Beyond Health Insurance: Remaining Disparities in U.S. Health Care in the Post-ACA Era Citation Sommers, B.D., McMurtry, C.L., Blendon, R.J, Benson, J.M., Sayde, J.M. 2017. “Beyond Health Insurance: Remaining Disparities in U.S. Health Care in the Post-ACA Era.” Milbank Quarterly. Forthcoming. Permanent link http://nrs.harvard.edu/urn-3:HUL.InstRepos:29695273 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Open Access Policy Articles, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#OAP Share Your Story The Harvard community has made this article openly available. Please share how this access benefits you. Submit a story . Accessibility Beyond Health Insurance: Remaining Disparities in U.S. Health Care in the Post-ACA Era Benjamin D. Sommers, M.D., Ph.D., Caitlin L. McMurtry, S.M., Robert J. Blendon, ScD John M. Benson, M.A., and Justin M. Sayde, S.M. Affiliations: From the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (B.D.S., C.L.M., R.J.B., J.M.B., J.M.S.); and the Department of Medicine, Harvard Medical School and Brigham & Women’s Hospital, Boston, MA (B.D.S.). Corresponding author: Dr. Benjamin D. Sommers, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue Room 406, Boston, Massachusetts 02115, [email protected]. 617-432-3271. Publication Note: This is a preprint of an Article accepted for publication in The Milbank Quarterly © 2016 The Milbank Memorial Fund. Funding/Disclosures: This project was supported by a research grant from the Robert Wood Johnson Foundation. Date: December 12, 2016 1 ABSTRACT Context: The Affordable Care Act (ACA) has reduced the U.S.’s uninsured rate to an historic low. But coverage is only one of many factors contributing to racial and income-based disparities in health care access, affordability, and quality. Methods: Using a novel 2015 national survey of over 8,000 Americans, we examined disparities between low-income and high-income adults, and between racial/ethnic minorities and whites. We conducted a series of regression analyses, starting with models that only took into account income or race, and then sequentially adjusted for health insurance, state of residence, demographics, and health status. We examined self-reported quality of care, cost-related delays in care, and emergency department (ED) use due to lack of available appointments. Then we used multivariate regression to assess respondents’ views of whether quality and affordability had improved over the past two years and whether the ACA was helping them. Findings: Quality of care ratings were significantly worse among lower-income adults than higher-income adults. Only 10-25% of this gap was explained by health insurance coverage. Cost-related delays in care and ED use due to lack of available appointments were nearly twice as common in the lowest-income group, and less than 40% of these disparities was explained by insurance. There were significant racial/ethnic gaps: reported quality of care was worse among blacks and Latinos than whites, with 16-70% explained by insurance. In contrast to these disparities, lower-income and minority groups were generally more likely than whites or higher- income adults to say that the ACA was helping them and that the quality and/or affordability of care had improved in recent years. Conclusions: Our post-health reform survey shows ongoing stark income and racial disparities in the health care experiences of Americans. While the ACA has narrowed these gaps, insurance expansion alone will not be enough to achieve health care equity. Key Words: Disparities, Health Care Access, Health Insurance, Health Reform 2 POLICY POINTS: • In a national survey of approximately 8000 adults in 2015, we found large income and race-based disparities in perceived health care quality, affordability, and use of the Emergency Department. • Lack of health insurance is one factor that contributes to worse health care experiences among lower-income Americans and racial/ethnic minorities, but it only explains a small to moderate portion of these disparities. • While the Affordable Care Act has led to significant improvements in health care access and affordability, large gaps remain. Repeal of the law would undo much of this progress, but even if the law remains in effect, policymakers need to address other social determinants that contribute to ongoing income and race-based disparities in health care. 3 INTRODUCTION Disparities in U.S health care are a source of considerable public health and policy concern, with substantial evidence that minorities and low-income Americans experience greater barriers to care and worse health outcomes across numerous measures.1,2 At the same time, the U.S. is currently in the midst of the largest overhaul of the health care system in more than 50 years, with the passage and implementation of the Affordable Care Act (ACA). Evidence shows that the ACA has expanded health insurance to nearly 20 million individuals and has brought the uninsured rate to an all-time low.3 Whether – and how much – this expansion of coverage has narrowed disparities in health care is unclear. Cross-sectional studies from before the ACA demonstrate