Gilbert gonzales

1. Gilbert Gonzales, MHA
Health Policy & Management
University of Minnesota
MN Health Services Research Conference
St. Paul, MN
March 3, 2015
Coverage & Access to Care for Children
with Chronic Health Conditions in the ACA

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Acknowledgments
Lynn A. Blewett
Michel Boudreaux
State Health Access Data Assistance Center (SHADAC)
Division of Health Policy & Management
University of Minnesota
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Research Question
Did the ACA’s guaranteed issue requirement
improve insurance coverage and access to care for
children with pre-existing conditions?
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Pre-Existing Conditions Prior to Health Reform
57 million people under 65 living with a pre-existing condition
Cancer, heart disease, asthma, arthritis, hypertension,
diabetes, HIV, obesity, high cholesterol, attention deficit
hyperactivity disorder (ADHD), stress and adjustment disorders
17 million children living with a pre-existing condition
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Source: Assistant Secretary for Planning and Evaluation (ASPE), 2011.

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Pre-Existing Conditions Prior to Health Reform
Health Insurance Companies in Individual Market
1. Denied health insurance coverage,
2. Denied coverage for specific services,
3. Increased premiums for people with pre-existing conditions.
19% of applicants in the individual market were denied
enrollment in 2010.
Group health plans were prohibited from denying coverage to
people with pre-existing conditions under federal law.
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Source: Government Accountability Office (GAO), March 2011.

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Pre-Existing Conditions Prior to Health Reform
State law varied on guaranteed issue
5 states required insurers in the individual market to guarantee issue
14 states provide partial protections for people with pre-existing conditions
(e.g. meeting minimum score on health status questionnaire, insurer of last resort, high risk pool)
Remaining states have no guaranteed issue provisions
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Source: Kaiser Family Foundation, 2012.

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Pre-Existing Conditions Under Health Reform
The Affordable Care Act
As of September 23, 2010, the ACA mandated guaranteed
issue requirements for children under 19 years.
The law did not enforce community rating.
• Families with chronically ill children potentially faced high
premiums that prevented them from obtaining coverage.
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Data
National Health Interview Survey (NHIS), 2007-2013
Treatment Group:
Children previously diagnosed with a chronic condition (n=10,909)
• Attention-deficit hyperactivity disorder (ADHD), mental retardation, Down syndrome,
asthma, cerebral palsy, sickle cell anemia, muscular dystrophy, autism, congenital or other
heart disease, and diabetes
Comparison Group:
Children not diagnosed with a chronic condition (n=41,450)
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Coverage and Access to Care
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50%
2%
41%
6% 6%
4%
95%
80%
55%
3%
32%
9%
4% 2%
93%
76%
ESI Individual Medicaid Uninsured Delayed
Medical Care
Forgone
Medical Care
Usual Source
of Care
Received
Checkup
With Chronic Conditions Without Chronic Conditions
Source: National Health Interview Survey, 2007-2010.

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Analysis
1. Pre-post changes in health insurance coverage
• Dependent ESI, Individual, Public, Uninsured
2. Pre-post changes in access to care measures
• Delayed care due to cost, Forgone care due to cost, Usual source of care,
Received well-child checkup
3. Difference-in-differences analysis
• Controlled for race and ethnicity, age, sex, health status, citizenship, household
language, family income, parents’ highest educational attainment, parents’ work
status, family structure, region and quarter of interview.
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Analysis
1. Pre-post changes in health insurance coverage
• Dependent ESI, Individual, Public, Uninsured
2. Pre-post changes in access to care measures
• Delayed care due to cost, Forgone care due to cost, Usual source of care,
Received well-child checkup
3. Difference-in-differences analysis
• Controlled for race and ethnicity, age, sex, health status, citizenship, household
language, family income, parents’ highest educational attainment, parents’ work
status, family structure, region and quarter of interview.
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Pre-Period: January 2007—September 2010
Post-Period: October 2011—December 2013

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Analysis
1. Pre-post changes in health insurance coverage
• Dependent ESI, Individual, Public, Uninsured
2. Pre-post changes in access to care measures
• Delayed care due to cost, Forgone care due to cost, Usual source of care,
Received well-child checkup
3. Difference-in-differences analysis
• Controlled for race and ethnicity, age, sex, health status, citizenship, household
language, family income, parents’ highest educational attainment, parents’ work
status, family structure, region and quarter of interview.
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Separate models for infants and toddlers (0-3 years),
young children (4-11 years), and adolescents (12-17 years)
Pre-Period: January 2007—September 2010
Post-Period: October 2011—December 2013

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Pre-Post Changes in Health Insurance
(Percentage Point Changes)
-5.2%
0.7%
6.0%
-1.6%
-2.6%
-1.0%
5.0%
-1.4%
-6.5%
-4.5%
-2.5%
-0.5%
1.5%
3.5%
5.5%
With Chronic Conditions Without Chronic Conditions
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Source: National Health Interview Survey, 2007-2013. * indicates p<0.05
*
*
*
*
*
Dependent ESI
Individual
Public
Uninsured

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Adjusted Difference-in-Differences (in red)
(Percentage Point Changes)
-5.2%
0.7%
6.0%
-1.6%
-2.6%
-1.0%
5.0%
-1.4%
-6.5%
-4.5%
-2.5%
-0.5%
1.5%
3.5%
5.5%
With Chronic Conditions Without Chronic Conditions
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Adjusts for race and ethnicity, age, sex, health status, citizenship, household language, family income, parents’ highest educational
attainment, parents’ work status, family structure, region and quarter of interview.
Source: National Health Interview Survey, 2007-2013. * indicates p<0.05
*
*
*
*
*
Dependent ESI
Individual
Public
Uninsured
-0.6 +1.9
-0.6
-0.4
*

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Pre-Post Changes in Access to Care
(Percentage Point Changes)
-4.6%
-2.6%
0.9%
3.0%
-1.4%
-0.6%
1.9%
4.2%
-6.5%
-4.5%
-2.5%
-0.5%
1.5%
3.5%
5.5%
With Chronic Conditions Without Chronic Conditions
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Source: National Health Interview Survey, 2007-2013. * indicates p<0.05
*
*
*
*
*
Delayed Care Forgone Care
Usual Source
of Care
Received Checkup

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Adjusted Difference-in-Differences (in red)
(Percentage Point Changes)
-4.6%
-2.6%
0.9%
3.0%
-1.4%
-0.6%
1.9%
4.2%
-6.5%
-4.5%
-2.5%
-0.5%
1.5%
3.5%
5.5%
With Chronic Conditions Without Chronic Conditions
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Adjusts for race and ethnicity, age, sex, health status, citizenship, household language, family income, parents’ highest educational
attainment, parents’ work status, family structure, region and quarter of interview.
Source: National Health Interview Survey, 2007-2013. * indicates p<0.05
*
*
*
*
*
Delayed Care Forgone Care
Usual Source
of Care
Received Checkup
-2.9 -1.8
-1.1
-1.5
**

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Conclusion
Adolescents (12-17 years) with chronic health conditions
Still taking up individual coverage and less likely to delay
or forgo medical care due to cost after the ACA
Similar findings not found among infants, toddlers and
young children
Results represent an early, lower-bound estimate
2010 mandate lacked a community rating provision
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www.shadac.org
@shadac
PhD Candidate
Graduate Research Assistant
gonza440@umn.edu
University of Minnesota
School of Public Health
Division of Health Policy & Management
Gilbert Gonzales, MHA