EFFECT OF THE ACA ON INSURANCE FOR CHILDREN WITH PRE-EXISTING - - PowerPoint PPT Presentation

EFFECT OF THE ACA ON INSURANCE FOR CHILDREN WITH PRE-EXISTING CONDITIONS

DIANA GOVIER, MPH JANGHO YOON, PHD

JUNE 24TH, 2017

COLLEGE OF PUBLIC HEALTH AND HUMAN SCIENCES School of Social and Behavioral Health Sciences

Agenda

• Background
• Specific Aims
• Methods
• Results
• Discussion
• Future Directions
• Limitations

Chronic conditions in U.S. children

• Chronic condition (CC): condition lasting 3 mo.-lifetime1
• ≈¼ US children have CCs1
• 5 most frequently reported CCs1
• Asthma (9%), learning disabilities (7.8%), ADD/ADHD (6.4%),

speech problems (3.7%), oppositional defiant/conduct disorder (3/3%)

• Vary by age, race/ethnicity, income, place of residence1
• Childhood CCs are on the rise2
• More likely insured than healthy counterparts3

Why should we care?

• Pre-existing conditions (PECs) insurance exclusions4
• asthma; diabetes; cancers; mental health conditions; illnesses

that put children at greater risk for needing healthcare5

• >20,000 denied individual coverage due to PECs6
• More likely underinsured than healthy counterparts7
• Increased unmet medical needs, delays in care, use of ER,

hospitalizations, co-morbidities, mortality, financial hardship

• Decreased medication management, usual source of care,

preventative services8-13

ACA policy change

Guaranteed issue: prohibition of exclusions and/or differential pricing/benefits based on PECs, health status, claims history, etc14

• Estimated 31,000 - 72,000 uninsured children would be

able to gain coverage who were previously denied15

• Estimated 90,000 insured children would gain coverage

for PECs previously excluded15

Specific aims

Aim I: Examine national trends in insurance for children 5-18 w/ and w/o PECs for years 2008 through 2013. Aim II: Examine effect of guaranteed issue on likelihood

• f having any insurance, public insurance, and private

insurance for children 5-18 w/PECs

Methods – Data & study sample

• 5 overlapping panels of Medical Expenditure Panel

Survey (MEPS) years 2008 – 2013

• 2011 lag year
• Oversampling of racial & ethnicity minorities
• Oversampling of low-income individuals
• Study sample: 18,701 children 5-18 yrs
• No exclusion criteria other than age

Methods – Dependent variables

• Any insurance (model 1) – binary variable indicating

whether child has any type of insurance

• Public insurance (model 2) – binary variable indicating

whether child has any public insurance

• Private insurance (model 3) – binary variable indicating

if child has any private insurance

Methods – Independent variables

• Policy implementation (Post) – binary variable

indicating time period

• Policy period on or after October 1st, 2010
• Pre-existing condition (PEC) – binary variable indicating

if child has PEC

• Defined as having asthma, ADD/ADHD, or special healthcare

needs

• Policy effect (PEC*Post) – interaction term indicating

post-policy time period and presence of PEC

• Time fixed-effects (T) – month dummy variables for

months Jan, 2008-Dec, 2013 to control for secular trends

Methods – Model specification

• Difference-in-differences (DID)
• Compares ∆ in treated to ∆ in controls as result of policy change16
• Mimics experimental research design using observational study data16
• Reduces confounding from unobserved factors16
• Model specification:

logit 𝑄𝑠(HIit=1) = β0  β1PECit  β2Ti  β3Posti*PECit  X1iβ + X2itβ + εit

• Covariates
• X1iβ = time in-varying covariates: race/ethnicity, sex
• X2itβ = time-varying covariates: age, poverty category, US Census region, MSA
• Average marginal effects (AME) to estimate effect of policy
• n children w/PECs

PEC prevalence increasing over time

Data Source: MEPS HC, 2008-2013 Adjusted for complex survey design effect

Insured rate among children increased during study period

Publicly insured rate continued to increase after ACA implementation

Privately insured rate decreased before ACA then stabilized for children w/PECs

Uninsured rated decreased before and after ACA implementation

ACA resulted in significant increase in probability of insurance for children w/PECs

Average marginal effect of guaranteed issue on probability of any insurance for chidren w/PECs Pr(any insurance)

• Avg. Marginal Effect

0.96** (0.32)

Note: Boostrapped standard errors w/300 repetitions Note: Statistically significant covariates: month, poverty category, age, sex, race, ethnicity, US Census region, metropolitan statistical area * Statistically significant at the 95% level. ** Statistically significant at the 99% level. *** Statistically significant at the 99.9% level.

• By ≈1.04%
• = %pt change from policy / pre-ACA % children insured w/PECs

ACA resulted in sign. increase in probability

• f pub/priv insurance for children w/PECs
• By ≈ 4.70% for pub ins & ≈ 2.02% for priv ins (not stat.

sigificant.)

