By ‘n By Hard Times Comes A-Knocking

The Affordable Care Act (ACA) helped people living in low-income areas of Kentucky, reducing income-related health disparities. Specifically, people living in zip codes with the highest concentrations of poverty reported the largest improvements in obtaining insurance coverage and delaying care due to costs.

In many ways, this outcome is predictable. The ACA expanded Medicaid to cover all people living in poverty (up to 138% of the Federal Poverty Level) and gave moderately low income people (100-400% FPL) financial assistance to buy private insurance. Before the ACA, the uninsured rate was much higher across the United States among low-income adults (31%) compared to the national average of 17%. The uninsured rate since the ACA expanded financial assistance to low income Americans fell 6% among all adults and 10% for low-income adults. Before the ACA, Kentucky offered Medicaid only to adults that were disabled, pregnant, or had dependent children, and earned <57% FPL, so the ACA changes were expected to add a large number of people to the Medicaid program in the state.

Although this study confirms that more people have health insurance after the ACA, it does not determine whether or not these gains have translated into improved access to care or health outcomes. Insurance does not guarantee access to see a doctor, and evidence has shown that patients with Medicaid have less access to care than patients with other types of insurance.

Early predictions about the American Health Care Act (AHCA) suggest it would reverse the trend toward reduced income-related health insurance disparities. The AHCA will undo the ACA’s Medicaid expansion and it caps tax credits to buy private insurance. Such caps may make health insurance unaffordable for low-income and older adults (over the age of 50).

The AHCA passed the House and has gone to the Senate for a vote. Interestingly, both of Kentucky’s Senators will both play a major role in the law’s fate there. Mitch McConnell is the majority leader who will try to drive a consensus to pass what has been renamed the Better Care Reconciliation Act. Rand Paul, a physician, has been a vocal opponent of the ACA, and introduced his own version of a repeal and replace act in February. The fate of insurance access for low-income Americans hangs in the balance .

commentary by Laura Medford-Davis

Abstract

OBJECTIVE: To evaluate the impact of Kentucky’s full rollout of the Affordable Care Act on disparities in access to care due to poverty.

DATA SOURCE: Restricted version of the Behavioral Risk Factor Surveillance System (BRFSS) for Kentucky and years 2011-2015.

STUDY DESIGN: We use a difference-in-differences framework to compare trends before and after implementation of the Affordable Care Act (ACA) in health insurance coverage, several access measures, and health care utilization for residents in higher versus lower poverty ZIP codes.

PRINCIPAL FINDINGS: Much of the reduction in Kentucky’s uninsured rate appears driven by large uptakes in coverage from areas with higher concentrations of poverty. Residents in high-poverty communities experienced larger reductions, 8 percentage points (pp) in uninsured status and 7.5 pp in reporting unmet needs due to costs, than residents of lower poverty areas. These effects helped remove pre-ACA disparities in uninsured rates across these areas.

CONCLUSION: Because we observe positive effects on coverage and reductions in financial barriers to care among those from poorer communities, our findings suggest that expanding Medicaid helps address the health care needs of the impoverished. PMID: 28439903 

Benitez, JA, et al. Health Services Research. Epub: April 25, 2017.