Affordable Care Act Provisions Research Articles

Impact of the Implementation of the Affordability Care Act on Gastric Cancer Survival Rates.

Introduction Gastric cancer, a significant public health concern, remains one of the most challenging malignancies to treat effectively. In the United States, survival rates for gastric cancer have historically been low, partly due to late-stage diagnosis and disparities in access to care. The Affordable Care Act (ACA)sought to address such disparities by expanding healthcare coverage and improving access to preventive and early treatment services. Objective This study aims to determine the causal effects of the ACA's implementation on gastric cancer survival rates, focusing on a comparative analysis between two distinct U.S. states: New Jersey, which fully embraced ACA provisions, and Georgia, which has not adopted the policy, as of 2023. Methods In this retrospective analysis, we utilized data from the Surveillance, Epidemiology, and End Results Program (SEER) registry to assess the impact of the ACA on cancer-specific survival (CSS) among gastric cancer patients. The study spanned the period from 2000 to 2020, divided into pre-ACA (2000-2013) and post-ACA (2016-2020) periods, with a two-year washout (2013-2015). We compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014) using a Difference-in-Differences (DiD) approach. We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities. Results Among 25,061 patients, 58.7% were in New Jersey (14,711), while 41.3% were in Georgia (10,350). The pre-ACA period included 18,878 patients (40.0% in Georgia and 60.0% in New Jersey), and 6,183 patients were in the post-ACA period (45.2% in Georgia and 54.8% in New Jersey). The post-ACA period was associated with a 20% reduction in mortality hazard among gastric cancer patients, irrespective of the state of residence (HR = 0.80, 95% CI: 0.73-0.88). Patients who were residents of New Jersey experienced a 12% reduction in mortality hazard compared to those who resided in Georgia in the post-ACA period (HR = 0.88, 95% CI: 0.78-0.99). Other factors linked to improved survival outcomes included surgery (OR = 0.30, 95% CI: 0.28-0.34) and female gender (OR=0.83, 95% CI: 0.76-0.91). Conclusion The study underscores the ACA's potential positive impact on CSS among gastric cancer patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.

Health Insurance Navigation Tools Intervention: A Pilot Trial Within the Childhood Cancer Survivor Study.

Childhood cancer survivors are at increased risk for underinsurance and health insurance-related financial burden. Interventions targeting health insurance literacy (HIL) to improve the ability to understand and use health insurance are needed. We codeveloped a four-session health insurance navigation tools (HINT) intervention, delivered synchronously by a patient navigator, and a corresponding booklet. We conducted a randomized pilot trial with survivors from the Childhood Cancer Survivor Study comparing HINT with enhanced usual care (EUC; booklet). We assessed feasibility, acceptability, and preliminary efficacy (HIL, primary outcome; knowledge and confidence with health insurance terms and activity) on a 5-month survey and exit interviews. Among 231 invited, 82 (32.5%) survivors enrolled (53.7% female; median age 39 years, 75.6% had employer-sponsored insurance). Baseline HIL scores were low (mean = 28.5; 16-64; lower scores better); many lacked knowledge of Affordable Care Act (ACA) provisions. 80.5% completed four HINT sessions, and 93.9% completed the follow-up survey. Participants rated HINT's helpfulness a mean of 8.9 (0-10). Exit interviews confirmed HINT's acceptability, specifically its virtual and personalized delivery and helpfulness in building confidence in understanding one's coverage. Compared with EUC, HINT significantly improved HIL (effect size = 0.94. P < .001), ACA provisions knowledge (effect size = 0.73, P = .003), psychological financial hardship (effect size = 0.64, P < .006), and health insurance satisfaction (effect size = 0.55, P = .03). Results support the feasibility and acceptability of a virtual health insurance navigation program targeted for childhood survivors to improve HIL. Randomized trials to assess the efficacy and sustainability of health insurance navigation on HIL and financial burden are needed.

