State laws extending eligibility of parents’ health insurance coverage to dependent youth were associated with improved access to care, particularly higher reports of health recent physical exams and lower reports of forgoing care due to cost. We found differential improvements in access to care by using 2 independent approaches, by comparing 19- to 23-year-olds in states with and without laws and by comparing 19- to 23-year-olds and 26- to 29-year-olds in 2 states that enacted laws limiting dependent eligibility to 24 years or younger.
Although we found differential improvements across all 4 access-to-care measures, the magnitude of the impact varied. We observed small differential improvements in insurance coverage and PMD identification but larger improvements in physical exams and not forgoing care. These results suggest that extension eligibility laws may have allowed young adults to move from less to more generous health insurance coverage (as provided by their parents’ employer-based plans), facilitating clinical contact via a physical exam. Therefore, while insurance coverage improved marginally, covered services improved such that dependent youth were less frequently forgoing care due to costs. Furthermore, our analyses including Massachusetts suggest that the individual mandate to obtain insurance was a powerful adjunct to the eligibility extension. Nearly all measures of access to care and preventive care improved significantly, with substantially larger differential improvements, with the exception of physical exams. In the context of Massachusetts’ mandate, demand for access to physicians may have increased and thus limited respondents’ ability to obtain a physical exam from the limited number of primary care physicians.9
The modest, but meaningful, improvements we observed in access to care occurred despite limitations of the state laws. For example, while these laws extended eligibility, they did not require that parents purchase coverage for dependent youth. Furthermore, the laws provided no subsidies to offset the cost of purchasing coverage and only 1 of the 3 intervention states in the main analysis limited increases on premiums. Adding a child to their policy may have made coverage unaffordable for some proportion of young adults and their parents, regardless of the value they placed on it. Thus, it may have been wealthier parents, or those with sick children, who took advantage of their state law.
One motivation for this work was to anticipate potential impacts of the provision of the ACA that extends insurance eligibility to young adults. There are several reasons that our findings may underestimate the impact of the ACA. Like the state laws, the ACA makes young adults eligible for their parents’ private health insurance plans. Unlike the state laws, the ACA applies to all individuals aged 18 to 26 years old and is not subject to limitations on state mandates. The Employee Retirement Income Security Act (ERISA) exempts self-insured employers from state (but not federal) insurance regulation.10
As half of privately insured adults in the United States are insured under self-insured plans, our analysis of state laws’ impacts almost certainly underestimates the ACA’s likely impact.11
There are other differences between the state laws and the ACA provision that have implications for the ACA’s potential impact. The ACA mandates eligibility for individuals younger than age 26 regardless of their marital, student, or dependent status; many states cover only the unmarried, full-time students, or dependent children who live at home with their parents. In addition, the ACA requires young adults to be included in any family insurance plan, but many state laws allow coverage only through riders, a separate plan added onto the parents’ policy. Finally, under the ACA, and unlike most state laws, premiums and benefits cannot be different for offspring of different ages. All of these conditions suggest a larger potential impact. However, in contrast, the ACA extends eligibility only to age 26, offers no subsidies, and imposes no caps on premium increases, whereas 6 states extend eligibility beyond 26 years and 4 impose premium caps. In sum, the ACA is likely to increase insurance uptake more than state laws because it supersedes ERISA, broadens eligibility to nonstudents and married dependent children, and allows children access to the same benefits as their parents and siblings. However, the ACA could have been designed to reach even more young adults had its age limit been 29, or if it had included regulated premiums, as some states have done.
Our study has several key strengths. We used a strong quasi-experimental approach that included a before-after comparison by using a difference-in-differences analysis and used 2 approaches to determine the impact of these state eligibility extension laws, comparing states that enacted and did not enact laws and comparing targeted and nontargeted age groups within states that enacted laws. However, our study also has limitations. The BRFSS provides self-reported data from a large, representative survey examining health risks and behaviors. Some questions that could have improved our study were not asked, such as whether young adults obtained insurance coverage independently or through their parents’ insurance policy, and some questions were not asked every year. In addition, the use of population data does not allow assessment of how well insurers complied with state requirements to extend insurance coverage eligibility. Finally, like any observational study, our findings are susceptible to unmeasured confounding. However, this last concern is largely mitigated by our multiple time series with control group design and our comparisons both across and within states, as mentioned earlier.