Association of the National Dependent Coverage Expansion With Insurance Use for Sexual and Reproductive Health Services by Female Young Adults

This cross-sectional study evaluates whether implementation of the Patient Protection and Affordable Care Act Dependent Coverage Expansion was associated with changes in the use of insurance for sexual and reproductive services among female young adults.


Introduction
Approximately 5.5 million young adults have gained parental insurance coverage under the Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE), which requires employers to allow the children of policyholders to stay on their parents' health plan through 26 years of age. 1 Research suggests that ACA-DCE implementation was associated with increased office visits and use of certain preventive services, including blood pressure and cholesterol screening, but not contraceptive use, sexually transmitted infection testing, or Papanicolaou testing among young adults. [2][3][4][5][6] Discrepancies in the types of preventive care used by young adults with parental coverage may be attributable to the sensitivity of sexual and reproductive health (SRH) services to confidentiality concerns, potentially obstructing service and/or insurance use for this confidential care. Although there has been discussion around the privacy implications of the ACA-DCE, [7][8][9] no research to our knowledge has evaluated the association of policy implementation with insurance use for SRH services.
Understanding the association of the ACA-DCE with insurance use for SRH care is important given the implications of insurer billing practices on dependent confidentiality. Explanation of benefits forms sent to policyholders detail services provided and to whom they were provided, indirectly violating dependent confidentiality. 10 Research consistently demonstrates a negative association between parental knowledge or involvement and SRH service use; 40% of sexually active female young adults indicated confidentiality concerns as the reason for not seeking STI testing, and 70% of adolescents with parents who were not already aware of their contraceptive use would stop using prescription contraception if parental notification of use were mandated. 11,12 However, less attention has been paid to the role of privacy concerns in SRH care decision-making among young adults or the specific association of implementation of the ACA-DCE with insurance use behavior.
Female young adult have higher rates of unintended pregnancy and human papillomavirus infection than do their older counterparts and are more likely to experience cost-related barriers to care. 13,14 Privacy concerns may lead those with parental coverage to delay, forgo, or pay out of pocket for services, perpetuating existing disparities. 15 Thus, the objective of this study was to evaluate the association between the implementation of the ACA-DCE and insurance use for contraception services and Papanicolaou testing among commercially insured female young adults subsequently eligible for dependent coverage under the ACA-DCE.  eligible for dependent coverage under the ACA-DCE, and the comparison group included female   young adults aged 27 to 29 years who were ineligible for coverage under the ACA-DCE based on their age. Because treatment status is contingent on enrollee birthday and start date of a parent's insurance (and consequently ambiguous), female young adults aged 26 years were excluded (n = 2 153 425). Use of narrow age ranges addressed some of the methodologic limitations of prior literature on the DCE, which failed to take into account dynamics in the age structure of the health insurance and labor markets. 16 The nature of the data source did not allow identification of individual-level insurance coverage transitions, and treatment status was therefore defined by age and subsequent eligibility for coverage under the ACA-DCE as opposed to coverage type. In other words, our analyses leveraged the substantial population-level, compositional shift in coverage type for those aged 23-25 years after implementation of the ACA-DCE. Enrollees in the comparison group with parental coverage (n = 3718) and all enrollees with spousal coverage (n = 3 033 773) were excluded, which allowed for more accurate identification of the target population of the ACA-DCE and more precise estimation of its association with aggregate SRH insurance use. Because pregnant patients are more likely to be connected with care, receive routine HIV testing, and do not use contraception, all services provided to enrollees with any evidence of delivery based on Healthcare Effectiveness Data and Information Set prenatal quality measures were excluded from the analysis. 17

Outcomes
Outcomes of interest included Papanicolaou testing and contraception services as defined by the Healthcare Effectiveness Data and Information Set and Office of Population Affairs performance measure modalities and codes. 18, 19 We used International Classification of Diseases, Ninth Revision,

International Statistical Classification of Diseases and Related Health Problems, Tenth Revision,
Healthcare Common Procedure Coding System, Current Procedural Terminology, and National Drug Codes to identify service use (codes used to define all services are listed in eTables 9-11 in the Supplement). Contraceptive modalities included subdermal implant, intrauterine device, injectable, pill, patch, ring, and diaphragm. 17 Although screening for sexually transmitted infection is an important sexual health service for young adults, we did not include this as an outcome owing to differing clinical guidelines between the treatment and comparison groups. 20 We included emergency department (ED) and well visits (during which no concurrent SRH services were provided) because confidentiality concerns should not influence insurance use for this type of care.