The Affordable Care Act and child asthma: Lowering health care barriers by raising our voices

BackgroundThis policy discussion addresses the provisions of the Affordable Care Act (ACA) that impact children with asthma. PurposeThe purpose of this policy paper is to inform health care professionals and lawmakers about ACA provisions affecting pediatric asthma care and provide recommendations for policy changes that can improve equitable care for children with asthma. MethodsThe issues addressed involve discrimination, Medicaid policy oversight, quality improvement stategy, data collection, school-based health care funding, accountable care organization reimbursement, and the extension of dependent coverage. DiscussionHealth care policy development that focuses on human rights, and not market valuation, could reduce health inequity among children with asthma. ConclusionPolicy recommendations are presented to improve asthma care for a population that is largely vulnerable due to age, socioeconomic status, and discrimination.

The association between the Patient Protection and Affordable Care Act and healthcare affordability among US adults with intellectual disability.

Historically, US adults with intellectual disability (ID) experience worse healthcare access than the general population. However, the implementation of the Patient Protection and Affordable Care Act (ACA) may have reduced disparities in healthcare access. Using a pre-ACA 2011-2013 sample and a post-ACA implementation 2014-2016 sample from the National Health Interview Survey data, we examined the association between the ACA's introduction and healthcare access among adults with ID (N=623). Negative binomial regression models were used to test the association between the ACA and the total number of foregone healthcare services. Binary logistic regression was used to explore whether the ACA's implementation was associated with the increased likelihood of possessing health insurance as well as the decreased likelihood of any and particular measures of foregone healthcare services due to cost. The study provides evidence that the ACA's implementation was associated with the decreased likelihood of the total number and any foregone care services owing to cost. Findings also revealed that the ACA's implementation was associated with expansion of health insurance coverage and decreasing instances of foregone care services for medical care, dental care, specialist visit and mental care among adults with ID. However, persons with ID were still at a higher risk of foregone prescription medicines, follow-up medical care and eyeglasses due to cost in the post-ACA years. The study provides evidence that healthcare access among Americans with ID improved after the ACA's implementation. However, challenges in access to follow-up care, eyeglasses and prescription medicines persist and require policy solutions, which extend beyond the ACA's provisions.

A pilot intervention to improve health insurance literacy and financial toxicity among recently diagnosed adolescents and young adults with cancer.

218 Background: Adolescents and young adults (AYAs; ages 18-39) with cancer report worries about costs and feeling uninformed about their insurance, which may impair their ability to navigate the health care system, use their insurance, and manage costs. We conducted a pilot randomized controlled trial (RCT) to assess a virtually delivered health insurance navigation intervention (“CHAT”) to improve health insurance literacy (HIL) and knowledge, increase awareness of insurance protections in the Affordable Care Act (ACA), and reduce financial toxicity and stress. Methods: CHAT is a 4-session program delivered by a patient navigator. Session content included learning about insurance, navigating your plan, insurance-related laws, &amp; managing care costs. Eligible participants had access to a wireless device, were within their first year of cancer diagnosis, and were treated at oncology sites from the University of Utah Healthcare and Intermountain Healthcare systems. We assessed feasibility and preliminary efficacy of CHAT compared to usual navigation care, including HIL (9 items on confidence using insurance), insurance knowledge (13 items on terms such as deductible &amp; copay), ACA protections (8 items), Perceived Stress Scale (PSS; 4 items), and COmprehensive Score for financial Toxicity (COST; 11 items) using t-tests. Results: From November 2020 to January 2022, 86 AYAs enrolled (46.2% approached consented); 68.6% were female, 72.1% white, 18.6% Hispanic, 34.9% age 18-25, 65.1% age 26-39, 83.7% had private insurance, and 10.5% public. Mean baseline HIL scores were 22.6 (range = 9-33, SD = 5.5). At baseline, 65.1% of participants were unaware of the ACA provision allowing appeals for coverage denials. 64.4% of intervention participants completed all 4 sessions; 86.0% completed the 5-month follow-up survey with data collection ongoing (74/86). At follow-up, compared to usual navigation care, CHAT participants had improvements in HIL, knowledge of insurance, and knowledge of ACA provisions (Table). While PSS improved more for CHAT than usual care, COST did not differ. Conclusions: Results support the feasibility and preliminary efficacy of CHAT with related improvements in HIL and knowledge of the ACA. Clinical trial information: NCT04448678. [Table: see text]

A Decade of ACOs in Medicare: Have They Delivered on Their Promise?

