Adult-Oriented Health Reform and Children’s Insurance and Access to Care: Evidence from Massachusetts Health Reform

  • Anna Jo Bodurtha SmithEmail author
  • Alyna T. Chien


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affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed.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.


Federal policy Legislation Insurance 



The Patient Protection and Affordable Care Act




Federal poverty level


National Survey of Children’s Heath



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.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflicts of interest relevant to this article to disclose.


The authors have no financial relationships relevant to this article to disclose.


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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Gynecology and ObstetricsJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Boston Children’s HospitalBostonUSA
  3. 3.Harvard Medical SchoolBostonUSA

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