Research
Original Investigation
Improvement in Preventive Care of Young Adults After the Affordable Care Act The Affordable Care Act Is Helping Josephine S. Lau, MD, MPH; Sally H. Adams, PhD, RN; M. Jane Park, MPH; W. John Boscardin, PhD; Charles E. Irwin Jr, MD
IMPORTANCE The 2010 Affordable Care Act (ACA) included expansion of insurance coverage
for young adults and improved access to preventive care. OBJECTIVE To examine the ACA’s initial effects on young adults’ receipt of preventive care. DESIGN, SETTING, AND PARTICIPANTS Secondary data analysis using a pre-post design that compared health care use by young adults (aged 18 to 25 years) from 2009 and 2011 Medical Expenditure Panel Surveys. Data were collected through computer-assisted personal interviews of a nationally representative sample of the noninstitutionalized US population. MAIN OUTCOMES AND MEASURES Differences by year in rates of receiving a routine examination in the past year, blood pressure screening, cholesterol screening, influenza vaccination, and annual dental visit. Three logistic regression models were developed to (1) compare pre-ACA (2009) and post-ACA (2011) rates of receiving preventive care and (2) determine if post-ACA increases in insurance coverage accounted for changes in preventive care rates. Model 1 was a bivariate model to determine differences in preventive care rates by year; model 2, a multivariable model adding insurance status (full-year private, full-year public, partial-year uninsured, and full-year uninsured) to determine whether insurance accounted for survey year differences; and model 3, a multivariable model adding covariates (usual source of care and sociodemographic variables) to determine whether they further accounted for differences by survey year or insurance status. RESULTS After ACA, young adults had significantly higher rates of receiving a routine examination (47.8% vs 44.1%; P < .05), blood pressure screening (68.3% vs 65.2%; P < .05), cholesterol screening (29.1% vs 24.3%; P < .001), and annual dental visit (60.9% vs 55.2%; P < .001) but not an influenza vaccination (22.1% vs 21.5%; P = .70). Full-year private insurance coverage increased (50.1% vs 43.4%; P < .001), and rates of lacking insurance decreased (partial-year uninsured, 18.4% vs 20.7%; P = .03; and full-year uninsured, 22.2% vs 27.1%; P < .001). Full-year public insurance rates remained stable (9.4% vs 8.8%; P = .53). Insurance status fully accounted for the pre- and post-ACA differences in routine examination and blood pressure screening and partially accounted for year differences for cholesterol screening and annual dental visits. Covariate adjustment did not affect year differences. CONCLUSIONS AND RELEVANCE The ACA provisions appear to increase insurance coverage and receipt of preventive services among young adults. Further studies are needed to replicate these findings as other ACA provisions are implemented. Author Affiliations: Division of Adolescent and Young Adult Medicine, University of California, San Francisco (Lau, Adams, Park, Irwin); Department of Epidemiology and Biostatistics, University of California, San Francisco (Boscardin).
JAMA Pediatr. 2014;168(12):1101-1106. doi:10.1001/jamapediatrics.2014.1691 Published online October 27, 2014.
Corresponding Author: Josephine S. Lau, MD, MPH, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, 3333 California St, Ste 245, San Francisco, CA 94118 ([email protected]).
1101
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Research Original Investigation
Young Adults and Preventive Care
T
he 2010 Affordable Care Act (ACA) provides an unprecedented expansion of health insurance coverage to young adults. As of 2011, a total of 3 million young adults had gained insurance coverage through the provision that extends dependent private insurance coverage up to 26 years of age, resulting in a decrease in the uninsured rate among young adults from 42% in 2010 to 36% in 2011.1-3 The uninsured rate for this group is projected to continue to fall with implementation of 2 additional provisions: Medicaid expansion within the states and insurance exchanges, which are estimated to expand coverage by 7.2 and 4.9 million additional young adults, respectively, by 2014.4 Most morbidity and mortality during young adulthood are preventable, and many health problems that develop during young adulthood, including obesity, mental health disorders, and infectious diseases, can become chronic and affect future health during a life course.5-10 Evidence-based guidelines for young adults have provided specific recommendations for identifying and proposing treatment to prevent the most deleterious effects of emerging health conditions during early adulthood. 