Journal of General Internal Medicine

, Volume 34, Issue 1, pp 65–74 | Cite as

Inequalities in Young Adult Health Insurance Coverage Post-federal Health Reform

  • Lauren E. WiskEmail author
  • Niraj Sharma
Original Research



Uninsurance for young adults (YAs) was greatly reduced by the Affordable Care Act (ACA). However, reforms may not be equally beneficial for all YAs and certain policies may exacerbate, rather than resolve, pre-existing disparities.


To investigate inequalities in YAs’ insurance coverage pre- (2000–2010) and post-federal health reforms (dependent coverage expansion, 2010–2013, and Medicaid/Marketplace expansions, 2014–2016), among a nationally representative sample.


A difference-in-differences estimator (controlling for sociodemographics) was used to determine the effects of the ACA for young adults (ages 19–25) compared to adolescents (ages 13–18) and older YA (ages 26–30) counterparts; triple-difference estimators quantified differential policy effects by sociodemographics.


Three hundred eighty-seven thousand six hundred thirty-five participants in the 2000–2016 National Health Interview Survey.

Main Measures

Respondents reported their health insurance coverage types during the last 12 months, reasons uninsured, and detailed sociodemographics.

Key Results

An adjusted difference-in-differences estimator quantified a 12.3 percentage point increase (p < 0.0001) in full-year coverage post-ACA for YAs compared to older counterparts, driven by increases in employer-sponsored private insurance while younger and older youth saw larger gains in Medicaid coverage. Triple-difference estimators identified subgroups experiencing less beneficial dependent coverage expansion effects, including females, lower socioeconomic status, non-citizens, non-English speakers, and several racial/ethnic minority groups. Later ACA reforms (Marketplace/Medicaid expansions) mitigated many of these widening disparities.


While the ACA significantly impacted YA insurance coverage, these gains were not of equal magnitude for all YAs and disparities remain. As such, more work needs to be done to ensure optimal and equitable access to high-quality, affordable insurance for all YAs.


insurance coverage National Health Policy health care disparities adolescence young adult 



We wish to thank the anonymous reviewers for their helpful comments which greatly improved the content of this paper. We presented earlier versions of the manuscript at the Society for General Internal Medicine meeting (Denver, 2018) and the Society for Adolescent Health and Medicine meeting (Seattle, 2018).


This work was financially supported by the Office of Faculty Development (OFD)/Basic/Translational Executive Committee (BTREC)/Clinical and Translational Research Executive Committee (CTREC) Faculty Career Development Fellowship 400384 (PI: Wisk) and Agency for Healthcare Research and Quality K12HS022986 (PI: Finkelstein).

Compliance with Ethical Standards


The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  1. 1.Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital and Department of PediatricsHarvard Medical SchoolBostonUSA
  2. 2.Division of General Medicine, Department of MedicineBrigham and Women’s HospitalBostonUSA
  3. 3.Division of General Pediatrics, Department of PediatricsBoston Children’s HospitalBostonUSA
  4. 4.Harvard Medical SchoolBostonUSA

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