• = % change from policy / pre-ACA % children insured w/PECs

Average marginal effect of guaranteed issue on probability of insurance for chidren w/PECs Pr(pub insurance) Pr(priv insurance)

• Avg. Marginal Effect

1.93* 1.11 (0.83) (0.86)

Note: Boostrapped standard errors w/300 repetitions Note: Statistically significant covariates: month, poverty category, age, sex, race, ethnicity, US Census region, metropolitan statistical area * Statistically significant at the 95% level. ** Statistically significant at the 99% level. *** Statistically significant at the 99.9% level.

Discussion

• From 2008-2013 decrease in uninsurance for children 5-18
• Unexpected results for effect of guaranteed issue on public

insurance

• Protections for children w/PECs could improve further
• Grandfathered plans are exempt from guaranteed issue
• Previously 45-55% children w/special HC needs/disability on

grandfathered plans6

• American Health Care Act (AHCA) makes future uncertain
• Could change insurance regulations for children w/PECs
• Allow insurers in states with community rating waivers to vary premiums

based on PEC-status for those with lapses in coverage >=63 days

Future Directions

• Guaranteed issue increased access to insurance for

children w/PECs, but important aspects uninvestigated

• More research needed to comprehensively discuss best

policy-practices for insurance for children w/PECs

• Health insurance coverage shown to increase access to &

utilization of healthcare services for children w/special healthcare needs18

• Did guaranteed issue affect healthcare utilization?
• Did guaranteed issue affect healthcare expenditures?
• How do these effects vary by region, race/ethnicity, and

family income?

• How has continuity of coverage changed for children

w/PECs?

Limitations

• Definition of PECs limited in detail
• Geographic indicators only include Census region
• Does not account for condition-specific carve-outs

prohibited by ACA’s guaranteed issue provision

References

1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. (2011). Child heath USA 2011. Rockville, Maryland: US Department of Health and Human Services. 2. Perrin, J., Bloom, S., & Gortmaker, S. (2007). The increase of childhood chronic conditions in the United States. The Journal of the American Medical Association, 2755-2759. 3. Davidoff, A. (2004). Insurance for children with special healthcare needs: patterns of coverage and burden on families to provide adequate

• insurance. Pediatrics, 394-403.

4. Department of Health and Human Services. (2010, June 28). Patient Protection and Affordable Care Act: Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections. Retrieved from Regulations: https://www.regulations.gov/#!documentDetail;D=HHS-OS-2010-0014-0001 5. Kaiser Family Foundation. (2016, September 29). Key facts about the uninsured population. Retrieved from The Henry J Kaiser Family Foundation: http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/ 6. Association of Maternal & Child Health Bureaus. (2012). AMCHP issue brief: the affordable care act and children and youth with autism spectrum disorder and other developmental disabilities. Washington, D.C.: AMCHP. 7. Kogan, M., Newacheck, P., Blumberg, S., Ghandour, R., & Singh, G. (2010). Underinsurance amoung children in the United States. New England Journal of Medicine, 841-851. 8. Cassedy, A., Fairbrother, G., & Newacheck, P. (2008). The impact of insurance instabilitiy on children's access, utilization, and satisfaction with health care. Ambulatory Pediatrics, 321-328. 9. Kogan, M., Alexander, G., & Teitelbaum, M. (1995). The effect of gaps in health insurance on continuity of regular source of care among pre-school aged children in the United States. Journal of the American Medical Association, 1429-1435. 10. Olson, L., Tang, S., & Newacheck, P. (2005). Children in the United States with discontinuous health insurance coverage. New England Journal of Medicine, 382-328. 11. Weissman, J., Gatsonis, C., & Epstein, A. (1992). Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. Journal of the American Medical Association, 2388-2394. 12. Collins, S., Davis, K., Doty, M., Kriss, J., & Holmgren, A. (2006, April). Gaps in health insurance: an all-American problem. The Commonwealth Fund. 13. Park, M., Brindis, C., Vaughn, B., Barry, M., Guzman, L., & Berger, A. (2013). Chronic conditions. San Francisco, CA: National Adolescent and Young Adult Health Information Center. 14. Patient Protection and Affordable Care Act. Available at: https://democrats.senate.gov/pdfs/reform/patient-protection-affordable-care-act- as-passed.pdf. Accessed June 10th, 2017. 15. McGinley, L., & Cary, M. (2010, September 23). Kids with preexisting illness get new protection for coverage but hurdles remain. Retrieved from Kaiser Health News: http://khn.org/news/kids-preexisting-conditions/ 16. Angrist, D., & Pischkke, J. (2009). Mostly Harmless Econometrics, An Empiricist's Companion. Princeton, New Jersey: Princeton University Press. 17. Newacheck, P., & Halfton, N. (1998, October 7). Prevalence and impact of disabling chronic conditions in childhood. American Journal of Public Health . Retrieved from Chronic Disease Epidemiology, Prevention, and Control, Fourth Edition: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.88.4.610 18. Jeffrey, A., & Newacheck, P. (2006). Role of insurance for children wit special healthcare needs: a synthesis of the evidence. Pediatrics, 1027-1038.

THANK YOU

Contact information: Diana Govier, govierd@oregonstate.edu Jangho Yoon, jangho.yoon@oregonstate.edu COLLEGE OF PUBLIC HEALTH AND HUMAN SCIENCES School of Social and Behavioral Health Sciences