11 Yet, young adults have historically had the lowest rate of health insurance coverage of any age group,12 decreasing the likelihood that they will use preventive care. 13,14 The ACA provisions to increase insurance coverage for young adults hold promise for improving access to preventive care. Because of the ACA, a wide range of preventive services is available, with no copayment, to young adults with private insurance and those who are newly eligible through Medicaid (in states adopting the ACA Medicaid expansion). These include services recommended by the US Preventive Services Task Force, vaccinations recommended by the Advisory Committee for Immunization Practices,15 and additional preventive services for women’s health and well-being developed under the auspices of the Health Resources and Services Administration.16 Earlier work13 assessing the receipt of preventive care services in a representative sample of young adults in California found that fewer than 1 in 5 received influenza vaccination, only 1 in 5 received emotional health screening or diet or exercise counseling, about 2 in 5 received sexually transmitted disease screening, and 1 in 2 received cholesterol screening. Those who lacked health insurance had significantly lower rates of receiving these services. Provisions in the ACA to increase insurance coverage among young adults have the potential to improve their health now and during their life course through increased access to health care and preventive care in particular. Using Medical Expenditure Panel Survey (MEPS) data from the years 2009 and 2011, the purpose of this study was 2-fold: (1) to determine whether rates of preventive care visits and services for young adults increased following the initial implementation of the ACA in 2010; and (2) to determine if increases in insurance coverage after ACA implementation accounted for any changes in preventive care rates. These findings can provide an early indication of changes in health care use in this age group. 1102
Methods Study Design and Sampling We examined MEPS data from the 2009 and 2011 public-use files; the 2009 data represent pre-ACA status and the 2011 data represent the initial stage of ACA implementation. The MEPS is a nationally representative household survey of the US population that collects data on socioeconomic characteristics, health, health insurance, use of medical care services, and health expenditures. The household member who is most knowledgeable about the family’s health care use serves as the respondent for each family member. The MEPS respondents are enrolled for 2 years of data collection, with a new panel beginning each year.17 This study protocol was approved by the Committee on Human Research at University of California, San Francisco, under the exempt status.
Participants Our analyses included the MEPS 18- to 25-year old young adult subsamples of the 2009 (subsample, n = 3768; full sample, N = 34 920) and 2011 (subsample, n = 3717; full sample, N = 33 622) data sets. The upper limit of 25 years of age was selected to be consistent with the age group identified in the ACA for extended health insurance coverage with dependent insurance coverage that became effective in 2010.
Study Variables Study variables were preventive care visits and preventive services outcomes. Participants responded to questions regarding approximately how long it had been since they attended a routine examination or received a blood pressure or cholesterol screening from a physician or other health professional. They were also asked about 2 additional items: how long it had been since they had an influenza vaccination and, on average, how often they receive an annual dental visit (referred to as past-year dental check-up). These 5 items were recoded into having had a visit or service vs not in the past year.
Independent Variables The survey year was dummy-coded as 2009 or 2011. A 4-item insurance variable was developed for 2009 and 2011 based on the presence and type of insurance reported for each month of the year: (1) full-year private insurance; (2) full-year public insurance; (3) partial-year uninsured; and (4) full-year uninsured. If a respondent reported having had private insurance for each month of the year, they were coded as having fullyear private insurance. Those who reported having public insurance for all 12 months were coded as having full-year public insurance. Those who reported having coverage for some but not all months were coded as partial-year uninsured and those who reported having no coverage for the 12 months were coded as full-year uninsured. A small number reported both private and public coverage for the 12-month period (Table 1), but this group is not included in the analyses of outcomes.
Covariate Variables Access to care and demographic variables used in the analyses as covariates included having a usual source of care, sex,
JAMA Pediatrics December 2014 Volume 168, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Birmingham User on 06/03/2015
jamapediatrics.com
Young Adults and Preventive Care
Original Investigation Research
Table 1. Rates and Differences in Sociodemographic and Health Care Access Factors for Young Adults From the MEPS
Table 2. Rates for Young Adults From the MEPS: Past-Year Routine Examination and Preventive Services
MEPS Participants, % Characteristic
2009 (n = 3768)
2011 (n = 3717)
51.3
50.2
MEPS Participants, % P Value for χ2
Sex Male Female
48.7
49.8
.48
Home language English
86.3
86.2
Non-English
13.7
13.9
Non-Hispanic white
59.8
58.1
Non-Hispanic black
14.3
13.8
.91
Service Received
2009
2011
Routine examination in past year
44.1
47.8
Blood pressure screening in past year
65.2
68.3
Cholesterol screening in past year
24.3
29.1
Influenza immunization in past year
21.5
22.1
Annual dental visit in past year
55.2
60.9
Abbreviation: MEPS, Medical Expenditure Panel Survey.
