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Coverage and Access to Care for Children with Chronic Health Conditions in the ACA
- 1. Gilbert Gonzales, MHA HealthPolicy & 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
- 2. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level Acknowledgments Lynn A. Blewett Michel Boudreaux State Health Access Data Assistance Center (SHADAC) Division of Health Policy & Management University of Minnesota 2
- 3. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level Research Question Did the ACA’s guaranteed issue requirement improve insurance coverage and access to care for children with pre-existing conditions? 3
- 4. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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 4 Source: Assistant Secretary for Planning and Evaluation (ASPE), 2011.
- 5. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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. 5 Source: Government Accountability Office (GAO), March 2011.
- 6. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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 6 Source: Kaiser Family Foundation, 2012.
- 7. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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. 7
- 8. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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) 8
- 9. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level Coverage and Access to Care 9 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.
- 10. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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. 10
- 11. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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. 11 Pre-Period: January 2007—September 2010 Post-Period: October 2011—December 2013
- 12. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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. 12 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
- 13. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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 13 Source: National Health Interview Survey, 2007-2013. * indicates p<0.05 * * * * * Dependent ESI Individual Public Uninsured
- 14. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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 14 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 *
- 15. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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 15 Source: National Health Interview Survey, 2007-2013. * indicates p<0.05 * * * * * Delayed Care Forgone Care Usual Source of Care Received Checkup
- 16. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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 16 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 **
- 17. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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 17
- 18. Click to editMaster title style Click to edit Master text styles Second level Third level Fourth level Fifth level 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