance under their parents’ health plan. This study examined the impact of the Affordable Care Act dependent coverage insurance expansion on emergency department (ED) utilization patterns and inpatient discharges rates.

Population Studied:  We used the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) and State Inpatient Databases (SID) between January 2009 and December 2012 (SID, 36 states; SEDD, 22 states), two years pre- and two years post-reform. We included discharges from community, nonrehabilitation hospitals as defined in the American Hospital Association Annual Survey for individuals aged 19-31. We gathered population characteristics for each state from the U.S. Census Bureau American Community Survey.

Study Design:We defined the dependent variables as ED visit counts and inpatient visit counts. To study the impact of the dependent care coverage expansion, we created indicator variables for the age cohort (19-25 years vs. 27–31 years) and the time after the dependent care coverage expansion. To examine visit rates by clinical conditions likely to be sensitive to access to ambulatory care services, we used inpatient- and ED-specific ACSC rates for asthma, pneumonia, seizures, mental health, and substance abuse. We estimated the change in rates of each event (ED visit or inpatient discharge) per population associated with the dependent care expansion by means of negative binomial count models with state and time fixed effects. To further understand the time dynamics of the impact of the coverage expansion by payer, we estimated a generalized model by interacting the policy variable (i.e., a dummy variable indicating ages 19–25 years) with each quarter indicator in the time following policy implementation for each payer type. We further limited the age ranges to 23-25 years compared with 27-29 years to determine whether the effect estimates remained consistent for narrower ranges of age groups that are more likely to be comparable than are wider ranges of age groups

Principal Findings:  In analyses of individuals ages 23-25 (compared to ages 27-29) we found a 3.8% increase in non-pregnancy related inpatient visits and a 2.2% increase in ED visits. An analysis by condition reveals that these increases are primarily found within the substance abuse and mental health categories, with no reduction in visit rates for ambulatory care sensitive conditions such as asthma and pneumonia. We also found that the impact of the expansion persisted into the second year.

Conclusions:  Our results reveal that the coverage expansions increased access to health care, did not shift care away from EDs, and likely improved the financial condition of EDs and hospitals due to a reduction in the number of uninsured young adults using medical care.