As the U.S. Senate takes up the proposed American Health Care Act (AHCA), a large study provides evidence that eliminating the individual mandate could jeopardize health care coverage for young adults. Analysis of insurance data found that without an individual mandate, young adults were more likely to lose health insurance -- even with the Obamacare provision allowing people under age 26 to be covered under their parents' health plan.

The study, led by Lauren Wisk, PhD, of the Division of Adolescent and Young Adult Medicine at Boston Children's Hospital, appears in the upcoming issue of the journal Health Services Research.

Wisk and colleagues analyzed data from 131,542 adolescents and young adults in Massachusetts, Maine and New Hampshire whose family was covered by Harvard Pilgrim Health Care between January 2000 and December 2012. Massachusetts introduced an individual mandate in 2007, while Maine and New Hampshire did not. This allowed a natural comparison before the individual mandate went into effect nationally (in 2014).

Wisk and colleagues found that having an individual mandate boosted the effect of the Dependent Coverage Expansion, which took effect in these three states (and others) in 2007 and nationally in 2010. "With an individual mandate, many more young adults used the dependent coverage provision, and people who were previously dropped from their parents' plan were more likely to get back on," says Wisk.

With both the individual mandate and the dependent coverage expansion in effect, young adults in Massachusetts:

were 23 percent more likely to keep their dependent coverage than their counterparts in Maine or New Hampshire

kept their dependent coverage for longer periods of time

were 33 percent more likely to regain dependent coverage after going off their parents' plan.

Threats to dependent coverage

The current AHCA (H.R. 1628) retains the dependent coverage provision, and it would seem to protect young adults. However, various other provisions in the AHCA could undercut that popular provision, says Wisk.

Without an individual mandate, more young adults and their families may choose to go without dependent coverage even when it's needed, Wisk says. She notes that the AHCA would limit the tax credits available to families and provide significantly less income-based assistance, which may make it too expensive for some families to keep a young adult child covered as a dependent. (See: http://files. kff. org/ attachment/ Proposals-to-Replace-the-Affordable-Care-Act-Summary-of-the-American-Health-Care-Act )

Moreover, while the current version of the AHCA retains coverage of pre-existing conditions, young adults who lose or drop their insurance could be charged 30 percent higher premiums for one year after resuming coverage, Wisk notes. Such lapses in insurance are common for young adults, who may leave dependent coverage as they enter college or get entry-level jobs, but then find their parents' policies offer better coverage.

"At Boston Children's we see many adolescents and young adults with chronic conditions who could lose access to their doctors under the ACHA when they change plans, or find that the AHCA changes make it too expensive to keep seeing their doctors," says Wisk. "Our study suggests that the individual mandate encourages young adults to have better, continuous access to the care they need. The AHCA could change that."

"Boston Children's Hospital was an early and strong supporter of the Massachusetts coverage expansion in 2006, and, more recently, the Affordable Care Act," says Josh Greenberg, the hospital's VP of Government Relations. "The individual mandate, with its accompanying subsidies to support low-income individuals, was always understood to be a critical component of our efforts to reach near-universal coverage. Young adults are especially vulnerable both socially and economically, and we should be careful about making changes that reduce coverage and could result in lifelong health complications."

Panel at Boston Children's to discuss how AHCA would affect children and youth

On Wednesday, May 31, Boston Children's offices of Government Relations and Community Health will host a panel, Grand Rounds: Spotlight on Health Care Policy--The Impact on Children and Families (10-11 a.m., Folkman Auditorium, 300 Longwood Avenue, Boston). Boston Children's President and CEO, Sandra L. Fenwick, will moderate a panel of experts. The event is free and open to the public (registration and information here).

Alison Galbraith, MD, MPH, of Boston Children's Hospital, Harvard Medical School and the Harvard Pilgrim Health Care Institute was senior author on the Health Services Research paper. Coauthors were Jonathan Finkelstein, MD, MPH, Sara Toomey, MD, MPH, Gregory Sawicki, MD, MPH, and Mark Schuster, MD, PhD, all of Boston Children's.

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The study was funded by the Agency for Healthcare Research and Quality (AHRQ; 5T32HS00063-21); a joint grant from AHRQ and the Centers for Medicare & Medicaid Services (U18 HS020513); the National Institute of Child Health and Human Development (K24HD060786) and the Thomas O. Pyle Fellowship in the Department of Population Medicine.

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