that coverage is just one aspect of disparities in health care experienced by racial/ethnic minorities and those with low incomes. Even among those without insurance, access to a regular source of care and health care utilization rates differ significantly among racial and ethnic groups,4,5 with studies suggesting contributions from factors such as educational attainment, language barriers, citizenship, and neighborhood effects.6,7 Previous health insurance expansions have a mixed record in terms of improving equity. Often called the model for the ACA, Massachusetts’ 2006 health reform led to improved access to outpatient care for vulnerable populations in the state, including non-elderly adults living in low- and middle income areas, elderly adults, and non-elderly Hispanic adults.8 Some studies have found that the state’s policy reduced disparities. For instance, the state’s reform was associated with a significant decrease in mortality and a narrowing of disparities, with mortality improvements largest among non-whites and those living in poorer counties.9 Another survey- based study found that improvements in self-reported health after Massachusetts health reform 4 were largest for lower-income adults and minorities.10 However, not all research has found a reduction in disparities after the state’s reform. In these studies, even though vulnerable populations in Massachusetts experienced improvements in cost-related barriers and coverage, similar or larger gains were observed among white and non-poor groups, resulting in no significant progress toward the elimination of racial disparities for many outcomes.11,12 State-level Medicaid expansions preceding the ACA have, by definition, disproportionately benefited lower-income individuals, since they are the ones eligible for the program. Evidence of Medicaid’s impact on racial disparities, however, is less clear. Large Medicaid expansions in the early 2000s in New York, Maine and Arizona were associated with significant reductions in all-cause mortality, as compared to demographically similar neighboring states that did not expand Medicaid. These gains were greatest among racial and ethnic minorities and residents of poorer counties, suggesting that state Medicaid expansions may reduce mortality disparities among vulnerable groups.13 Other studies of Medicaid expansions have found improvements in access to care and self-reported health, but have not provided information on how these effects varied by race or socioeconomic status.14,15 Researchers have also examined the impact of the ACA’s 2010 dependent coverage provision (which allowed adults to remain on their parents’ plans through age 25) on disparities among young adults. Studies indicate significant gains in insurance coverage and reduced out- of-pocket spending, but mixed progress when it comes to narrowing disparities. Among young adults ages 19-25, the dependent coverage provision increased private coverage for men and women, for most racial and ethnic minorities, for those with limited English proficiency, and for those with and without citizenship.16 However, net gains were greater for whites than for other 5 racial or ethnic minorities,17 and one study found evidence that the policy primarily benefited higher-income families.18 While much of the research on disparities has focused on race and ethnicity, gaps in health care coverage and access related to income are also of significant concern. Moreover, widening income inequality19 – combined with the steady rise of health care costs over the past several decades20 – poses particular challenges for health care access, which the ACA in part was designed to mitigate.21 Since the beginning of the ACA’s major insurance expansions in 2014, several studies have demonstrated larger coverage gains among lower-income groups and minorities, with some concurrent improvements in access to primary care and affordability of care.22-26 For instance, one study found that reductions in the uninsured rate among blacks and Latinos were nearly twice as large as those among whites.23 Meanwhile, the uninsured rate for those living below the poverty level fell from 33% in 2013 to 25% by 2016, compared to a much smaller drop from 12% to 8% among those with incomes from 250-400% of the poverty level.26 While many of these prior studies have used pre-post comparisons or quasi-experimental study designs to evaluate the effect of coverage expansions on disparities, as noted earlier, other studies have used multivariate cross-sectional approaches to evaluate the extent to which baseline income and racial disparities in access to care and health care quality can be attributed to insurance differences across groups. These comparisons indicate that coverage plays a significant role in these gaps, but is not the only factor at play.6 However, to our knowledge, there has been little post-ACA analysis of the remaining disparities in health care – particularly in terms of perceived health care quality – and how much of a role health insurance coverage still plays in these gaps. 6 Our study objectives were: 1) to examine disparities based on