Did the ACA Improve Rates of Well Child and Depression Screening Visits for Commercially Insured Adolescents?

Despite a rich and growing literature on the impact of the Affordable Care Act (ACA) on adults, there are few studies of the ACA’s effect on privately insured adolescents (ages 12-18). Spencer, et al. (2018) found moderate improvement in preventive care use by adolescents between 2012 and 2014, but less than 50% of privately insured adolescents received any preventive services. The American Academy of Pediatrics (AAP; Marcell, et al., 2018) has identified cost sharing as ongoing barrier to adolescents receiving the full benefit of ACA insurance reforms. However, Ellis, et al. (2017) found that the demand for child health services, including preventive services, is less elastic than the adult demand for services for adults. Therefore, ACA cost sharing reforms may not enough to increase uptake of adolescent preventive services. In this study, we updated Spencer’s estimates of preventive service use for privately insured adolescents and examined whether differences in cost sharing could explain post-ACA rates of preventive service utilization. We examined this question using two preventive services: well child visits and depression screening. While private insurance plans must cover both services for adolescents, well child visits may be offered with cost sharing and depression screening must be offered without cost sharing. Using national, 2010 -2016 Marketscan^TM commercial claims for over 24 million adolescents, we estimated utilization, allowed amounts, and out of pocket spending well child visits and outpatient depression screens. We used HEDIS 2018 definitions to define our outcomes and identify our eligible population. We estimated demand elasticities and cross-elasticities for these services using a model informed by Ellis et al (2015). We performed a quarterly, interrupted time series analysis comparing changes in utilization before (2010-2013) and after the ACA (2014-2016). We controlled for patient characteristics, plan type, and regional characteristics. We also controlled for regional variation in preventive service utilization through adolescent flu vaccination rates. We found demand for adolescents well child visits and depression screening were close to inelastic. Unadjusted well care visit rates for eligible adolescents rose from 32% in the pre-ACA period to 35% in the post-ACA prior. Unadjusted adolescent depression screening rates rose steadily from 1% in 2010 to 6% 2016. Adolescents who had well child visits were more likely to have depression screens than adolescents who did not. Utilization of well-child visits varied from less than 20% of eligible adolescents to nearly 70% of eligible adolescents depending on the metro region and state. Our findings suggest that ACA was associated with minimal improvements in privately insured adolescent utilization of preventive services. The association between well-child visits and depression screening suggests that either billing for depression screens may be better reported in regions with better preventive service uptake or that well child visits have strong spillover effects for other preventive care. Health care leaders and policy makers concerned about low rates of adolescent preventive service utilization should support efforts to raise well-child visit rates nationally, and continue to promote the uptake of preventive services such as depression screening as part of an annual visit.