Uninsured Primary Care Visit Disparities Under the Affordable Care Act

Abstract

Purpose: Health insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity.

Methods: We undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured).

Results: After the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78).

Conclusion: The lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.

Trial registration: ClinicalTrials.gov NCT02657499.

Keywords: Medicaid; Patient Protection and Affordable Care Act; health care disparities; health insurance; health policy.

Figure 1

Rates of payment type for primary care visits by race and and ethnicity.

Figure 1

Rates of payment type for primary care visits by race and and ethnicity.

Figure 1

Rates of payment type for primary care visits by race and and ethnicity.

Figure 1

Rates of payment type for primary care visits by race and and ethnicity.

Figure 1

Rates of payment type for primary care visits by race and and ethnicity.

Figure 1

Rates of payment type for primary care visits by race and and ethnicity.

Figure 2

Payment visit type after ACA implementation by race and ethnicity. ACA = Patient Protection and Affordable Care Act; DD = difference-in-difference; DDD = difference-in-difference-in-difference. NH = non-Hispanic. ^a Statistically significant DDD estimates, minority vs NH white between expansion status (reference: pre-ACA, NH white, nonexpansion states), P <0.05. ^b All DD estimates between expansion status within racial/ethnic group (reference: pre-ACA, nonexpansion states) were significant, P <0.05.