Accountable care organizations (ACOs) were envisioned as a way to address both health care cost growth and uneven quality in US health care. They emerged in the early 2000s, with the 2010 Affordable Care Act (ACA) establishing a Medicare ACO program. In the decade since their launch, ACOs have grown into one of Medicare's flagship payment reform programs, with millions of beneficiaries receiving care from hundreds of ACOs. While great expectations surrounded ACOs' introduction into Medicare, their impacts to date have been modest. ACOs have achieved some savings and improvements in measured quality, but disagreement persists over the meaning of those results: Do ACOs represent important, incremental steps forward on the path toward a more efficient, high-quality health care system? Or do their modest achievements signal a failure of large-scale progress despite the substantial investments of resources? ACOs have proven to be politically resilient, largely sidestepping the controversies and partisan polarization that have led to the demise of other ACA provisions. But the same features that have enabled ACOs to evade backlash have constrained their impacts and effectiveness. After a decade, ACOs' long-term influence on Medicare and the US health care system remains uncertain.

A health insurance navigation intervention tool (HINT) for survivors of childhood cancer: Randomized pilot trial results from the Childhood Cancer Survivor Study.

6508 Background: Childhood cancer survivors are vulnerable to being underinsured and health insurance-related financial burden. Low health insurance literacy reduces survivors’ ability to utilize health insurance. We conducted a pilot randomized controlled trial (RCT) to assess a virtually delivered health insurance navigation tool (HINT) intervention to improve health insurance literacy (HIL) and decrease financial burden. Methods: Using a multiphase, mixed methods design, we developed and tested a theoretically-driven 4-session intervention that included: 1) Learning About Survivorship Healthcare Needs, 2) Learning About Your Plan in Relation to Policy, 3) Navigating Your Plan and Obstacles, and 4) Managing Care Costs. Eligible CCSS participants were insured and had wireless device access. We assessed feasibility and preliminary efficacy of HINT versus enhanced usual care (EUC; health insurance booklet) on HIL (16-item instrument assessing knowledge and confidence with health insurance terms and activity, ACA provisions knowledge (8-items), psychological financial burden (7-items assessing worry due to medical costs), and satisfaction with health insurance coverage (1 item) using multivariable linear regression. Results: From 8/20 to 5/2021, 82 participants enrolled (39.7% participation rate); 53.7% female; 82% white, 7% Hispanic, and 7% black; 52.4% &lt;40 years of age; and 57.3% from a Medicaid expansion state. 25.6% reported previously being uninsured. 57.3% were diagnosed &lt;10 years of age, and 40.1% had ≥1 severe chronic health condition. There were gaps in health insurance literacy (HIL mean 28.5, sd=9.0; 16-60 (high-low); 39.0% were not familiar with the Affordable Care Act (ACA), and many lacked ACA provisions knowledge (e.g., appeals for coverage denials (56.1%). 82% completed 4 sessions; 92.6% completed the 5-month follow-up survey. Compared to EUC, HINT significantly improved HIL, ACA provisions knowledge, psychological financial hardship, and health insurance satisfaction (p’s ≤ 0.03). Conclusions: Findings affirm health insurance literacy gaps among a national sample of insured long-term survivors. Results support the feasibility and preliminary efficacy of HINT on improving health insurance literacy, satisfaction, and psychological financial burden. HINT is the first intervention to demonstrate improvements in long-term survivors’ health insurance literacy and psychological financial burden. Clinical trial information: NCT04520061. [Table: see text]

The Affordable Care Act and suicide incidence among adults with cancer.

Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer. We identified US patients with cancer aged 18-74years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions. We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39years) (- 64.36 per 100,000, 95% CI = - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer. We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicideamong cancer survivors.

Did the affordable care act increase the availability of employer‐sponsored health insurance?

