The Affordable Care Act Improves Healthcare Access and Utilization Among Young Adults with Sickle Cell Disease
Authors: Darlington Wendy , Watson Sydeaka P , Henderson Tara O , Cunningham John M , Conti Rena M 
Published: October 2019

Abstract
Introduction: The Dependent Coverage Provision (DCP) of the 2010 Affordable Care Act aims to improve (1) access to medical care among individuals aged 18-25 nationwide and (2) the efficiency of care by increasing appropriate outpatient care and reducing avoidable inpatient care. Individuals became eligible for coverage under their parents' private insurance in late September 2010. Previous studies have demonstrated improvement in access to care among those eligible for DCP, but no studies have examined the experience of young adults with serious disease requiring chronic medical care such as sickle cell disease (SCD). We hypothesized SCD patients aged 18-25 had increased access to commercial insurance, higher use of outpatient and lower use of inpatient care in the years following DCP implementation compared to patients ineligible for DCP.
Methods: This national analysis of patients aged 0-30 with qualifying SCD claims was performed using the Truven Health Analytics MarketScan Commercial Claims and Encounters dataset 2003-2013. The dataset contains commercial insurance claims of employees and dependants representing more than 50 million lives annually. We included patients with a continuous 12 month enrollment, and >1 inpatient or outpatient SCD claim in a given year. SCD claims included those with ICD-9 codes for homozygous SCD (HgbSS), sickle cell thalassemias (HgbSC, HgbSbo, HgbSb+) with and without crises, or splenic sequestration and/or acute chest syndrome. We defined 2003-2010 as pre-DCP and 2011-2013 as post-DCP. Inflation adjusted annual average per person spending, defined as reimbursements paid to providers, of SCD related inpatient and outpatient care was calculated. Descriptive statistics of number and share of patients by year and age cohort were calculated. Descriptive statistics of number of outpatient and inpatient claims by year and age cohort were calculated. A segmented regression analysis was performed to test for changes in trend of patient share by age cohort after the DCP. Access is defined as share of individuals having any claim type during the year. A difference-in-differences analysis was performed to study changes in medical care use and spending among individuals aged 18-25 pre and post-DCP, compared to those 26-30 and 12-17.
Results:
ACCESS: The absolute number of individuals increased in each age cohort during the study years. There was a significant increase in the share of 18-25 aged SCD patients compared to other SCD cohorts after DCP implementation (p = 0.03, Figure 1).
USE: SCD patients aged 18-25 experienced a statistically significant increased likelihood of having an outpatient claim after the DCP compared to those 26-30 (p<0.001). This difference in outpatient use was not seen after the DCP between those 18-25 and those 12-17 (p=0.42). In contrast, those aged 18-25 years did not experience a significant change in inpatient claims compared to those 26-30 (p = 0.05) or 12-17 (p = 0.17). However, we do observe a trend towards decreased inpatient claims among young adults compared to the 26-30 year cohort.
SPENDING: Average per person outpatient spending pre and post DCP were: 18-25 year cohort $132 to $108; 12-17 year cohort $131 to $127; and 26-30 year cohort $134 to $100. Average per person inpatient spending pre- and post-DCP were: 18-25 years- $12064 to $16343; 12-17 years- $12700 to $17017; and 26-30 years- $10967 to $17852.
Conclusion: Our analysis is the first to demonstrate early success of the DCP among a young adult population suffering from serious disease requiring chronic medical care. We find 18-25 year old SCD patients accessed private insurance at a greater rate and increased their use of less costly outpatient care after the DCP. Inpatient use did not change significantly among this cohort after DCP implementation. We observe inpatient costs to increase among each age cohort, including those 18-25, after the DCP. This result cannot be attributed to technologic change - no new invasive treatments or procedures have been introduced during the study period. Additional work is needed to better understand this result, including an analysis of frequency and length of stay. Limitations include underestimating the number of SCD patients due to missed ICD9 codes and the lack of clinical correlates within the data. Future analysis should replicate this analysis with other chronic conditions as well as measures of quality of care such as patient reported outcomes.
Figure 1 Figure 1.

Disclosures
Henderson: Seattle Genetics: Research Funding.