Person:

Sommers, Benjamin

Abstract: Objective: To examine patterns of insurance coverage among nine Latino subgroups and assess heterogeneous effects of the Affordable Care Act (ACA) among these groups.

Data sources: American Community Survey (2010-2014).

Study design: We examined pre-ACA disparities in coverage using linear probability models. Then we used interrupted time series and triple-difference models to evaluate coverage changes associated with the ACA and Medicaid expansion, respectively.

Principal findings: Pre-ACA coverage disparities between Latino subgroups were nearly 30 percentage points, which was larger than the gap between Whites and Latinos as a whole. Coverage changes associated with the ACA and Medicaid expansion differed significantly between subgroups, with the largest gains among South Americans, Central Americans, and Mexicans.

Conclusions: Latino subgroups show marked heterogeneity in baseline coverage rates and responses to the ACA.

The Affordable Care Act expands Medicaid in 2014 to millions of low-income adults in states that choose to participate in the expansion. Since 2010 California, Connecticut, Minnesota, and Washington, D.C., have taken advantage of the law’s option to expand coverage earlier to a portion of low-income childless adults. We present new data on these expansions. Using administrative records, we documented that the ramp-up of enrollment was gradual and linear over time in California, Connecticut, and D.C. Enrollment continued to increase steadily for nearly three years in the two states with the earliest expansions. Using survey data on the two earliest expansions, we found strong evidence of increased Medicaid coverage in Connecticut (4.9 percentage points; (p<0.001)) and positive but weaker evidence of increased coverage in D.C. (3.7 percentage points; (p=0.08)). Medicaid enrollment rates were highest among people with health-related limitations. We found evidence of some crowd-out of private coverage in Connecticut (30–40 percent of the increase in Medicaid coverage), particularly for healthier and younger adults, and a positive spillover effect on Medicaid enrollment among previously eligible parents.

The Affordable Care Act enables young adults to remain as dependents on their parents’ health insurance until age twenty-six, and recent evidence suggests that as many as three million young adults have gained coverage as a result. However, there has been no evidence yet on the policy’s effect on access to care, and questions remain about the coverage impact on important subgroups. Using data from two nationally representative surveys, comparing young adults who gained access to dependent coverage to a control group (adults ages 26–34) who were not affected by the new policy, we found sizable coverage gains for adults ages 19–25. The gains continued to grow throughout 2011 (up 6.7 percentage points from September 2010 to September 2011), with the largest gains seen in unmarried adults, nonstudents, and men. Analysis of the timing of the policy impact suggested that early gains in coverage were greatest for people in worse health. We found strong evidence of increased access to care because of the law, with significant reductions in the number of young adults who delayed getting care and in those who did not receive needed care because of cost.

Context: The Affordable Care Act (ACA) has reduced the U.S.’s uninsured rate to an historic low. But coverage is only one of many factors contributing to racial and income-based disparities in health care access, affordability, and quality.

Methods: Using a novel 2015 national survey of over 8,000 Americans, we examined disparities between low-income and high-income adults, and between racial/ethnic minorities and whites. We conducted a series of regression analyses, starting with models that only took into account income or race, and then sequentially adjusted for health insurance, state of residence, demographics, and health status. We examined self-reported quality of care, cost-related delays in care, and emergency department (ED) use due to lack of available appointments. Then we used multivariate regression to assess respondents’ views of whether quality and affordability had improved over the past two years and whether the ACA was helping them.

Findings: Quality of care ratings were significantly worse among lower-income adults than higher-income adults. Only 10-25% of this gap was explained by health insurance coverage. Cost-related delays in care and ED use due to lack of available appointments were nearly twice as common in the lowest-income group, and less than 40% of these disparities was explained by insurance. There were significant racial/ethnic gaps: reported quality of care was worse among blacks and Latinos than whites, with 16-70% explained by insurance. In contrast to these disparities, lower-income and minority groups were generally more likely than whites or higher-income adults to say that the ACA was helping them and that the quality and/or affordability of care had improved in recent years.

Conclusions: Our post-health reform survey shows ongoing stark income and racial disparities in the health care experiences of Americans. While the ACA has narrowed these gaps, insurance expansion alone will not be enough to achieve health care equity.