The Effects of the Patient Protection and Affordable Care Act on Children's Health Coverage

Background: Prior research of the impacts of the Patient Protection and Affordable Care Act (PPACA) on children's health coverage has been largely descriptive and focused on the Medicaid expansions. Objective: This study examined the causal impacts of the PPACA Medicaid expansions and of the PPACA as a whole on children's health coverage through 2016. Research Design: We utilized quasiexperimental difference in differences designs to estimate the Medicaid expansion and overall PPACA effects. The first model compared coverage changes between Medicaid expanding and nonexpanding states by household income level. The second model identified the overall PPACA effects by estimating coverage changes across differences in pre-PPACA area-level uninsured rates in expanding states for which the identifying assumptions were valid. We used data from the American Community Survey for years 2011 through 2016 for 3,630,988 children aged 0-18 years living in the 50 states and District of Columbia. Results: The PPACA Medicaid expansions led to gains in public coverage for children at <= 405% federal poverty line especially in 2015-2016. Gains were largest for children at 138%-255% federal poverty line (similar to 4 percentage-point increase in 2016). These gains however were mostly due to switching from private to public coverage (ie, crowd-out effects). As a whole however, the PPACA reduced children's uninsured rate in Medicaid-expanding states by about 3 percentagepoints in 2016. Conclusions: The PPACA resulted in a meaningful decline in children's uninsured rate in Medicaid-expanding states. PPACA provisions targeting private coverage take-up offset crowd-out effects of the Medicaid expansions resulting in lower children's uninsured rates.