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I know you all read my recent NEJM study (and the AcademyHealth blog post I wrote about it). If you didn't, though, it's also the topic of this week's Healthcare Triage News!

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One common argument that opponents of the Affordable Care Act sometimes make is that an expansion of government into healthcare will result in what's known as crowd-out, where as government influence becomes larger, it's more difficult for private influences to exist.  They crowd-out the private insurance.  But that's not always the case, as seen in a study just released by the New England Journal of Medicine.

Guess what?  It's my study!  This is Healthcare Triage news.


Let's go right to the research!  The New England Journal of Medicine, "Dependent Coverage under the Affordable Care Act and Medicaid Coverage for Childbirth".  In the United States, rates of uninsurance have been historically high among young adults, or those 19-26 years of age.  One of the first implemented provisions of the Affordable Care Act or ACA was a mandate that all private insurance family policies cover dependents until 26 years of age.

Estimates suggest that this provision has reduced the rate of uninsurance among young adults by approximately 10%.  Childbirth, the major reason for hospitalization of young adults, has received little attention in prior literature on the mandate.

Medicaid is a huge source of coverage for babies born in the United States, even before the Affordable Care Act.  Medicaid covered all pregnant mothers who were earning less than 133% of the federal poverty level.  In 2010, Medicaid financed 45% of all births in the United States.  This means, of course, that relatively few births are uninsured.  In 2009, only about 5% of deliveries to young adults were uninsured, more than 60% were Medicaid covered.

One of the provisions of the Affordable Care Act was that young adults could stay on their insurance until they were 26.  It's possible, therefore, that this would mean that some of them would no longer need to rely on Medicaid for coverage in giving birth.  We wanted to test that hypothesis.  

We used two different data sources.  The first was the Natality Files in the CDC, and the second was the nationwide inpatient sample from (?~1:58).  For both, we compared mothers age 19-25 years to mothers age 27-29 years, before and after the young adult provision went into effect, which means before 2010 and after 2011.  We found that the rates of Medicaid coverage births for young adults, while increasing before 2010, decreased after 2011.  They were also increasing before 2010 for 27-29 year olds, but continued to increase after 2011. 

Private coverage, on the other hand, while decreasing before 2010 showed an increase in young adults after 2011.  The reduction in private coverage for those aged 27-29 years seen before 2010 seemed to continue after 2011 as well.  

The results were similar in both data sources.  In other words, the young adult provision of the Affordable Care Act seems to be associated with a significant increase in private coverage of childbirth among young adults and a significant decrease in Medicaid coverage.  Granted, it's a specific expenditure, but it's not an uncommon one.  As people take sides over the added public expense that the Affordable Care Act leads to in the nation's public healthcare spending, getting young adults off of Medicare's rolls and onto private insurance for childbirth is an interesting step in a direction that may surprise some.

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