AbstractThe 2010 Affordable Care Act (ACA) included two provisions, the Employer Shared Responsibility Provision (the “employer mandate”) and the Small Business Health Options Program (“SHOP”), aimed at increasing the availability of employer‐sponsored health insurance (ESI) among workers at small firms. To examine whether these provisions led to greater ESI availability, I use 2011–2017 Medical Expenditure Panel Survey (MEPS) data in a difference‐in‐difference framework that compares changes in ESI availability among workers at small and large firms before and after the ACA's provisions come into effect. My estimates show that there is a 3.5 percentage point increase in ESI availability among workers at smaller firms after 2013. When focusing on workers most likely to be affected by the employer mandate, I find a larger 5.2 percentage point increase in ESI availability, amounting to a 39% decline in the proportion who do not have ESI available. However, I find no evidence that greater ESI availability led to increases in ESI coverage rates. Instead, descriptive estimates suggest that gains in health insurance coverage after 2013 consist of significant increases in the number of working adults who report having Medicaid coverage, including among workers who are offered ESI. I use MEPS data for my analysis because, along with employment, firm size, and health insurance details, MEPS also provides health status and healthcare access/utilization information. Looking at changes in these health measures, I find only limited evidence to suggest that the ACA's provisions improved access to care or measures of health status for workers.

Preterm birth and foetal-neonatal death rates associated with the Affordable Care Act Medicaid expansion (2014-19).

The Affordable Care Act (ACA) or Patient Protection and Affordable Care Act of 2010 represented a significant expansion of insurance coverage and regulatory reform.1 While initially mandatory, the June 2012 Supreme Court ruling in ‘National Federation of Independent Business v. Sebelius’ established this reform as elective and state-dependent.2 Since 2012, 39 states (and the District of Columbia) have adopted the ACA expanded reform. The ACA expansion increased eligibility for adults with income up to 138% the federal poverty level (FPL).3 In addition, coverage of children had previously varied by state and by age groups, and under the ACA expansion, children ≤18 were covered up to 138% FPL as well. Medicaid currently provides coverage for 40–50% of all pregnancies under a 200% FPL requirement, yet 65% of women subsequently lost postpartum coverage and preventative care.4 The ACA provisions allow for greater coverage of women prior to pregnancy and postpartum, which has resulted in a 28% reduction in insurance churning among low-income women.5 In addition, the rate of uninsured adults in states, which did not adopt the ACA expansion, is twice that of ACA-expanded states.6

The Impact of the Affordable Care Act on Dental Care: An Integrative Literature Review.

The goal of the Patient Protection and Affordable Care Act (ACA) is to increase access to health insurance and decrease health care cost while improving health care quality. With more articles examining the relationship between one of the ACA provisions and dental health outcomes, we systematically reviewed the effect of the ACA on dental care coverage and access to dental services. We searched literature using the National Library of Medicine’s Medline (PubMed) and Thomson Reuters’ Web of Science between January 2010 and November 2020. We identified 33 articles related to dental coverage, and access/utilization of dental care services. This systematic review of studies showed that the ACA resulted in gains in dental coverage for adults and children, whereas results were mixed with dental care access. Overall, we found that the policy led to a decrease in cost barriers, an increase in private dental coverage for young adults, and increased dental care use among low-income childless adults. The implementation of the ACA was not directly associated with dental insurance coverage among people in the U.S. However, results suggest positive spillover effects of the ACA on dental care coverage and utilization by people in the national level dataset.

Associations between ACA-related policies and a clinical recommendation with HPV vaccine initiation.

We examined associations between the 2010 Affordable Care Act (ACA) provisions, 2011 Advisory Committee on Immunization Practices (ACIP) recommendation, and 2014 ACA-related health insurance reforms with HPV vaccine initiation rates by sex and health insurance type. Using 2009-2015 public and private health insurance claims for 551,764 males and females aged 9-26years (referred to as youth) from Maine, New Hampshire, and Massachusetts, we conducted linear regression models to examine the associations between three policy changes and HPV vaccine initiation rates by sex and health insurance type. In 2009, HPV vaccine initiation rates for males and females were 0.003 and 0.604 per 100 enrollees, respectively. Among males, the 2010 ACA provisions and ACIP recommendation were associated with significant increases in HPV vaccine uptake among those with private plans (0.207 [0.137, 0.278] and 0.419 [0.353, 0.486], respectively) and Medicaid (0.157 [0.083, 0.230] and 0.322 [0.257, 0.386], respectively). Among females, the 2010 ACA provisions were associated with significant increases in HPV vaccine uptake among Medicaid enrollees only (0.123 [0.033, 0.214]). The ACA-related health insurance reforms were associated with significant increases in HPV vaccine uptake for male and female Medicaid enrollees (0.257 [0.137, 0.377] and 0.214 [0.102, 0.327], respectively), but no differences among privately insured youth. By 2015, there were no differences in HPV vaccine initiation rates between males (0.278) and females (0.305). Both ACA provisions and the ACIP recommendation were associated with significant increases in HPV vaccine initiation rates among privately and publicly insured males in three New England states, closing the gender gap. In contrast, females and youth with private insurance did not exhibit the same changes in HPV vaccine uptake over the study period.

