Uninsured Primary Care Visit Disparities Under the Affordable Care Act

The Article in Brief

Uninsured Primary Care Visit Disparities Under the Affordable Care Act

Heather Holderness , and colleagues

Background Historically, racial and ethnic minorities in the United States have been significantly less likely to have insurance coverage than non-Hispanic whites. The Affordable Care Act was designed, in part, to reduce health disparities. This study aimed to assess changes in insurance coverage at community health center visits by race and ethnicity after Affordable Care Act Medicaid expansion.

What This Study Found Expansion of Medicaid coverage under the Affordable Care Act has contributed to sizeable decreases in medical visits in which people were uninsured. This is true across all racial and ethnic groups, although disparities remain. Using electronic health record data from 10 states that expanded Medicaid and six states that did not, the study examined 359 community health centers and 870,319 patients with more than four million visits. Rates of Medicaid-insured visits increased in expansion states for all racial/ethnic groups immediately following ACA Medicaid expansion, whereas no significant change was observed for Medicaid-insured visits for any racial/ethnic group in non-expansion states. Rates of uninsured visits decreased for all racial/ethnic groups in both expansion and non-expansion states, but the declines were more immediate and pronounced in expansion states. Specifically, rates of Medicaid-insured visits in expansion states increased 60 percent from before the Affordable Care Act to after its implementation among non-Hispanic whites, 77 percent for Hispanics, and 40 percent for non-Hispanic blacks. The most notable changes in non-expansion states were in private insurance visit rates: all racial/ethnic groups increased significantly in the post-implementation period, with Hispanics utilizing community health centers with private coverage at 3.6 times their rate prior to the ACA. This suggests that fewer Hispanic patients were eligible for Medicaid and therefore sought private coverage to comply with the Affordable Care Act's individual mandate. In spite of these improvements, disparities remain. For example, Hispanic patients had the highest uninsured visit rates before Medicaid expansion and, after Medicaid expansion, a significantly smaller decline in rates of uninsured visits than non-Hispanic whites and non-Hispanic blacks. Thus, gaps in Medicaid coverage appear to have continued for Hispanic patients while disparities have been reduced for non-Hispanic blacks.

Implications

• These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.