Abstract
ObjectiveWe examined whether the Affordable Care Act (ACA) Medicaid expansion reduced socioeconomic inequalities in health care utilization.MethodsWe used data from the Behavioral Risk Factor Surveillance System, covering the 50 U.S. states and the District of Columbia, between 2011 and 2016. We selected outcome indicators, viz. ability to afford needed health care, having a personal doctor, use of health services in the past year (routine check-up, flu shot and dental visits), and attending screenings for breast, cervical, and colon cancers. Socioeconomic status was measured by household income. We calculated two indices of inequality by household income for each outcome: Slope Index of Inequality (SII) and Relative Index of Inequality (RII). We estimated difference-in-differences models to examine the impact of ACA Medicaid expansion on socioeconomic inequality in use of health care services.ResultsThe ACA Medicaid expansion appeared to reduce the socioeconomic gap in individuals reporting financial ability in accessing health care (difference-in-differences estimators, -0.045 for SII and RII), having a personal doctor (-0.037 for SII and RII), and receiving routine check-ups (-0.027 for SII and -0.039 for RII). However, the expansion was not associated with reduction in the socioeconomic gap for preventive health care visits or dental care.ConclusionsThe ACA Medicaid expansion had mixed effects on socioeconomic disparities in health care utilization. Medicaid expansion may not be sufficient to address socioeconomic disparities in preventive services uptake.
Highlights
Health insurance coverage helps increase access to health care services including preventive and primary care and could contribute to population health improvement [1]
The Affordable Care Act (ACA) Medicaid expansion appeared to reduce the socioeconomic gap in individuals reporting financial ability in accessing health care, having a personal doctor (-0.037 for Slope Index of Inequality (SII) and Relative Index of Inequality (RII)), and receiving routine check-ups (-0.027 for SII and -0.039 for RII)
In 2010, as a part of the Affordable Care Act (ACA), Medicaid expansion was signed into law to improve access to health insurance for low-income Americans living below 138% of federal poverty level [2]
Summary
The data were from the BRFSS between 2011 and 2016 in order to cover the periods before and after the ACA Medicaid expansion (launched in 2014). The impact of ACA Medicaid expansion on socioeconomic inequality in health care services utilization expanded Medicaid by December 2015 while the control group included the states which did not expand Medicaid or later than December 2015. The expansion states exhibited lower socioeconomic disparities in health services utilization (both SII and RII) compared to the non-expansion states. The ACA Medicaid expansion was not associated with reduction of income-based inequalities in the utilization of preventive health care services including having visiting a dentist, getting a flu shot, or screening for breast, colon and cervical cancers. The sensitivity analyses excluding substantial and mild expansion states made our findings more robust; we found that income-based inequalities in all non-preventive health care services (e.g. financial ability to access to care, having personal doctor and routine check-up) were significantly reduced (Table 3). Excluding the two states that did not include dental visits in the Medicaid expansion did not alter our main findings
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