A Punch to the Gut for Young Americans

Appendicitis is not pleasant. Commonly described as a dull mid-abdominal ache that sharpens as it moves toward the right lower quadrant, it is often accompanied by nausea and vomiting. Worse than appendicitis, however, are the possible complications of a ruptured appendix: peritonitis, abscess, and septicemia.

What keeps an inflamed appendix from perforating? Timely medical intervention. Lack of access is a known reason patients with appendicitis fail to access care in time to prevent perforation. The authors of this study use this established relationship to explore a more nebulous question: has the Dependent Coverage Provision (DCP) of the Affordable Care Act improved young adults’ access to care?

The DCP allows young adults to stay on their parents’ insurance plans until their 26th birthday. Since 2010, it is estimated to have helped 3-7% of uninsured young adults gain insurance. The study authors evaluated whether that has led to objective improvements in access to care. They analyzed changes in insurance rates and ICD-9-CM codes for perforation or abscess among young adults with acute appendicitis, comparing changes among 19-25 year olds, who were eligible for insurance through the DCP, and 26-34 year olds, who were ineligible.

Controlling for  sex, race/ethnicity, baseline co-morbidities, community income, rurality, and hospital teaching status, they found that, post-DCP, 19-25 year olds increased private coverage while 26-34 year olds decreased (net 5.8% difference). Accordingly, the uninsured rate decreased among young adults 19-25 while it increased in young adults 26-34 (net -3.6%).

These differences correlated to perforation rates: 19-25 year olds experienced no significant change, while 26-34 year olds saw a significant increase. These changes occurred against a backdrop of nationally increasing perforation rates. Thus, the DCP may have protected these 19-25 year olds.

As lawmakers vow to ‘repeal and replace’, they must consider that the DCP shows remarkable promise for improving young adults’ access to care. Repealing all of the Affordable Care Act, without maintaining the dependent coverage provision, would be a punch to the gut for young Americans.

This Policy Prescriptions® review is written by Hannah Abrams, a medical student at Baylor College of Medicine, as part of our Health Policy Journal Club Series.

Abstract

BACKGROUND: The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act allowed young adults to remain on their parents’ health insurance plans until age 26 years. Although the provision improved coverage and survey-reported access to care, little is known regarding its impact on timely access for acute conditions. This study aims to assess changes in insurance coverage and perforation rates among young adults with acute appendicitis-an established metric for population-level health care access-after the DCP.

METHODS: The National Inpatient Sample and difference-in-differences linear regression were used to assess prepolicy/postpolicy changes for policy-eligible young adults (aged 19-25 y) compared with a slightly older, policy-ineligible comparator group (aged 26-34 y).

RESULTS: After adjustment for covariates, 19-25 year olds experienced a 3.6-percentage point decline in the uninsured rate after the DCP (baseline 22.5%), compared with 26-34 year olds (P<0.001). This coincided with a 1.4-percentage point relative decline in perforated appendix rate for 19-25 year olds (baseline 17.5%), compared with 26-34 year olds (P=0.023). All subgroups showed significant reductions in uninsured rates; however, statistically significant reductions in perforation rates were limited to racial/ethnic minorities, patients from lower-income communities, and patients presenting to urban teaching hospitals.

CONCLUSIONS: Reductions in uninsured rates among young adults after the DCP were associated with significant reductions in perforated appendix rates relative to a comparator group, suggesting that insurance expansion could lead to fewer delays in seeking and accessing care for acute conditions. Greater relative declines in perforation rates among the most at-risk subpopulations hold important implications for the use of coverage expansion to mitigate existing disparities in access to care.

PMID: 27367865  Scott, JW, et al. Medical Care. 2016; 54 (9): 818-26