Abstract
Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)—the individual mandate, expansion of Medicaid eligibility, and essential benefits. How these provisions affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed. We study Massachusetts health reform because it enacted these key provisions statewide in 2006. Methods We used a difference-in-differences (DD) approach to assess the impact of Massachusetts health reform on uninsurance and access to care among children 0–17 years in Massachusetts compared to children in other New England states. The National Survey of Children’s Health provided the pre-reform year and two post-reform years (1 and 5 years post-reform). We analyzed outcomes for children overall and children previously and newly-eligible for Medicaid under Massachusetts health reform, adjusting for age, sex, race/ethnicity, non-English language, and having special health care needs. Results Compared to other New England states, Massachusetts’s enactment of the individual mandate, Medicaid expansion, and essential benefits was associated with trends at 5 years post-reform toward lower uninsurance for children overall (DD = − 1.1, p-for-DD = 0.05), increased access to specialty care (DD = 7.7, p-for-DD = 0.06), but also with a decrease in access to preventive care (DD=-3.4, p-for-DD = 0.004). At 1 year post-reform, access to specialty care improved for children newly-Medicaid-eligible (DD = 18.3, p-for-DD = 0.03). Conclusions for Practice Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Abbreviations
- ACA:
-
The Patient Protection and Affordable Care Act
- DD:
-
Difference-in-differences
- FPL:
-
Federal poverty level
- NSCH:
-
National Survey of Children’s Heath
References
Abdus, S., & Selden, T. M. (2013). Adherence with recommended well-child visits has grown, but large gaps persist among various socioeconomic groups. Health Aff (Millwood), 32(3), 508–515. https://doi.org/10.1377/hlthaff.2012.0691.
Adams, S. H., Park, M. J., & Irwin, C. E. (2015). Adolescent and young adult preventive care: comparing national survey rates. American Journal of Preventive medicine, 49(2), 238–247. https://doi.org/10.1016/j.amepre.2015.02.022.
Adams, S. H., Park, M. J., Twietmeyer, L., Brindis, C. D., & Irwin, C. E. (2018). Association between adolescent preventive care and the role of the affordable care act. JAMA Pediatrics, 172(1), 43–48. https://doi.org/10.1001/jamapediatrics.2017.3140.
Allred, N. J., Wooten, K. G., & Kong, Y. (2007). The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19- to 35-month-old children. Pediatrics, 119, 4–11. https://doi.org/10.1542/peds.2006-2089C.
Centers for Disease Control and Prevention. (2013). 2011–2012 National Survey of Children’s Health Frequently Asked Questions. Retrieved February 8, 2013, from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/slaits/nsch_2011_2012/01_Frequently_asked_questions/NSCH_2011_2012_FAQs.pdf.
Cohen, R., & Martinez, M. (2015). Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–June 2015. Retrieved January 2, 2016, from http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201511.pdf.
Connaughton, J. E., & Madsen, R. A. (2012). U.S. State and Regional Impact of the 2008/2009 Recession. JRAP, 42(3), 177–187. Retrieved from http://ageconsearch.umn.edu/bitstream/143779/2/12-3-1.pdf.
Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., & Zapata, D. (2017). Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States. Journal of policy analysis and management: [the journal of the Association for Public Policy Analysis and Management], 36(1), 178–210. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27992151.
Davidoff, A., Dubay, L., Kenney, G., & Yemane, A. (2003). The effect of parents’ insurance coverage on access to care for low-income children. Inquiry, 40(3), 254–68. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14680258.
DeVoe, J. E., Marino, M., Angier, H., O’Malley, J. P., Crawford, C., Nelson, C., … Gold, R. (2015). Effect of expanding medicaid for parents on children’s health insurance coverage: Lessons from the Oregon experiment. JAMA Pediatrics, 169(1), e143145. https://doi.org/10.1001/jamapediatrics.2014.3145.
DeVoe, J. E., Tillotson, C., & Wallace, L. S. (2008). Uninsured children and adolescents with insured parents. JAMA, 300(16), 1904–1913. https://doi.org/10.1001/jama.2008.516.
DeVoe, J. E., Tillotson, C. J., Angier, H., & Wallace, L. S. (2015). Predictors of children’s health insurance coverage discontinuity in 1998 versus 2009: Parental coverage continuity plays a major role. Maternal and Child Health Journal, 19(4), 889–896. https://doi.org/10.1007/s10995-014-1590-0.
DeVoe, J. E., Tillotson, C. J., Marino, M., O’Malley, J., Angier, H., Wallace, L. S., & Gold, R. (2015). Trends in type of health insurance coverage for US children and their parents, 1998–2011. Academic Pediatrics, 16(2), 192–199. https://doi.org/10.1016/j.acap.2015.06.009.
