Coverage and Access for Americans With Cardiovascular Disease or Risk Factors After the ACA: A Quasi-Experimental Study

Abstract

BACKGROUND: Atherosclerotic cardiovascular disease (CVD) is the leading cause of death in the USA. Many with CVD or cardiovascular risk factors (CVRFs) lacked insur- ance coverage and access to care before enactment of the Affordable Care Act (ACA). OBJECTIVE: To assess the effect of the ACA on insurance coverage, access to care, and racial/ethnic disparities among non-elderly adults with CVD or CVRFs. DESIGN: Quasi-experimental policy intervention. PARTICIPANTS: Nationally representative, non- institutionalized sample of 1,014,450 adults aged 18 to 64 years with CVD or at least 2 established CVRFs in the pre-ACA (2012–2013) and post-ACA (2015–2016) periods. INTERVENTION: Implementation of ACA provisions on 1 January 2014. MAIN MEASURES: Insurance coverage, having a check- up, having a personal physician, and not having to forgo a needed physician visit because of cost. KEY RESULTS: Following ACA implementation, insur- ance coverage increased by 6.9 percentage points (95% CI, 6.6 to 7.2), not having to forgo a physician visit in- creased by 3.6 percentage points (CI, 3.3 to 3.9), having a check-up increased by 2.1 percentage points (CI, 1.8 to 2.6), and having a personal physician increased by 1 percentage point (0.6 to 1.3); changes were approximately doubled for those with lower incomes (< $35,000/year). Changes in coverage varied substantially by state and all outcomes improved more in Medicaid expansion states. Although racial/ethnic minorities had greater improve- ments in some outcomes, approximately 13% black and 29% Hispanic adults continued to lack coverage and ac- cess to care post-ACA. CONCLUSION: The ACA increased coverage and access for adults with CVD or multiple CVRFs; substantial gaps remain, particularly for minorities and those in Medicaid non-expansion states.