Statistical Analysis
We used a difference-in-differences (DID) approach to evaluate aggregate changes in insurance use for the target group of the ACA-DCE provision (age 23-25 years) before vs after ACA-DCE implementation compared with changes in a comparison group (age 27-29 years). The focus of this study was on the association between the ACA-DCE and SRH service use based on population-level, compositional changes in young adult's type of insurance coverage after implementation of the ACA-DCE (ie, shifts from exclusively having policyholder coverage to having a mix of parental coverage and policyholder coverage). The preimplementation period was from January 1, 2007, to December 31, 2009, and the postimplementation period was from January 1, 2011, to December 31, 2016. We excluded 2010 as a washout period.
The validity of the DID study design is based on the assumption that there would have been no differing change in outcomes between the treatment and comparison groups had the intervention not occurred. 21 We tested this assumption by statistically examining prepolicy biannual trends (eTable 1 in the Supplement) for similarity (ie, parallel trends). 22 To assess the association of the ACA-DCE with insurance use for services, we used linear probability models, which can be interpreted as absolute percentage point changes in the probability of insurance use for each outcome (eMethods in the Supplement). The person-year was our unit of analysis. We estimated the DID with a binary indicator for use or nonuse of each service, with state and year fixed effects to account for potential unobserved heterogeneity and clustered SEs at the state-level. All models adjusted for time-variant covariates with the potential to influence service use, including age, plan type, whether or not enrollees were covered by a high-deductible plan, residence in a micropolitan or metropolitan statistical area, and a categorical variable indicating the number of comorbidities (0, 1, and Ն2) based on the Elixhauser Comorbidity Index. 23 We conducted additional sensitivity tests to evaluate the robustness of results to DID assumptions. All analyses were replicated with the placebo outcomes (ED and well visits), which should not be sensitive to confidentiality concerns. We also repeated analyses with enrollees aged 23 to 25 years who had only parental coverage and those with only policyholder coverage in the postimplementation period to identify the extent to which aggregate changes were associated with coverage status. We replicated analyses excluding data from 2014 to 2016, which may have been subject to secondary effects of ACA coverage expansions (ie, Medicaid expansions and insurance exchanges) that could have differentially influenced the treatment and comparison groups. We also estimated the change in each individual year after implementation of the ACA-DCE compared with the preimplementation baseline to assess whether and to what extent insurance use for SRH care was a function of other policy changes occurring during the postimplementation period. In addition, to assess potential differences in care-seeking behavior between the treatment and comparison groups, we replicated all analyses excluding enrollees who did not use any services during the study period. Statistical significance was set at α = .05 with 2-tailed hypothesis tests, and analyses were performed from January 2019 to February 2020 using Stata, version 15 (StataCorp LLC). Table 1 presents study sample characteristics stratified by the pre-ACA-DCE implementation period    The treatment group included female young adults aged 23 to 25 years who were eligible for coverage, and the comparison group included female young adults aged 27 to 29 years who were not eligible for coverage.

Discussion
In this national cross-sectional study, large shifts from self-coverage to parental coverage under the ACA-DCE were associated with a reduction in insurance use for Papanicolaou testing and contraception services among commercially insured female young adults aged 23 to 25 years.
Implementation of the ACA-DCE was also associated with a smaller yet statistically significant relative increase in ED and well visits.
These results suggest that female young adults newly eligible for parental coverage were less likely to use SRH services after ACA-DCE implementation, as captured by claims data; this findings may be attributable to enrollees electing to pay out of pocket for these services or forgoing these services. Because Papanicolaou testing is recommend for all female young adults (sexual activity notwithstanding), it is possible that factors other than confidentiality concerns were associated with insurance use behavior. Alternatively, confidentiality concerns about this procedure may be a relic of previous clinical guidelines that included sexual activity criteria or to well-documented confusion about the purpose of Papanicolaou testing. 24,25 It is also possible that the sensitivity of Papanicolaou testing associated with ACE-DCE eligibility is attributable to a spillover effect from other SRH services; clinicians routinely perform Papanicolaou tests during contraceptive visits, and higher use in the comparison group may be associated with a higher likelihood of any type of SRH visit as opposed to actively seeking out Papanicolaou testing. The steady decrease in both groups over the study period may in part be associated with changes in cervical cancer screening guidelines, which reduced the recommended frequency of Papanicolaou testing from annually to biannually and then to once every 3 years. 26 Guideline recommendations and changes were the same for female young adults aged 21 to 29 years across the study period and consequently should not have differentially influenced outcomes in the treatment vs comparison groups.
Our finding that contraceptive insurance use decreased among young adult enrollees deviates from prior research that suggests the ACA is associated with improved access to and use of contraceptive care. [27][28][29][30] Findings are, however, consistent with the literature on confidentiality and SRH service use among adolescents and young adults. 12,31 The large secular increase in contraceptive insurance use observed in the comparison group was likely associated with implementation of the contraceptive mandate, which required insurers to cover contraception without cost-sharing. 28 Moving forward, it will be important to understand whether or not young adults are aware of these policies, if they take advantage of them, and their influence on health service use and outcomes.
Ultimately, insurance use behavior of young adults may be associated with privacy perceptions as opposed to insurer policies or privacy breaches.

Limitations
This study has limitations. First, given the large sample size, it is possible that small differences are statistically significant but not meaningful. Results should therefore be carefully interpreted, especially for smaller effect sizes. However, even a 1-percentage point change at the individual level translates conservatively to tens of thousands of forgone services at the population level. Second, differences between enrollees with parental and policyholder coverage that cannot be captured with insurance claims data could bias results if these differences are associated with sexual behavior and subsequent need for SRH care, although to our knowledge, there is no published literature to support this theory.
Third, differences between the treatment and comparison groups may also lead to selection bias if policyholder coverage "crowds-out" parental coverage for those in the treatment group with privacy concerns. However, prior research has demonstrated the opposite-eligible young adults were more likely to forgo self-coverage and use parental coverage after ACA-DCE implementation. 36 Fourth, because these data did not allow identification of individual-level insurance coverage transitions, outcome estimates were based on a compositional change in the treatment group after policy implementation and included enrollees with both parental and policyholder coverage. As a result, these findings likely underestimate the association between ACA-DCE implementation and insurance use among those who gained parental coverage under the provision.
Fifth, our findings may not be generalizable to privately insured female young adults in the US.
Although the use of narrow age ranges strengthens the internal validity of this study, it did not allow estimation of the association between the ACA-DCE and insurance use among young adults aged 19 to 22 years. The provision may have differentially influenced insurance use by younger enrollees who are at higher risk for unintended pregnancies 14 and who may be more sensitive to confidentiality concerns.

Conclusions
In this cross-sectional study, implementation of the ACA-DCE was associated with a decrease in insurance use for contraception and Papanicolaou testing, potentially because of privacy concerns.
These findings raise questions about the capacity of parental coverage expansions to improve access to essential services among young adults.