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Impact of the Affordable Care Act
The Patient Accountability and Affordable Care Act, generally referred to as the Affordable Care Act, or ACA, was signed into law in March 2010. The ACA was designed to expand insurance coverage, improving access to health care.
Key provisions were included to benefit those of lower SES, including Medicaid expansion and federal health subsidies for those living at 138% of the federal poverty level, and large subsidies for those at 100% to 400% of the federal poverty level who purchased insurance plans through ACA exchanges. In January 2014, the most impactful ACA provisions took effect, including the expansion of Medicaid in 24 states and the District of Columbia.6
Data from the 2011 to 2015 Behavioral Risk Factor Surveillance System (BRFSS) found that, from 2013 to 2015, there was a 15% increase in health insurance coverage among poor populations in states that voted to expand Medicaid under the ACA. In addition to the significant increase in rates of the insured, there was also a 7.7% increase in those who reported access to a primary care physician, and a 7.5% reduction in reports of avoiding care due to prohibitive cost; these changes were also mostly limited to poor populations, but also extended to specific vulnerable populations, including immigrants.6,25
Expansion states also saw increased coverage and lower uninsured rates in rural areas; in fact, growth in Medicaid and decline in the uninsured rates in rural areas exceeded those in metropolitan areas.25
In an analysis of data from the Consumer Expenditure Survey from 2010 to 2015, Glied et al.6 found that low-income families in Medicaid expansion states saved an average of $382 annually in health care-associated costs and were less likely to report out-of-pocket spending on insurance premiums and medical care compared to families in non-expansion states.26 Americans who benefited most from ACA provisions were the unemployed, those without a college degree, and those earning a low income; in other words, those who were most likely to be excluded from an employer-based health insurance program.6
The proportion of nonelderly adults lacking health insurance fell from 20.5% in 2013 to 12.3% in 2017, a decline of 40%, while all U.S. racial and ethnic groups saw comparable, proportionate declines in uninsured rates, according to a 2019 analysis of data from the American Community Survey by Chaudry et al.27
Latino Health Insurance Coverage with the Affordable Care Act
Because uninsured rates started off much higher among Hispanic and black non-Hispanic adults than among white non-Hispanic adults, the coverage gap between blacks and whites declined from 11.0 percentage points in 2013 to 5.3 percentage points in 2017.
Likewise, the coverage gap between Hispanics and non-Hispanic whites declined dropped from 25.4 points to 16.6 points. The percentage of uninsured adults ages 19-64 was 25.1% among Hispanics, 13.8% among blacks, and 8.5% among whites. Hispanic noncitizens (such as green card holders) also made gains in their insurance coverage, although this group did not qualify for Medicaid or for subsidies.27
Latinos also saw greater healthcare coverage improvements in states that expanded Medicaid than in those that did not, with a 14-percentage point decline in expansion states (from 36% uninsured to 22% uninsured) compared to only 11 percentage points in non-expansion states (from 47% to 36%), according to an analysis of American Community Survey data between 2013 and 2015.
It is important to note that many non-expansion states, including Florida, Georgia, North Carolina, and Texas, have large black and Latino populations. Also noteworthy is that the rate of uninsured was lower in Medicaid expansion states even before expansion took effect and this was true for all groups.28
Well before the ACA, Latinos and blacks were significantly more likely than whites to face barriers in access to health care.
After the ACA was implemented, researchers found a 5% reduction, from 27% to 22%, in the number of Latinos who avoided seeking medical care due to prohibitive cost. While this is a trend in the right direction, it narrows the gap only somewhat, as only 10% of whites report avoiding care due to high cost. There was also a 4% reduction in Latinos who did not have access to a primary care physician.28
Compared to the pre-ACA era, there were significant increases in health insurance coverage and well-child visits in the post-ACA era, according to a cross-sectional review of data from the National Health Interview Survey, Ortega et al.29 The largest gains in insurance coverage were seen in Latino youth, though the rates of uninsured Latino youth remain the highest in the country. Additionally, disparities in health care utilization between black and Latino youth compared to white youth did not improve.29
Despite the gains seen in health insurance coverage and access to care following passage of the ACA, there is still much room for improvement. Shartzer et al.30 found that while more low- and moderate-income adults reported having a primary care physician in March 2015 compared to September 2013, 25.7% of adults still do not have a regular source of care, and these adults were more likely to be younger, low-income, and Latino.30
Yue et al.31 reviewed data from 2013 (pre-ACA) and 2015 (post-ACA) to determine whether there were any significant changes in health outcome measures among low-income adults. Results showed that among low-income adults, Medicaid expansion was associated with significant gains in health insurance coverage, having a primary care physician, and reported health care affordability. Despite these gains, Latinos saw the fewest benefits.31
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References for this section »
6. Griffith K, Evans L, Bor J. The affordable care act reduced socioeconomic disparities in health care access. Health Aff. 2017;36(8):1503-1510. doi:10.1377/hlthaff.2017.0083
25. Guth M, Garfield R, Rudowitz R. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review – Report – 8891-06 | KFF.; 2020. https://www.kff.org/report-section/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-report/. Accessed June 11, 2020.
26. Glied SA, Chakraborty O, Russo T. How Medicaid Expansion Affected Out-of-Pocket Health Care Spending for Low-Income Families.; 2017. https://www.commonwealthfund.org/publications/issue-briefs/2017/aug/how-medicaid-expansion-affected-out-pocket-health-care-spending. Accessed June 11, 2020.
27. Chaudry A, Jackson A, Glied SA. Did the Affordable Care Act Reduce Racial and Ethnic Disparities in Health Insurance Coverage? | Commonwealth Fund.; 2019. https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/did-ACA-reduce-racial-ethnic-disparities-coverage. Accessed June 11, 2020.
28. Hayes SL, Riley P, Radley DC, Mccarthy D. Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference? Senior Researcher The Commonwealth Fund Reducing Racial and Ethnic Disparities in Access to Care: Has the ACA Made a Difference? 2 BACKGROUND.
29. Ortega AN, McKenna RM, Chen J, Alcalá HE, Langellier BA, Roby DH. Insurance Coverage and Well-Child Visits Improved for Youth Under the Affordable Care Act, but Latino Youth Still Lag Behind. Acad Pediatr. 2018;18(1):35-42. doi:10.1016/j.acap.2017.07.006
30. Shartzer A, Long SK, Anderson N. Access to care and affordability have improved following affordable care act implementation; problems remain. Health Aff. 2016;35(1):161-168. doi:10.1377/hlthaff.2015.0755
31. Yue D, Rasmussen PW, Ponce NA. Racial/Ethnic Differential Effects of Medicaid Expansion on Health Care Access. Health Serv Res. 2018;53(5):3640-3656. doi:10.1111/1475-6773.12834
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