Better off at Age 19 or 26?: A beginning step to testing the ability of the Affordable Care Act to meeting the grand challenge of closing health insurance gaps for children and youth with special healthcare needs as they transition into adulthood


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School of Public Policy


Public Policy

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Children and Youth with special healthcare needs (CYSHCN) experience gaps in health insurance coverage as they transition into adulthood by aging out of children'spublic health insurance programs or off their parents? private health insurance policies (Anderson, Dobkin, & Gross, 2012; Fishman, 2001). CYSHCN are a vulnerable, high medical care use population and the continuity of their insurance coverage is a key part of their healthcare transition into adulthood. Effective September 23, 2010, the Affordable Care Act (ACA) stipulated that private insurance policies were required to cover children under their parents? policies until age 26. This dissertations explores whether this policy change (e.g. moving the cutoff for private insurance from age 19 to age 26) helped youth with special healthcare needs as well as overall youth in terms of lessening the number of insurance gaps they experienced as they transitioned to adulthood. A literature review of uninsurance on children and young adults in general as well as for CYSHCN was conducted. Four themes emerged: policy changes are associated with insurance discontinuity in children'spublic insurance programs, the lack of a common definition of CYSHCN to apply to standardized datasets, the existence of demographic effects with a focus on age and race/ethnicity and the association of medical insurance transition with key ages. Hill and Shaefer's(2011) conceptual model of the dynamics of child health insurance coverage was used along with the 2008 Survey of Income and Program Participation (SIPP) in a difference in difference research design. An algorithm to subset out CYSHCN from the SIPP was developed. The difference in difference regression equation encompassed both CYSHCN and overall youth before and after the intervention in the following two age groups: 19 to 26 (treatment group) and 27 to 29 (control group). Ordinary Least Squares (OLS), Fixed Effects (FE), Random Effects (RE) models were employed. Due to the SIPP's stratified sampling, techniques such as robust standard errors and robust clustering of the standard errors by state were used in addition to the regular standard error. OLS, FE and RE estimates found that the policy significantly lessened insurance gaps for youth with special healthcare needs. OLS estimates found that the policy significantly lessened insurance gaps for overall youth but both RE and FE provided no strong evidence of reduced insurance gaps for overall youth. This study also found that the policy'simpact was greater for CYSHCN than for overall youth. Falsification tests assuming that the reform took place at various placebo dates were also performed. Falsification results were consistent in all specifications and strengthen the main results and conclusions. The experiences of CYSHCN are a litmus test of how the healthcare delivery system and infrastructure is working in general, with insurance coverage availability being an important policy lever. This dissertations proposal'sexploration of the ACA age 26 policy is only a first step in the process of studying insurance adequacy for transitioning CYSHCN. More extensive research needs to be done in the area of youth with special healthcare needs and their retention of medical insurance as they transition into adulthood.