Impact of Dependent Coverage Expansion and an Individual Mandate on Adolescent and Young Adult Insurance Coverage

Background/Objectives: Although access to care may improve for adolescents and young adults (AYA) as a result of health care reform, it is unclear how the Affordable Care Act’s individual mandate and dependent coverage expansion will affect AYA’s coverage rates. As experience from state policies may help predict effects of national reforms, we sought to examine the effect of state-level dependent coverage expansions with and without an individual mandate on AYA insurance coverage.

Methods: We used data from 148,299 AYA aged 16–26 years who had continuous insurance coverage for ≥12 months from a non-profit health plan during 1/00-12/12. We employed a pre-post comparison design with 3 periods: pre-reform (1/00-5/06), post-Massachusetts reform (6/06-9/10), and post-national reform (10/10-12/12).  A difference-in-difference (DID) estimator was used to determine the proportion of youth in each period who retained vs. lost dependent coverage while their family remained insured, comparing youth insured in Massachusetts (state dependent coverage expansion with an individual mandate) to those insured in Maine and New Hampshire (state dependent coverage expansions without an individual mandate), adjusting for potential confounders (e.g., sex, chronic condition status, neighborhood poverty).

Results:  Prior to 2006 reforms, 24.2% of AYA in Massachusetts lost dependent coverage while their family remained insured; that percentage dropped to 14.8% through 2010 and to 7.5% after 2010. DID estimators revealed that implementation of dependent coverage expansion with an individual mandate on the state level (Massachusetts) was associated with a significant decrease in the percentage of AYA who lost dependent coverage by an additional 6.5 percentage points compared to states expanding dependent coverage without a mandate (Maine and New Hampshire); an additional 2.5 percentage point decrease was seen in Massachusetts vs. Maine and New Hampshire after federal dependent coverage expansion in 2010 (both p<.001). Loss of dependent coverage was more likely for youth living in low-income neighborhoods and less likely for youth with chronic conditions. 

Conclusions: Implementation of an individual mandate along with a dependent coverage expansion is associated with a significant reduction in loss of dependent coverage for AYA, although we do not have information about whether AYAs who lost dependent coverage subsequently gained insurance from another source. The recent federal implementation of an individual mandate may prevent loss of coverage, better than dependent coverage expansion alone. Maintaining dependent coverage into young adulthood could affect continuity of care for AYA; however, effects on health care utilization and outcomes remain unknown.