ORIGINAL ARTICLE
Will Health Care Reform Reduce Disparities in Insurance Coverage? Evidence From the Dependent Coverage Mandate Dan M. Shane, PhD and Padmaja Ayyagari, PhD
Objectives: We used data from the Medical Expenditure Panel Survey to assess the impact of the Affordable Care Act’s dependent coverage mandate on disparities in health insurance coverage rates and evaluated whether non-Hispanic blacks and Hispanics gained coverage at the same rates as non-Hispanic whites. Methods: To estimate changes in insurance rates, we employed a difference-in-difference regression approach comparing 7962 young adults aged 19–25 to 9321 adults aged 27–34. Separate regressions were estimated for non-Hispanic blacks, Hispanics, and non-Hispanic whites to understand whether the mandate had differential effects by race/ethnicity. Separate regressions by income level and race/ethnicity were also estimated. Results: Insurance rates increased by 9.3 percentage points among non-Hispanic whites, 7.2 percentage points among Hispanics, and 9.4 percentage points among non-Hispanic blacks. These changes were not significantly different from each other. Among individuals with income of 400% of Federal Poverty Level. *Significant at P = 0.10. **Significant at P = 0.05. ***Significant at P = 0.01.
A
B
0.2
0.2
0.13∗∗∗
0.15
0.15
0.09∗∗∗
0.10∗∗∗
0.10∗∗∗
0.1
COVERAGE CHANGE (DEPENDENTS ON POLICY) COVERAGE CHANGE (POLICY HOLDERS)
0.05
0
0.11∗∗∗
0.10∗∗∗ 0.1
0.05
COVERAGE CHANGE (DEPENDENTS ON POLICY) COVERAGE CHANGE (POLICY HOLDERS)
0.05
0.01 0
-0.02
-0.02
-0.02
-0.05
-0.03
-0.1
OVERALL
BLACK
HISPANIC
WHITE
-0.05
-0.1
-0.02
-0.04∗
OVERALL
MARRIED
UNMARRIED
FIGURE 3. Effect of dependent coverage mandate on insurance rates: robustness checks. A, Policy holders versus dependent by race. B, Policy holders versus dependents by marital status.***Significant at P = 0.01. *Significant at P = 0.10.
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2014 Lippincott Williams & Wilkins
www.lww-medicalcare.com |
533
Shane and Ayyagari
133% and 400% of the FPL, non-Hispanic blacks gained coverage at the highest rates. Non-Hispanic blacks also exhibited the highest gains among the group at >400% of the FPL, increasing coverage by 15 percentage points, whereas Hispanics and non-Hispanic whites did not increase coverage rates significantly. Therefore, disparities between non-Hispanic blacks and non-Hispanic whites were reduced among higher-income groups (133%–400% FPL and >400% FPL), whereas they remained unchanged for Hispanics relative to non-Hispanic whites at these income levels. It is encouraging that all racial/income groups benefitted significantly from the dependent coverage mandate. However, unequal gains from the mandate among the poorest Americans points to the increased significance of the Medicaid expansion in remedying racial/ethnic disparities among individuals r133% of the FPL. That many US states are not expanding Medicaid to individuals up to 133% of the FPL may be dire news for racial/ethnic coverage disparities among young adults in those states. Given our results for individuals >400% of the FPL, the level where Federal tax subsidies to purchase coverage in the Marketplaces end, the lack of improvement in Hispanic coverage rates is notable. Understanding the mechanisms for the lack of an effect among higher-income young Hispanics is an area for future work. We acknowledge limitations of our study. First, we did not directly map young adults to their parents and thus are not able to ascertain that young adults gained coverage directly through their parents’ plans. Robustness checks using dependent coverage among unmarried persons strongly suggest that parental coverage is the mechanism. Second, as this is the first full year of implementation and we do not include data from 26 year olds or from 2010, it is possible that our results are underestimates of the true effect. Additional years of the mandate will be required to assess the full
534 | www.lww-medicalcare.com
Medical Care
Volume 52, Number 6, June 2014