Dhingra, S. S., Zack, M. M., Strine, T. W., Druss, B. G., & Simoes, E. (2013). Change in health insurance coverage in Massachusetts and other New England States by perceived health status: Potential impact of health reform. American Journal of Public Health, 103(6), e107–e114. https://doi.org/10.2105/AJPH.2012.300997.
Dimick, J. B., & Ryan, A. M. (2014). Methods for evaluating changes in health care policy: The difference-in-differences approach. JAMA, 312(22), 2401–2402. https://doi.org/10.1001/jama.2014.16153.
Dubay, L., & Kenney, G. (2003). Expanding public health insurance to parents: effects on children’s coverage under Medicaid. Health Serv Res, 38(5), 1283–301. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1360947&tool=pmcentrez&rendertype=abstract.
Ellimoottil, C., Miller, S., Ayanian, J. Z., & Miller, D. C. (2014). Effect of insurance expansion on utilization of inpatient surgery. JAMA surgery, 149(8), 829–836. https://doi.org/10.1001/jamasurg.2014.857.
Gifford, E. J., Weech-Maldonado, R., & Short, P. F. (2005). Low-income children’s preventive services use: implications of parents’ Medicaid status. Health Care Financ Rev, 26(4), 81–94. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17288070.
Goldstein, M. M., & Rosenbaum, S. (2013). From EPSDT to EHBs: the future of pediatric coverage design under government financed health insurance. Pediatrics, 131 Suppl(Supplement_2), S142–S148. https://doi.org/10.1542/peds.2013-0252e.
Grace, A. M., Noonan, K. G., Cheng, T. L., Miller, D., Verga, B., Rubin, D., & Rosenbaum, S. (2014). The ACA’s pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with exclusions. Health Aff (Millwood), 33(12), 2136–2143. https://doi.org/10.1377/hlthaff.2014.0743.
Guendelman, S., Wier, M., Angulo, V., & Oman, D. (2006). The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California. Health Serv Res, 41(1), 125–147. https://doi.org/10.1111/j.1475-6773.2005.00460.x.
Guidance Regarding Minimum Creditable Coverage (MCC) Certification On and After January 1, 2009. (n.d.). Boston, MA. Retrieved January 26, 2016, from https://betterhealthconnector.com/wp-content/uploads/rules-and-regulations/AdminBulletin01-08.pdf.
Hakim, R. B., & Bye, B. V. (2001). Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries. Pediatrics, 108(1), 90–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11433059.
Johnson, R. C., & Schoeni, R. F. (2011). Early-life origins of adult disease: National longitudinal population-based study of the United States. American Journal of Public Health, 101(12), 2317–2324. https://doi.org/10.2105/AJPH.2011.300252.
Kenney, G. M., Haley, J. M., Anderson, N., & Lynch, V. (2015). Children eligible for medicaid or CHIP: Who Remains Uninsured, and Why? Academic Pediatrics, 15(3), S36–43. https://doi.org/10.1016/j.acap.2015.01.009.
Kenney, G. M., Long, S. K., & Luque, A. (2010). Health reform in Massachusetts cut the uninsurance rate among children in half. Health Affairs (Millwood), 29(6), 1242–1247. https://doi.org/10.1377/hlthaff.2010.0314.
Kogan, M. D., Newacheck, P. W., Blumberg, S. J., Ghandour, R. M., Singh, G. K., Strickland, B. B., & van Dyck, P. C. (2010). Underinsurance among children in the United States. The New England Journal of Medicine, 363(9), 841–851. https://doi.org/10.1056/NEJMsa0909994.
Long, S. K., & Dahlen, H. (2014). Expanding coverage to low-income childless adults in Massachusetts: Implications for national health reform. Health Services Research, 49(2), 2129–2146. https://doi.org/10.1111/1475-6773.12189.
Long, S. K., Stockley, K., & Dahlen, H. (2012). Massachusetts health reforms: uninsurance remains low, self-reported health status improves as state prepares to tackle costs. Health Affairs (Millwood), 31(2), 444–451. https://doi.org/10.1377/hlthaff.2011.0653.
McDonough, J. E. (2011). Inside national health reform. Berkeley: University of California Press.
Meara, E., Golberstein, E., Zaha, R., Greenfield, S. F., Beardslee, W. R., & Busch, S. H. (2014). Use of hospital-based services among young adults with behavioral health diagnoses before and after health insurance expansions. JAMA psychiatry, 71(4), 404–411. https://doi.org/10.1001/jamapsychiatry.2013.3972.
Miller, S. (2012). The effect of the Massachusetts reform on health care utilization. Inquiry, 49(4), 317–26. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23469675.
