Adult-Oriented Health Insurance Reform and Children's Health Insurance: the Massachusetts Experience and Implications for the Affordable Care Act

BACKGROUND: The Massachusetts health reform and the Affordable Care Act (ACA) were focused on adults, but have the potential to reduce uninsurance and increase access to affordable health care for children. Little is known about the impact of Massachusetts health reform on children, including the vulnerable sub-population of children with special health care needs (CSHCN). OBJECTIVES: The first two aim of this thesis were to examine whether Massachusetts health reform was associated with lower levels of child uninsurance, increased access to care, and improved financial protection for: (1) children generally and (2) CSHCN specifically. The third aim of this thesis is to explore ESI eligibility among uninsured children and uninsured CSHCN prior to the implementation of ACA’s individual and employer mandates in 2015. METHODS: For aims 1 and 2, we used a difference-in-differences approach to compare changes in uninsurance, access to care, and financial protection (CSHCN only) in the intervention group, Massachusetts, and the comparison group, other states, before and after Massachusetts health reform. For children overall, we used parent-reported data from the 2003, 2007, and 2011-2012 National Survey of Children’s Health. For CSHCN, we used parent-reported data from the 2005-2006 and 2009-2010 National Survey of Children with Special Health Care Needs. For aim 3, we conducted a cross-sectional analysis using the 2011-2012 National Survey of Children’s Health to estimate the proportions of uninsured children and uninsured CHSCN, who were eligible for ESI, but not enrolled, and to assess the barriers that parents reported to obtaining ESI for their uninsured, ESI-eligible children. RESULTS: Massachusetts health reform was not associated with significant changes in uninsurance for children overall or CSHCN. Access to a personal doctor increased for children previously-eligible for public insurance and did not change for children overall or CSHCN. Access to specialty care increased for children newly-eligible for public insurance under Massachusetts health reform and for privately-insured CSHCN. For CSHCN, there were no significant changes in financial protection under Massachusetts health reform. Nationwide, one-fifth of uninsured children—around 1.2 million children, including 174,000 uninsured CSHCN—were eligible for ESI, but not enrolled prior to ACA implementation. Cost and application difficulties were the main barriers to ESI enrollment. CONCLUSION: Massachusetts health reform had some positive impact on children’s access to care, but did not decrease uninsurance or improve financial protection. Comparable provisions within the ACA may produce similarly modest outcomes for children and CSHCN. Child-oriented reforms, including making ESI more affordable and enrollment easier, may be necessary to reduce uninsurance and significantly increase access to affordable health care for children