contribution of this ACA provision to reducing disparities in insurance coverage by race and ethnicity. REFERENCES 1. DeNavas-Walt C, Proctor BD, Smith JC. Income, Poverty, and Health Insurance Coverage in the United States: 2009. Washington, DC: US Government Printing Office; 2010. US Census Bureau. 2. Hargraves JL, Hadley J. The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care. Health Serv Res. 2003;38:809–829. 3. Lillie-Blanton M, Hoffman C. The role of health insurance coverage in reducing racial/ethnic disparities in health care. Health Aff. 2005;24: 398–408. 4. Dunlop DD, Song J, Manheim LM, et al. Racial/ethnic differences in the development of disability among older adults. Am J Public Health. 2007;97:2209–2215. 5. Thorpe R Jr, Koster A, Bosma H, et al. Racial differences in mortality in older adults: factors beyond socioeconomic status. Ann Behav Med. 2012;43:29–38. 6. Clemans-Cope L, Kenney GM, Buettgens M, et al. The Affordable Care Act’s coverage expansions will reduce differences in uninsurance rates by race and ethnicity. Health Aff. 2012;31:920–930. 7. Zhu J, Brawarsky P, Haas JS. Massachusetts health reform and disparities in coverage, access and health status. J Gen Intern Med. 2010;25:1356–1362. 8. Collins S, Rasmussen P, Garber T, et al. Covering young adults under the Affordable Care Act: the importance of outreach and Medicaid expansion: findings from the Commonwealth Fund Health Insurance Tracking Survey of Young Adults, 2013. Issue Brief (Commonw Fund). 2013;21:1–15. 9. Sommers BD, Kronick R. The Affordable Care Act and insurance coverage for young adults. JAMA. 2012;307:913–914. 10. Sommers BD, Buchmueller T, Decker SL, et al. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. Health Aff. 2013;32:165–174. 11. Akosa YA, Moriya AS, Simon K. Effects of Federal Policy to insure young adults: evidence from the 2010 Affordable Care Act’s dependentcoverage mandate. Am Econ J. 2013;5:1–28. 12. O’Hara B, Brault MW. The disparate impact of the ACA-dependent expansion across population subgroups. Health Serv Res. 2013;48:1581–1592. 13. StataCorp LP. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP; 2011.
r
2014 Lippincott Williams & Wilkins
Will Health Care Reform Reduce Disparities in Insurance Coverage? Evidence From the Dependent Coverage Mandate Dan M. Shane, PhD and Padmaja Ayyagari, PhD
Objectives: We used data from the Medical Expenditure Panel Survey to assess the impact of the Affordable Care Act’s dependent coverage mandate on disparities in health insurance coverage rates and evaluated whether non-Hispanic blacks and Hispanics gained coverage at the same rates as non-Hispanic whites. Methods: To estimate changes in insurance rates, we employed a difference-in-difference regression approach comparing 7962 young adults aged 19–25 to 9321 adults aged 27–34. Separate regressions were estimated for non-Hispanic blacks, Hispanics, and non-Hispanic whites to understand whether the mandate had differential effects by race/ethnicity. Separate regressions by income level and race/ethnicity were also estimated. Results: Insurance rates increased by 9.3 percentage points among non-Hispanic whites, 7.2 percentage points among Hispanics, and 9.4 percentage points among non-Hispanic blacks. These changes were not significantly different from each other. Among individuals with income of 400% of Federal Poverty Level. *Significant at P = 0.10. **Significant at P = 0.05. ***Significant at P = 0.01.
A
B
0.2
0.2
0.13∗∗∗
0.15
0.15
0.09∗∗∗
0.10∗∗∗
0.10∗∗∗
0.1
COVERAGE CHANGE (DEPENDENTS ON POLICY) COVERAGE CHANGE (POLICY HOLDERS)
0.05
0
0.11∗∗∗
0.10∗∗∗ 0.1
0.05
COVERAGE CHANGE (DEPENDENTS ON POLICY) COVERAGE CHANGE (POLICY HOLDERS)
0.05
0.01 0
-0.02
-0.02
-0.02
-0.05
-0.03
-0.1
OVERALL
BLACK
HISPANIC
WHITE
-0.05
-0.1
-0.02
-0.04∗
OVERALL
MARRIED
UNMARRIED
FIGURE 3. Effect of dependent coverage mandate on insurance rates: robustness checks. A, Policy holders versus dependent by race. B, Policy holders versus dependents by marital status.***Significant at P = 0.01. *Significant at P = 0.10.
