ACA provision for young adults leaves racial disparities intact among trauma patients
The Affordable Care Act (ACA) allowed millions of young adults to retain health care coverage through their parents' insurance plans, but new research finds that many young African-American and Hispanic adults who need coverage for trauma care may not get it. The results of the study are published online as an "article in press" in the Journal of the American College of Surgeons and will appear in a print edition later this year.
Before the dependent care provision of the Affordable Care Act became law in September 2010, approximately 30 percent of young adults were uninsured,1 according to the Centers for Medicare & Medicaid Services. The lack of insurance was especially pronounced among ethnic minorities.
The dependent care provision, one of the earliest adopted provisions of the ACA, requires private health insurance companies that offer employer-based coverage to continue covering dependent children up to age 26, instead of dropping them from coverage around age 18. Within the first year of enactment of this provision, more than 2.5 million young adults had obtained health care coverage,2 according to the U.S. Department of Health and Human Services.
John W. Scott, MD, MPH, a general surgery resident at Brigham and Women's Hospital, Boston, Mass., and a research fellow at the hospital's Center for Surgery and Public Health, and colleagues researched how well the dependent care provision addressed the ethnic disparities in health care coverage, particularly for young ethnic minority adults needing trauma care.
Trauma is the number one cause of death3 for people age 15 to 34, reports the Centers for Disease Control and Prevention. "Ensuring adequate access to high quality care through health insurance coverage is a priority for policymakers and trauma surgeons alike," Dr. Scott and his colleagues wrote.
Using the National Trauma Data Bank (NTDB), they analyzed patient data on two groups of patients who sought trauma care between 2007 and 2012. The first group included 529,844 young adults, age 19 to 25, who became eligible for health care coverage under the dependent care provision. The second group included 484,974 adults, age 27 to 34, who were not eligible for the provision. The two groups had similar demographics, insurance coverage rates, employment status, medical conditions, and injuries.
Dr. Scott and his colleagues analyzed how annual insurance status changed among 19 to 25-year-old African-American, Hispanic, and white patients before and after the dependent care provision. They then compared that information with insurance status for 26 to 34- year-olds in the same racial and ethnic groups.
They found that although the dependent care provision allowed more young adult trauma patients to have health care coverage, it did not close the racial gap in coverage. "White patients had lower pre-policy uninsured rates and greater coverage gains than did African-Americans and Hispanics," the study authors wrote.
The NTDB analysis showed that the uninsured rates for 19 to 25-year-olds dropped by 4.9 percentage points for whites, but it only dropped by 2.9 percentage points and 1.7 percentage points for African Americans and Hispanics, respectively.
"We were not completely surprised by these findings," Dr. Scott said. "The policy is based on whether you have parents with jobs that offer employer-based insurance. We know that if you're a minority you're less likely to have employer-sponsored health insurance."
Their results also showed geographic differences in the ethnic disparities. African Americans in the Midwest and Northeast had the greatest reduction in uninsured young people. Hispanics also showed the greatest reduction in uninsured people in the Midwest.
The most pronounced racial disparities from the change in coverage existed in the South and West. Dr. Scott noted that these regions also happen to be where many of the states that have not elected to expand Medicaid are located.
Under the Affordable Care Act, state governments can choose whether to expand eligibility for health coverage under Medicaid, the public health insurance program for low-income individuals and families. As of March 2015, 29 states had decided to expand Medicaid,4 according to the Kaiser Family Foundation. Six states are still considering expansion and 16 states have decided against it.
"The dependent coverage provision is a good first step in expanding access to care, however, additional, complementary provisions—like the Medicaid expansion—could help to fill in these gaps we've identified. If access does not continue to improve, those left behind by the dependent care provision will have an even harder time catching up," Dr. Scott said.
Because of the significant need for access to trauma care, Dr. Scott said it's important for surgeons—and uninsured young people—to pay attention to how ACA provisions are carried out in their states.
"As surgeons, we like to believe that we don't think about insurance cards, and we don't care what the patient looks like. But there are plenty of data that suggest that insurance really matters for trauma patients. And as trauma surgeons, we should be concerned that this group—young ethnic minority trauma patients—may not benefit from efforts to improve access to care."
1. Centers for Medicare & Medicaid Services. The Center for Consumer Information & Insurance Oversight. Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Families and Businesses. Available at: www.cms.gov/CCIIO/Resources/Fi … hild_fact_sheet.html. Accessed April 2, 2015.
2. U.S. Department of Health & Human Services. ASPE Issue Brief. 2.5 Million Young Adults Gain Health Insurance Due to the Affordable Care Act. Available at: aspe.hhs.gov/health/reports/20 … ngAdultsACA/ib.shtml. Accessed April 2, 2015.
3. Centers for Disease Control and Prevention. 10 Leading Causes of Death by Age Group, United States – 2010. Available at: www.cdc.gov/injury/wisqars/pdf … Age_Group_2010-a.pdf. Accessed April 2, 2015.
4. Kaiser Family Foundation. The Effects of the Medicaid Expansion on State Budgets: An Early Look in Select States. Available at: kff.org/report-section/the-eff … -states-issue-brief/. Accessed April 2, 2015.