race/ethnicity and income in perceived health care quality, access to care, and affordability of care, using a post-ACA sample of adults; 2) to estimate what proportion of these disparities could be attributed to differences in health insurance coverage across groups; and 3) to compare perceptions across groups of how the ACA and recent trends have affected these outcomes. METHODS Survey Data Our study data are from the “Patients’ Perspectives on Health Care in the United States” Survey, a project conducted by the Harvard T.H. Chan School of Public Health, the Robert Wood Johnson Foundation, and National Public Radio.27 The survey was a random-digit dialing telephone survey (of both cellphones and landlines), fielded by the research firm SSRS. Interviews were available in English and Spanish, and calls were completed between September 8 and November 9, 2015, among adults ages 18 or older. In each contacted household, one eligible respondent was selected at random to participate in the survey. The study contained eight different subsamples, each with roughly 1000 respondents. The first group was a nationally-representative sample in all 50 states and the District of Columbia. The other samples were from seven states – Florida, Kansas, New Jersey, Ohio, Oregon, Texas, and Wisconsin. These states were selected to represent a geographically and demographically diverse group of states that have not been studied extensively by other polls and represent a range of policy environments related to the Affordable Care Act. The final sample contained 1002 adults in the national sample and 7036 adults total in the seven states. The study oversampled African-American/blacks, Latinos, and adults with annual 7 household incomes of less than $25,000. The overall response rate was 15%, calculated according to the American Association for Public Opinion Research’s RR3 definition.28 Data from each of the eight subsamples were weighted by cell phone/landline use and demographics (sex, age, race/ethnicity, education, and household income) to reflect the appropriate population, based on data from the U.S. Census Bureau and National Health Interview Survey. Further details about the survey design are available in the Appendix. The survey collected data on demographic information, personal health care experiences, perceptions of health care in their respective states, and changes in these measures over the past year. The survey’s chief advantages for our research purposes were its timeliness, enabling analysis of outcomes nearly two years in the implementation of the ACA, and the use of several health-care related domains that are not typically covered by federal surveys. Study Outcomes We assessed several outcomes related to perceived quality and affordability of care, use of the Emergency Department due to lack of available appointments (as a measure of health care access), and perceptions of the ACA. For quality, we asked respondents, “Overall, how would you rate the health care you receive?” on a four-point scale (Excellent, Good, Fair, or Poor). We then asked whether the quality of care had gotten better, worse, or stayed the same over the past two years. For affordability, we asked respondents whether they had ever needed health care in the past two years, but did not get it because they could not afford that care. We also asked whether their care had become more affordable, less affordable, or stayed the same over the past two years. 8 For Emergency Department (ED) use, we asked whether they had used the ED in the past two years, and then among those with an ED visit, whether the primary reason was that “Other facilities were not open or you could not get an appointment.” We focus on this particular outcome rather than any ED use since numerous factors influence ED use that are not likely to be related to health insurance (such as transportation issues, availability of paid sick leave, and geographic proximity); we focus on appointment availability as a meaningful assessment of access to outpatient care. Finally, we asked each respondent, “Would you say the Affordable Care Act, also called Obamacare, has directly helped you, directly hurt you, or has it not had a direct impact?” Covariates Several of our models included covariates as described below. Covariates were selected based on Andersen’s revised behavioral model for access to health care.29 Those factors which increase one’s likelihood of using medical care, which Andersen terms “predisposing characteristics,” included sex, age, education, and race and ethnicity. We used insurance information, income, and state of residence as our main indicators of enabling resources – that is, those factors that affect one’s ability to obtain health care services. Finally, we added self- reported health status (on a five-point scale) as a proxy measure of one’s need for medical care. Statistical Analysis We analyzed our data in several steps. First, we assessed for the presence of disparities in our study outcomes in unadjusted models by race/ethnicity and separately by income. Race/ethnicity was categorized into white non-Latino, black non-Latino, Latino, and 9