Race/ethnicity
Non-Hispanic Asian Hispanic
4.5
4.7
18.1
20.1
American Indian or Alaskan Native
0.8
0.9
Multiracial
2.2
1.8
≥400
30.4
27.3
200-399
29.8
30.1
100-199
20.8
21.7
Original Investigation
Improvement in Preventive Care of Young Adults After the Affordable Care Act The Affordable Care Act Is Helping Josephine S. Lau, MD, MPH; Sally H. Adams, PhD, RN; M. Jane Park, MPH; W. John Boscardin, PhD; Charles E. Irwin Jr, MD
IMPORTANCE The 2010 Affordable Care Act (ACA) included expansion of insurance coverage
for young adults and improved access to preventive care. OBJECTIVE To examine the ACA’s initial effects on young adults’ receipt of preventive care. DESIGN, SETTING, AND PARTICIPANTS Secondary data analysis using a pre-post design that compared health care use by young adults (aged 18 to 25 years) from 2009 and 2011 Medical Expenditure Panel Surveys. Data were collected through computer-assisted personal interviews of a nationally representative sample of the noninstitutionalized US population. MAIN OUTCOMES AND MEASURES Differences by year in rates of receiving a routine examination in the past year, blood pressure screening, cholesterol screening, influenza vaccination, and annual dental visit. Three logistic regression models were developed to (1) compare pre-ACA (2009) and post-ACA (2011) rates of receiving preventive care and (2) determine if post-ACA increases in insurance coverage accounted for changes in preventive care rates. Model 1 was a bivariate model to determine differences in preventive care rates by year; model 2, a multivariable model adding insurance status (full-year private, full-year public, partial-year uninsured, and full-year uninsured) to determine whether insurance accounted for survey year differences; and model 3, a multivariable model adding covariates (usual source of care and sociodemographic variables) to determine whether they further accounted for differences by survey year or insurance status. RESULTS After ACA, young adults had significantly higher rates of receiving a routine examination (47.8% vs 44.1%; P < .05), blood pressure screening (68.3% vs 65.2%; P < .05), cholesterol screening (29.1% vs 24.3%; P < .001), and annual dental visit (60.9% vs 55.2%; P < .001) but not an influenza vaccination (22.1% vs 21.5%; P = .70). Full-year private insurance coverage increased (50.1% vs 43.4%; P < .001), and rates of lacking insurance decreased (partial-year uninsured, 18.4% vs 20.7%; P = .03; and full-year uninsured, 22.2% vs 27.1%; P < .001). Full-year public insurance rates remained stable (9.4% vs 8.8%; P = .53). Insurance status fully accounted for the pre- and post-ACA differences in routine examination and blood pressure screening and partially accounted for year differences for cholesterol screening and annual dental visits. Covariate adjustment did not affect year differences. CONCLUSIONS AND RELEVANCE The ACA provisions appear to increase insurance coverage and receipt of preventive services among young adults. Further studies are needed to replicate these findings as other ACA provisions are implemented. Author Affiliations: Division of Adolescent and Young Adult Medicine, University of California, San Francisco (Lau, Adams, Park, Irwin); Department of Epidemiology and Biostatistics, University of California, San Francisco (Boscardin).
JAMA Pediatr. 2014;168(12):1101-1106. doi:10.1001/jamapediatrics.2014.1691 Published online October 27, 2014.
Corresponding Author: Josephine S. Lau, MD, MPH, Division of Adolescent and Young Adult Medicine, University of California, San Francisco, 3333 California St, Ste 245, San Francisco, CA 94118 ([email protected]).
1101
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Birmingham User on 06/03/2015
Research Original Investigation
Young Adults and Preventive Care
T
he 2010 Affordable Care Act (ACA) provides an unprecedented expansion of health insurance coverage to young adults. As of 2011, a total of 3 million young adults had gained insurance coverage through the provision that extends dependent private insurance coverage up to 26 years of age, resulting in a decrease in the uninsured rate among young adults from 42% in 2010 to 36% in 2011.1-3 The uninsured rate for this group is projected to continue to fall with implementation of 2 additional provisions: Medicaid expansion within the states and insurance exchanges, which are estimated to expand coverage by 7.2 and 4.9 million additional young adults, respectively, by 2014.4 Most morbidity and mortality during young adulthood are preventable, and many health problems that develop during young adulthood, including obesity, mental health disorders, and infectious diseases, can become chronic and affect future health during a life course.5-10 Evidence-based guidelines for young adults have provided specific recommendations for identifying and proposing treatment to prevent the most deleterious effects of emerging health conditions during early adulthood. 