Mosquera, R. A., Avritscher, E. B. C., Samuels, C. L., Harris, T. S., Pedroza, C., Evans, P., … Tyson, J. E. (2014). Effect of an enhanced medical home on serious illness and cost of care among high-risk children with chronic illness: A randomized clinical trial. JAMA, 312(24), 2640–2648. https://doi.org/10.1001/jama.2014.16419.
National Survey of Children’s Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. (n.d.). Retrieved from http://www.childhealthdata.org/browse/survey.
Okoro, C. A., Dhingra, S. S., Coates, R. J., Zack, M., & Simoes, E. J. (2014). Effects of Massachusetts health reform on the use of clinical preventive services. Journal of General Internal Medicine, 29(9), 1287–1295. https://doi.org/10.1007/s11606-014-2865-2.
Rosen, H., Saleh, F., Lipsitz, S. R., Meara, J. G., & Rogers, S. O. (2009). Lack of insurance negatively affects trauma mortality in US children. Journal of Pediatric Surgery, 44(10), 1952–1957. https://doi.org/10.1016/j.jpedsurg.2008.12.026.
Rowland, D. (2009). Health care and Medicaid–weathering the recession. The New England Journal of Medicine, 360(13), 1273–1276. https://doi.org/10.1056/NEJMp0901072.
Sabik, L. M., & Bradley, C. J. (2015). The impact of near-universal insurance coverage on breast and cervical cancer screening: Evidence from Massachusetts. Health Economics, 25(4), 391–407. https://doi.org/10.1002/hec.3159.
Shakib, J., Buchi, K., Smith, E., Korgenski, K., & Young, P. C. (2015). Timing of initial well-child visit and readmissions of newborns. Pediatrics, 135(3), 469–474. https://doi.org/10.1542/peds.2014-2329.
Skalland, B. J., & Blumberg, S. J. (2012). Nonresponse in the National Survey of Children’s Health, 2007. Vital and health statistics., Ser 2(156), 1–22. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23088067.
Smith, A. J. B., & Chien, A. T. (2014). Massachusetts health reform and access for children with special health care needs. Pediatrics, 134(2), 218–226. https://doi.org/10.1542/peds.2013-3884.
Sommers, B. D., Chua, K.-P., Kenney, G. M., Long, S. K., & McMorrow, S. (2016). California’s early coverage expansion under the affordable care act: A county-level analysis. Health Services Research, 51(3), 825–845. https://doi.org/10.1111/1475-6773.12397.
Sommers, B. D., & Epstein, A. M. (2011). Why states are so miffed about Medicaid–economics, politics, and the “woodwork effect”. The New England Journal of Medicine, 365(2), 100–102. https://doi.org/10.1056/NEJMp1104948.
Sommers, B. D., Long, S. K., & Baicker, K. (2014). Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Annals of Internal Medicine, 160(9), 585–593. https://doi.org/10.7326/M13-2275.
Sonier, J., Boudreaux, M. H., & Blewett, L. A. (2013). Medicaid “Welcome-Mat” effect of affordable care act implementation could be substantial. Health Affairs (Millwood), 32(7), 1319–1325. https://doi.org/10.1377/hlthaff.2013.0360.
The Henry, J.. Kaiser Family Foundation. (2016). Medicaid/CHIP upper income eligibility limits for children, 2000–2015. Retrieved January 14, 2016, from http://kff.org/medicaid/state-indicator/medicaidchip-upper-income-eligibility-limits-for-children-2000-2015/.
Tom, J. O., Mangione-Smith, R., Grossman, D. C., Solomon, C., & Tseng, C.-W. (2013). Well-child care visits and risk of ambulatory care-sensitive hospitalizations. The American journal of managed care, 19(5), 354–60. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23781890.
Tom, J. O., Tseng, C.-W., Davis, J., Solomon, C., Zhou, C., & Mangione-Smith, R. (2010). Missed well-child care visits, low continuity of care, and risk of ambulatory care-sensitive hospitalizations in young children. Archives of Pediatrics & Adolescent Medicine, 164(11), 1052–1058. https://doi.org/10.1001/archpediatrics.2010.201.
Funding
Dr. Smith’s work on this study was supported by the Arnold P. Gold Foundation and the Harvard Medical School Scholars in Medicine Office. Dr. Chien’s work on this study was supported by a Faculty Career Development Fellowship Award from Boston Children’s Hospital.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors have no conflicts of interest relevant to this article to disclose.
Disclosure
The authors have no financial relationships relevant to this article to disclose.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Appendix
Appendix
See Tables 5, 6, 7, 8, 9 and 10.
Rights and permissions
About this article
Cite this article
Smith, A.J.B., Chien, A.T. Adult-Oriented Health Reform and Children’s Insurance and Access to Care: Evidence from Massachusetts Health Reform. Matern Child Health J 23, 1008–1024 (2019). https://doi.org/10.1007/s10995-019-02731-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10995-019-02731-6