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Despite ACA insurance expansion, racial inequalities persist

Although lower rates of uninsured visits after the implementation of the Affordable Care Act indicate that the law helped expand coverage to community health center patients, these gains were not universal, according to findings recently published in Annals of Family Medicine.

“Evidence of the impact of the Affordable Care Act’s Medicaid expansion is essential to understanding if, and how, the program improves the health care and health of Americans,” Heather Angier, MPH, of the University of Wisconsin School of Medicine and Public Health, told Healio Family Medicine in an interview. “Further, it helps to influence and continue the national dialogue — amongst patients, clinicians and policymakers — regarding the future of health reform.”

Researchers analyzed electronic health records of 870,319 community health center patients, with more than 4 million ambulatory visits, from 16 states, 10 of which had expanded Medicaid eligibility. Analyses included difference-in-difference and difference-in-difference-in-difference estimates by generalized estimating equation models. The primary outcome was type of health insurance: private insurance, no insurance or Medicaid insurance.

Angier and colleagues found that after ACA was put into place, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the largest increases in Medicaid-insured visit rates after the law’s implementation in expansion states (rate ratio = 1.77; 95% CI, 1.56-2.02), and the biggest gains in privately insured visit rates in nonexpansion states (rate ratio = 3.63; 95% CI, 2.73-4.83).

Researchers also observed that in expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (difference-in-difference = 2.03; 95% CI, 1.53-2.7). This relative change was more than two times greater in expansion states vs. nonexpansion states (difference-in-difference-in-difference = 2.06; 95% CI, 1.52-2.78).
More clinic visits are paid by Medicaid across all demographics studied, and fewer visits are uninsured following the expansion, especially in states that expanded Medicaid,” Angier said. “However, despite the benefit, our analysis determined that some disparities remain. For example, Hispanic patients represented the highest rate of uninsured clinic visits both before and after ACA expansion compared with their non-Hispanic counterparts.

“Physicians should encourage their patients to apply for Medicaid (in expansion states) or private health insurance subsidies (in nonexpansion states),” she continued. “They should target these conversations to their Hispanic and non-Hispanic black patients to help mitigate insurance disparities.” – by Janel Miller

Disclosures: The researchers report no relevant financial disclosures.