11 Yet, young adults have historically had the lowest rate of health insurance coverage of any age group,12 decreasing the likelihood that they will use preventive care. 13,14 The ACA provisions to increase insurance coverage for young adults hold promise for improving access to preventive care. Because of the ACA, a wide range of preventive services is available, with no copayment, to young adults with private insurance and those who are newly eligible through Medicaid (in states adopting the ACA Medicaid expansion). These include services recommended by the US Preventive Services Task Force, vaccinations recommended by the Advisory Committee for Immunization Practices,15 and additional preventive services for women’s health and well-being developed under the auspices of the Health Resources and Services Administration.16 Earlier work13 assessing the receipt of preventive care services in a representative sample of young adults in California found that fewer than 1 in 5 received influenza vaccination, only 1 in 5 received emotional health screening or diet or exercise counseling, about 2 in 5 received sexually transmitted disease screening, and 1 in 2 received cholesterol screening. Those who lacked health insurance had significantly lower rates of receiving these services. Provisions in the ACA to increase insurance coverage among young adults have the potential to improve their health now and during their life course through increased access to health care and preventive care in particular. Using Medical Expenditure Panel Survey (MEPS) data from the years 2009 and 2011, the purpose of this study was 2-fold: (1) to determine whether rates of preventive care visits and services for young adults increased following the initial implementation of the ACA in 2010; and (2) to determine if increases in insurance coverage after ACA implementation accounted for any changes in preventive care rates. These findings can provide an early indication of changes in health care use in this age group. 1102
Methods Study Design and Sampling We examined MEPS data from the 2009 and 2011 public-use files; the 2009 data represent pre-ACA status and the 2011 data represent the initial stage of ACA implementation. The MEPS is a nationally representative household survey of the US population that collects data on socioeconomic characteristics, health, health insurance, use of medical care services, and health expenditures. The household member who is most knowledgeable about the family’s health care use serves as the respondent for each family member. The MEPS respondents are enrolled for 2 years of data collection, with a new panel beginning each year.17 This study protocol was approved by the Committee on Human Research at University of California, San Francisco, under the exempt status.
Participants Our analyses included the MEPS 18- to 25-year old young adult subsamples of the 2009 (subsample, n = 3768; full sample, N = 34 920) and 2011 (subsample, n = 3717; full sample, N = 33 622) data sets. The upper limit of 25 years of age was selected to be consistent with the age group identified in the ACA for extended health insurance coverage with dependent insurance coverage that became effective in 2010.
Study Variables Study variables were preventive care visits and preventive services outcomes. Participants responded to questions regarding approximately how long it had been since they attended a routine examination or received a blood pressure or cholesterol screening from a physician or other health professional. They were also asked about 2 additional items: how long it had been since they had an influenza vaccination and, on average, how often they receive an annual dental visit (referred to as past-year dental check-up). These 5 items were recoded into having had a visit or service vs not in the past year.
Independent Variables The survey year was dummy-coded as 2009 or 2011. A 4-item insurance variable was developed for 2009 and 2011 based on the presence and type of insurance reported for each month of the year: (1) full-year private insurance; (2) full-year public insurance; (3) partial-year uninsured; and (4) full-year uninsured. If a respondent reported having had private insurance for each month of the year, they were coded as having fullyear private insurance. Those who reported having public insurance for all 12 months were coded as having full-year public insurance. Those who reported having coverage for some but not all months were coded as partial-year uninsured and those who reported having no coverage for the 12 months were coded as full-year uninsured. A small number reported both private and public coverage for the 12-month period (Table 1), but this group is not included in the analyses of outcomes.
Covariate Variables Access to care and demographic variables used in the analyses as covariates included having a usual source of care, sex,
JAMA Pediatrics December 2014 Volume 168, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Birmingham User on 06/03/2015
jamapediatrics.com
Young Adults and Preventive Care
Original Investigation Research
Table 1. Rates and Differences in Sociodemographic and Health Care Access Factors for Young Adults From the MEPS
Table 2. Rates for Young Adults From the MEPS: Past-Year Routine Examination and Preventive Services
MEPS Participants, % Characteristic
2009 (n = 3768)
2011 (n = 3717)
51.3
50.2
MEPS Participants, % P Value for χ2
Sex Male Female
48.7
49.8
.48
Home language English
86.3
86.2
Non-English
13.7
13.9
Non-Hispanic white
59.8
58.1
Non-Hispanic black
14.3
13.8
.91
Service Received
2009
2011
Routine examination in past year
44.1
47.8
Blood pressure screening in past year
65.2
68.3
Cholesterol screening in past year
24.3
29.1
Influenza immunization in past year
21.5
22.1
Annual dental visit in past year
55.2
60.9
Abbreviation: MEPS, Medical Expenditure Panel Survey.
Race/ethnicity
Non-Hispanic Asian Hispanic
4.5
4.7
18.1
20.1
American Indian or Alaskan Native
0.8
0.9
Multiracial
2.2
1.8
≥400
30.4
27.3
200-399
29.8
30.1
100-199
20.8
21.7