Associations between insurance-related affordable care act policy changes with HPV vaccine completion

BackgroundAlthough all 11- or 12-year-olds in the US were recommended to receive a 3-dose series of the human papillomavirus (HPV) vaccine within a 12-month period prior to 2016, rates of completion of the HPV vaccine series remained suboptimal. The effects of the Affordable Care Act (ACA), including private insurance coverage with no cost-sharing and health insurance expansions, on HPV vaccine completion are largely unknown. The aim of this study was to examine the associations between the ACA’s 2010 provisions and 2014 insurance expansions with HPV vaccine completion by sex and health insurance type.MethodsUsing 2009–2015 public and private health insurance claims from Maine, New Hampshire, and Massachusetts, we identified 9-to-26-year-olds who had at least one HPV vaccine dose. We conducted a logistic regression model to examine the associations between the ACA policy changes with HPV vaccine completion (defined as receiving a 3-dose series within 12 months from the date of initiation) as well as interactions by sex and health insurance type.ResultsOver the study period, among females and males who initiated the HPV vaccine, 27.6 and 28.0%, respectively, completed the series within 12 months. Among females, the 2010 ACA provision was associated with a 4.3 percentage point increases in HPV vaccine completion for the privately-insured (0.043; 95% CI: 0.036–0.061) and a 5.7 percentage point increase for Medicaid enrollees (0.057; 95% CI: 0.032–0.081). The 2014 health insurance expansions were associated with a 9.4 percentage point increase in vaccine completion for females with private insurance (0.094; 95% CI: 0.082–0.107) and a 8.5 percentage point increase for Medicaid enrollees (0.085; 95% CI: 0.068–0.102). Among males, the 2014 ACA reforms were associated with a 5.1 percentage point increase in HPV vaccine completion for the privately-insured (0.051; 95% CI: 0.039–0.063) and a 3.4 percentage point increase for Medicaid enrollees (0.034; 95% CI: 0.017–0.050). In a sensitivity analysis, findings were similar with HPV vaccine completion within 18 months.ConclusionsDespite low HPV vaccine completion overall, both sets of ACA provisions were associated with increases in completion among females and males. Our results suggest that expanding Medicaid across the remaining states could increase HPV vaccine completion among publicly-insured youth and prevent HPV-related cancers.

Exploring Factors Associated With Full Implementation of the Affordable Care Act's Medicaid Tobacco Cessation Provisions

Medicaid enrollees use tobacco at rates more than double that of the general population. To address this disparity, the Affordable Care Act (ACA) contained provisions to increase access to tobacco cessation treatments for Medicaid enrollees. There have been relatively low levels of implementation of these provisions by Medicaid programs. This research aims to evaluate the potential political, economic, and policy factors associated with implementation of each of the four tobacco‐cessation‐related ACA provisions. In 2017, UC San Diego researchers collected survey data from 51 Medicaid programs on tobacco cessation treatment policies and state‐level variables from publicly available sources. Implementation of these provisions was associated with state‐level variables such as having a budget shortfall during the recession years, Democratic control of the Governorship or legislature, and higher state cigarette taxes. Further guidance from the Centers for Medicare and Medicaid Services will be necessary to achieve full implementation of these ACA provisions.

The Affordable Care Act and access to care across the cancer control continuum: A review at 10years.

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes.

