Health Insurance Coverage and Access As Teens with Disabilities Transition to Adulthood

Background and Purpose:  The transition from pediatric to adult health care systems is fraught with hurdles to be overcome for youth with disabilities.  While less than 10% of children were uninsured in 2008 and 2009, more than 30% of young adults ages 19-25 reported being uninsured at some point during each of these two years.  The Affordable Care Act (ACA) was created to reduce these hurdles, allowing young adults longer time, through age 25, to navigate this transition through the dependent coverage provision, eliminating exclusions and denials due to pre-existing conditions, and providing options for health insurance coverage that don’t require a disability designation by the Social Security Administration as part of the enrollment process.

Pre-ACA, just over 40% of youth with disabilities were estimated to be meeting federal guidelines for health care transition planning. While this paper does not discuss transition ease, it does examine whether two insurance mechanisms within the ACA – the dependent coverage provision and Medicaid expansion – reduced the gap in insurance coverage and access to care between children and young adults with disabilities.  These issues have been examined by others for all young adults or young adults with specific conditions or characteristics, but not overall for young adults with disabilities.

Methods.  Using data from the 2006-2009 and 2011-2015 National Health Interview Survey, we estimate the change in insurance coverage and access to care from pre- to post-ACA time periods for teens (ages 13-18) and young adults (ages 19-25) with disabilities (N=10,136) in bivariate analysis and a difference-in-difference model. We also estimate differences in insurance coverage and access to care for these groups in Medicaid expansion and non-expansion states.

Results.  Both teens and young adults with disabilities made significant gains in insurance coverage (4.55 and 8.96 percentage point gains respectively, p<.001) and access to care (4.01 and 3.14 percentage points decline in delayed care due to cost, p<.05) under the dependent coverage provision and Medicaid expansion. 

Conclusions.  Medicaid expansion had a greater impact on both insurance coverage and on access to care than did the dependent coverage provision.  The benefits of these changes flowed primarily to young adults with disabilities, rather than to transition-age teens.  While it may seem odd to estimate the impact of the dependent coverage provision on teens, as they are not in the age group covered by this provision, their inclusion provides a counterfactual with which to compare the impacts of this provision on young adults.  What we find is that teens actually lost private coverage from pre- to post-ACA periods, likely due to changes in economic or employment circumstances of their parents during the late 2000s downturn in the US economy.  

These results provide the basis for life-long changes in the potential of these young adults, by severing the requirement that adults with disabilities live in poverty in order to maintain health insurance coverage and gain access to needed health care.