The Affordable Care Act Reduced Socioeconomic Disparities In Health Care Access

Abstract

The United States has the largest socioeconomic disparities in health care access of any wealthy country. We assessed changes in these disparities in the United States under the Affordable Care Act (ACA). We used survey data for the period 2011-15 from the Behavioral Risk Factor Surveillance System to assess trends in insurance coverage, having a personal doctor, and avoiding medical care due to cost. All analyses were stratified by household income, education level, employment status, and home ownership status. Health care access for people in lower socioeconomic strata improved in both states that did expand eligibility for Medicaid under the ACA and states that did not. However, gains were larger in expansion states. The absolute gap in insurance coverage between people in households with annual incomes below $25,000 and those in households with incomes above $75,000 fell from 31 percent to 17 percent (a relative reduction of 46 percent) in expansion states and from 36 percent to 28 percent in nonexpansion states (a 23 percent reduction). This serves as evidence that socioeconomic disparities in health care access narrowed significantly under the ACA.

Keywords: Access To Care; Affordable Care Act; Insurance Coverage < Insurance; Medicaid; Socioeconomic Disparities.

EXHIBIT 1. Insurance coverage in 2013 and 2015, by household income and state Medicaid expansion status

SOURCE Authors’ analysis of data for 2013 and 2015 from the Behavioral Risk Factor Surveillance System (BRFSS). NOTES The exhibit displays the percentage of noninstitutionalized US adults ages 18–64 who reported that they had insurance coverage, by BRFSS household income category. As explained in more detail in the text, to be considered an expansion state, a state must have expanded eligibility for Medicaid through the Affordable Care Act by mid-2015.

EXHIBIT 2. Changes from 2013 to 2015 in health care access among states that expanded eligibility for Medicaid, by household income

SOURCE Authors’ analysis of data for 2013 and 2015 from the Behavioral Risk Factor Surveillance System (BRFSS). NOTES The exhibit displays changes in the percentage of noninstitutionalized US adults ages 18–64 who reported that they had insurance coverage, had a primary care provider, and did not avoid care due to cost, by BRFSS household income category. As explained in more detail in the text, to be considered an expansion state, a state must have expanded eligibility for Medicaid through the Affordable Care Act by mid-2015.

EXHIBIT 4. Percent changes in health care access gaps between low- and high-income US adults, 2013 to 2015

SOURCE Authors’ analysis of data for 2011–15 from the Behavioral Risk Factor Surveillance System. NOTES The exhibit displays percent changes from 2013 to 2015 in health care access gaps between low- and high-income noninstitutionalized US adults ages 18–64. The data are stratified by whether the state expanded Medicaid. Percent changes were calculated as the access gap in 2015 divided by the access gap in 2013, minus one. All changes in access gaps were statistically significant (p < 0:05). Low income means household income of less than $25,000. High income means household income of more than $75,000. As explained in more detail in the text, to be considered an expansion state, a state must have expanded eligibility for Medicaid through the Affordable Care Act by mid-2015. Changes in access gaps by educational attainment, employment status, and homeownership are shown in online Appendix Exhibit S8 (see Note 27 in text).