Parent-Child Insurance Discordance and Family Health Care Financial Burden among Low-Income Families

• In Event: ACA Insurance Policies

Abstract

Introduction
Insurance coverage and healthcare use for low-income U.S. children are highly intertwined with parental coverage through spillover effects. Limited cost-sharing in Medicaid reduces barriers to accessing healthcare, but the financial impact of discordant child-parent insurance remains unclear. With the expiration of enhanced premium tax credits for Affordable Care Act Marketplace plans and increasing work requirements and barriers for parental Medicaid enrollment under the One Big Beautiful Bill Act, families of low-income Medicaid-insured children are increasingly vulnerable to the financial burdens associated with discordant family coverage. 

Purpose
This study examines the prevalence of parent-child insurance discordance among children enrolled in Medicaid and evaluates the association between different types of parental coverage and family medical costs and financial burden. 

Methods
We conducted a cross-sectional analysis using pooled 2016-2022 Medical Expenditure Panel Survey data. The analytical sample included 21,559 children (~3.7 million weighted annually) aged <19 in families with incomes <400% FPL who had Medicaid for 12 months. Children-parent dyads were categorized as concordant if the child and primary parent both had 12-month Medicaid coverage and discordant, categorized by parent insurance type, if not. To estimate absolute probability changes in financial burden (problems paying medical bills, paying them over time, or inability to pay at all), we calculated average marginal effects from multivariable logistic regression models. We used two-part generalized linear models with a Gamma-log distribution to estimate adjusted average family medical expenditures (out-of-pocket (OOP) plus premiums). All models were weighted and adjusted for child and parent sociodemographics, health status, and household income.

Results
From 2016-2022, 57% of children with Medicaid were in discordant dyads, including parents on ACA Marketplace (3.0%), employer-sponsored insurance (ESI) (13.4%), or uninsured (25.2%). Adjusted annual family medical expenditures among concordant families averaged $2,526. For discordant families, average expenditures were $4,802 with an ACA Marketplace plan (difference from concordant: +$2,276; 95% CI: $557, $3,996), $4,862 when the parent had ESI (difference: +$2,336; 95% CI: $1,478-$3,170), and $3,001 when the parent was uninsured (difference: +$474; 95% CI: -$580, $1,528). 

Compared to the adjusted 10.7% probability of family medical financial burden among concordant Medicaid families, the probability of financial burden was 6.6 percentage points higher (95% CI: -0.2, 13.4) among parents with ACA Marketplace plans, 10.7 percentage points higher (95% CI: 5.4, 16.1) among parents with ESI, and 12.3 percentage points higher (95% CI: 7.6, 17.1) among uninsured parents. 

Discussion/Policy Implications
Family insurance discordance creates significant financial barriers for families even when children have comprehensive Medicaid coverage. ESI premiums and cost-sharing among low-income families is associated with a similar probability of financial burden as remaining uninsured. Burdensome expenditures were somewhat less for discordant families with ACA Marketplace coverage, but this may worsen with expiration of pandemic-era enhanced premium tax credits. Policy efforts should prioritize promoting continuous Medicaid eligibility for adults and extending enhanced ACA Marketplace subsidies to protect families of low-income children.

Author

• Ava Gehlen-Williams, Boston University
  Presenting Author