How Have ACA Insurance Expansions Affected Health Outcomes? Findings From The Literature.

A growing body of literature examining the effects of the Affordable Care Act (ACA) on nonelderly adults provides promising evidence of improvements in health outcomes through insurance expansions. Our review of forty-three studies that employed a quasi-experimental research design found encouraging evidence of improvements in health status, chronic disease, maternal and neonatal health, and mortality, with some findings corroborated by multiple studies. Some studies further suggested that the beneficial effects have grown over time and thus may continue to grow if the ACA insurance expansions remain in force. However, not all studies reported a significant positive relationship between ACA provisions that expanded insurance coverage and health status. We highlight the challenges facing researchers, including the importance of nonmedical factors in determining individual health and the use of outcome data predominantly drawn from self-reports. In closing, we identify opportunities to enhance researchers' understanding of the relationship between the ACA insurance expansions and health outcomes using new data sources, including electronic health records.

Patient Costs, Bundled Payment, And More

Patient Costs, Bundled Payment, And More

Texas Arguments Lead Heavy ACA Action.

Arguments in Texas raise questions about the ACA's fate as enrollment holds steady and new state reinsurance waivers are approved.

Looking to the Future: Medical Students' Views on Health Care Reform and Professional Responsibility.

Although medical students will influence the future U.S. health care system, their opinions on the Patient Protection and Affordable Care Act (ACA) have not been assessed since the 2016 presidential election and elimination of key ACA provisions. Understanding medical students' views on health care policy and professional obligations can provide insight into issues that will be shaped by the next generation of physicians. From October 2017 to November 2017, the authors conducted an electronic survey of medical students from seven U.S. institutions to elicit opinions regarding the ACA and their professional responsibility to address health policy. Participant demographics and responses were tabulated, and multiple logistic regression models were used to assess the associations of demographic characteristics with student opinions. Completed surveys were returned by 1,660/4,503 (36.9%) eligible medical students. Respondent demographics were similar to national estimates. In total, 89.1% (1,475/1,660) supported the ACA, and 82.0% (1,362/1,660) reported that they understood the health care law. Knowledge of the law's provisions was positively associated with support for the ACA (P < .001). Most students (85.8%; 1,423/1,660) reported addressing health policy to be a professional responsibility. Political affiliation was consistently associated with student opinions. Most medical students support the ACA, with greater levels of support among medical students who demonstrated higher levels of objective knowledge about the law. Furthermore, students indicated a professional responsibility to engage in health policy, suggesting that tomorrow's physicians are likely to participate in future health care reform efforts.

Coverage and Access for Americans with Cardiovascular Disease or Risk Factors After the ACA: a Quasi-experimental Study.

Atherosclerotic cardiovascular disease (CVD) is the leading cause of death in the USA. Many with CVD or cardiovascular risk factors (CVRFs) lacked insurance coverage and access to care before enactment of the Affordable Care Act (ACA). To assess the effect of the ACA on insurance coverage, access to care, and racial/ethnic disparities among non-elderly adults with CVD or CVRFs. Quasi-experimental policy intervention. Nationally representative, non-institutionalized sample of 1,014,450 adults aged 18 to 64years with CVD or at least 2 established CVRFs in the pre-ACA (2012-2013) and post-ACA (2015-2016) periods. Implementation of ACA provisions on 1 January 2014. Insurance coverage, having a check-up, having a personal physician, and not having to forgo a needed physician visit because of cost. Following ACA implementation, insurance coverage increased by 6.9 percentage points (95% CI, 6.6 to 7.2), not having to forgo a physician visit increased by 3.6 percentage points (CI, 3.3 to 3.9), having a check-up increased by 2.1 percentage points (CI, 1.8 to 2.6), and having a personal physician increased by 1 percentage point (0.6 to 1.3); changes were approximately doubled for those with lower incomes (< $35,000/year). Changes in coverage varied substantially by state and all outcomes improved more in Medicaid expansion states. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 13% black and 29% Hispanic adults continued to lack coverage and access to care post-ACA. The ACA increased coverage and access for adults with CVD or multiple CVRFs; substantial gaps remain, particularly for minorities and those in Medicaid non-expansion states.