r
2014 Lippincott Williams & Wilkins
www.lww-medicalcare.com |
533
Shane and Ayyagari
133% and 400% of the FPL, non-Hispanic blacks gained coverage at the highest rates. Non-Hispanic blacks also exhibited the highest gains among the group at >400% of the FPL, increasing coverage by 15 percentage points, whereas Hispanics and non-Hispanic whites did not increase coverage rates significantly. Therefore, disparities between non-Hispanic blacks and non-Hispanic whites were reduced among higher-income groups (133%–400% FPL and >400% FPL), whereas they remained unchanged for Hispanics relative to non-Hispanic whites at these income levels. It is encouraging that all racial/income groups benefitted significantly from the dependent coverage mandate. However, unequal gains from the mandate among the poorest Americans points to the increased significance of the Medicaid expansion in remedying racial/ethnic disparities among individuals r133% of the FPL. That many US states are not expanding Medicaid to individuals up to 133% of the FPL may be dire news for racial/ethnic coverage disparities among young adults in those states. Given our results for individuals >400% of the FPL, the level where Federal tax subsidies to purchase coverage in the Marketplaces end, the lack of improvement in Hispanic coverage rates is notable. Understanding the mechanisms for the lack of an effect among higher-income young Hispanics is an area for future work. We acknowledge limitations of our study. First, we did not directly map young adults to their parents and thus are not able to ascertain that young adults gained coverage directly through their parents’ plans. Robustness checks using dependent coverage among unmarried persons strongly suggest that parental coverage is the mechanism. Second, as this is the first full year of implementation and we do not include data from 26 year olds or from 2010, it is possible that our results are underestimates of the true effect. Additional years of the mandate will be required to assess the full
534 | www.lww-medicalcare.com
Medical Care
Volume 52, Number 6, June 2014
contribution of this ACA provision to reducing disparities in insurance coverage by race and ethnicity. REFERENCES 1. DeNavas-Walt C, Proctor BD, Smith JC. Income, Poverty, and Health Insurance Coverage in the United States: 2009. Washington, DC: US Government Printing Office; 2010. US Census Bureau. 2. Hargraves JL, Hadley J. The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care. Health Serv Res. 2003;38:809–829. 3. Lillie-Blanton M, Hoffman C. The role of health insurance coverage in reducing racial/ethnic disparities in health care. Health Aff. 2005;24: 398–408. 4. Dunlop DD, Song J, Manheim LM, et al. Racial/ethnic differences in the development of disability among older adults. Am J Public Health. 2007;97:2209–2215. 5. Thorpe R Jr, Koster A, Bosma H, et al. Racial differences in mortality in older adults: factors beyond socioeconomic status. Ann Behav Med. 2012;43:29–38. 6. Clemans-Cope L, Kenney GM, Buettgens M, et al. The Affordable Care Act’s coverage expansions will reduce differences in uninsurance rates by race and ethnicity. Health Aff. 2012;31:920–930. 7. Zhu J, Brawarsky P, Haas JS. Massachusetts health reform and disparities in coverage, access and health status. J Gen Intern Med. 2010;25:1356–1362. 8. Collins S, Rasmussen P, Garber T, et al. Covering young adults under the Affordable Care Act: the importance of outreach and Medicaid expansion: findings from the Commonwealth Fund Health Insurance Tracking Survey of Young Adults, 2013. Issue Brief (Commonw Fund). 2013;21:1–15. 9. Sommers BD, Kronick R. The Affordable Care Act and insurance coverage for young adults. JAMA. 2012;307:913–914. 10. Sommers BD, Buchmueller T, Decker SL, et al. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. Health Aff. 2013;32:165–174. 11. Akosa YA, Moriya AS, Simon K. Effects of Federal Policy to insure young adults: evidence from the 2010 Affordable Care Act’s dependentcoverage mandate. Am Econ J. 2013;5:1–28. 12. O’Hara B, Brault MW. The disparate impact of the ACA-dependent expansion across population subgroups. Health Serv Res. 2013;48:1581–1592. 13. StataCorp LP. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP; 2011.
r
2014 Lippincott Williams & Wilkins
