Affordable Care Act Health Research Articles

Access to Care and Outcomes With the Affordable Care Act for Persons With Criminal Legal Involvement

By expanding health insurance to millions of people in the US, the Patient Protection and Affordable Care Act (ACA) may have important health, economic, and social welfare implications for people with criminal legal involvement-a population with disproportionately high morbidity and mortality rates. To scope the literature for studies assessing the association of any provision of the ACA with 5 types of outcomes, including insurance coverage rates, access to care, health outcomes, costs of care, and social welfare outcomes among people with criminal legal involvement. The literature search included results from PubMed, CINAHL Complete, APA Psycinfo, Embase, Social Science Database, and Web of Science and was conducted to include articles from January 1, 2014, through December 31, 2023. Only original empirical studies were included, but there were no restrictions on study design. Of the 3538 studies initially identified for potential inclusion, the final sample included 19 studies. These 19 studies differed substantially in their definition of criminal legal involvement and units of analysis. The studies also varied with respect to study design, but difference-in-differences methods were used in 10 of the included studies. With respect to outcomes, 100 unique outcomes were identified across the 19 studies, with at least 1 in all 5 outcome categories determined prior to the literature search. Health insurance coverage and access to care were the most frequently studied outcomes. Results for the other 3 outcome categories were mixed, potentially due to heterogeneous definitions of populations, interventions, and outcomes and to limitations in the availability of individual-level datasets that link incarceration data with health-related data. In this scoping review, the ACA was associated with an increase in insurance coverage and a decrease in recidivism rates among people with criminal legal involvement. Future research and data collection are needed to understand more fully health and nonhealth outcomes among people with criminal legal involvement related to the ACA and other health insurance policies-as well as the mechanisms underlying these relationships.

Association of County Race and Ethnicity Characteristics With Number of Insurance Carriers and Insurance Network Breadth

While the Affordable Care Act (ACA) set out to eliminate insurer discrimination based on preexisting conditions, the ACA health exchanges allow insurers to select what markets to enter and afford them great freedom on how they design their physician networks. Strategic market participation and physician network design based on population race, ethnicity, and health characteristics may give rise to a present-day form of redlining within health insurance markets-ie, a systematic underprovision of insurance plans and in-network practitioners within areas that are populated with higher proportions of non-Hispanic Black residents. To examine if markets with relatively higher non-Hispanic Black populations have systematically fewer insurers and lower network inclusion of physicians residing within these areas. This cohort study conducted a regression analysis of the US ACA health insurance exchange marketplace across 34 states with federal exchanges and physicians located within the 500 most populous US cities in 2014. County-level data were sourced from individual market and issuer enrollment databases and county health rankings; census tract data came from a national database of physician networks in 2014 marketplace plans, US Census Bureau data, and the Centers for Disease Control and Prevention's PLACES database. Adjustment was made for a rich set of county (or census tract) controls and state fixed effects to capture broad market and/or policy differences across states. Analyses were performed in June 2021. The raw count of insurers within a county and the mean percentage of insurance networks that physicians participate in within each census tract. A total of 2270 counties were examined within our first analyses. In the counties analyzed, a mean (SD) of 23.0% (3.2%) of the population was aged 18 years or younger, and a mean (SD) of 11.0% (15.8%) of the population had non-Hispanic Black race and ethnicity. For the second analysis, 16 006 to 25 096 census tracts were examined (depending on physician specialty). With adjustment for population size, age, and race and ethnicity, a 1-SD increase in the county non-Hispanic Black population was associated with a 14.1% reduction in the number of insurers (mean [SE] marginal effect size, -2.18 [0.13]; P < .001). Accounting for additional county-level risk selection controls and state fixed effects, a 1-SD increase in the non-Hispanic Black population was associated with a 2.3% reduction in available insurers (marginal effect size, -0.36 [0.17]; P = .04). For practitioners network breadth inclusion, a 1-SD increase in the non-Hispanic Black population was associated with a 15.8% (marginal effect size, -0.32 [0.01]; P < .001) to 24.7% (marginal effect size, -0.14 [0.02]; P < .001) reduction in the physicians' network participation depending on their specialty. Adjusting for additional state fixed effects yielded estimates of 6% (marginal effect size, -0.08 [0.01]; P < .001) to 13.5% (marginal effect size, -0.12 [0.02]; P < .001) reductions in practitioner network participation. These findings suggest that strategic decisions by insurers may contribute toward markets with higher racial or ethnic minority populations having systematically fewer participating insurers, as well as a higher prevalence of local physicians not included in coverage networks. These findings call for further examination of potential insurance redlining within the ACA marketplaces.

ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance.

The Patient Protection and Affordable Care Act (ACA) required new private insurance plans to provide breast pumps with no cost sharing beginning August 2012, and in January 2014 expanded this requirement to Marketplace plans and expanded Medicaid coverage. We first examined the associations between the ACA reforms in 2012 and 2014 with rates of breast pump claims between Medicaid enrollees and those with private insurance. We next examined the associations between the monthly rate of breast pump claims with breastfeeding initiation and duration by insurance type. Using 2011-2015 public and private health insurance claims in All-Payer Claims Databases from Massachusetts, Maine, and New Hampshire, we conducted a linear regression model to evaluate the associations between the 2012 and 2014 ACA health insurance reforms with rates of breast pump claims by health insurance status. We then linked the monthly rates of breast pump claims per 1,000 live births to the Pregnancy Risk Assessment Monitoring System with self-reported breastfeeding initiation and duration. We estimated probit regression models to examine the associations between monthly rates of breast pump claims per state, insurance type, age group, and breastfeeding outcomes. For the 2012 ACA reform, breast pump claims increased by 183.4 (143.7-223.1) per 1,000 live births for women with private insurance, but decreased for Medicaid enrollees (-99.3 [-139.0 to -59.6]). For the 2014 ACA reforms, the opening of health insurance Marketplaces had no effect on breast pump claims for women with private insurance (8.3 [-43.6 to 60.2]), whereas Medicaid expansion increased claims by 119.4 (67.5-171.3) per 1,000 live births for Medicaid enrollees. Every additional 10 breast pump claims per 1,000 live births was associated with a 1.08 percentage point increase in breastfeeding initiation among women with private insurance (0.108 [0.018-0.198]), but not Medicaid enrollees (0.076 [-0.078 to 0.230]). In contrast, every additional 10 breast pump claims per 1,000 live births was associated with a 1.79 percentage point increase in breastfeeding for 4 or more weeks for women with private insurance (0.179 [0.063-0.294]) and a 2.05 percentage point increase among women with public insurance (0.205 [0.033-0.376]). Interaction analysis revealed no significant differences in associations by insurance type across breastfeeding outcomes. The ACA breastfeeding coverage requirements fill a gap for women wanting to obtain a breast pump to support breastfeeding. The monthly rate of breast pump claims, as an indicator of access, translated into higher levels of breastfeeding for women with private and public insurance with the potential to reduce socioeconomic disparities.

Medicaid Expansion And Health Services Use For Adults Experiencing Homelessness In Arkansas.

More than 500,000 people in the US experience homelessness at any given time, many of whom now qualify for Medicaid in states that expanded coverage under the Affordable Care Act (ACA). In this article we use a novel data set from Arkansas to provide the first estimates of the association between gaining coverage through the ACA's Medicaid expansion and health services use for a population experiencing homelessness. We find that Medicaid expansion was associated with large initial increases in inpatient hospitalizations and emergency department visits-which declined steadily over time-among adults experiencing homelessness compared with use by a sample of adult traditional Medicaid enrollees. Our results provide evidence of substantial pent-up demand for health care among a population experiencing homelessness in Arkansas that gained health insurance coverage as a result of Medicaid expansion.

Inducing Labor: the Impact of Health Insurance on Post-Natal Labor Supply

In this paper we analyze the role of access to health insurance plays in the widely documented, sharp fall in mother's labor supply following childbirth. Our analysis exploits variation created by the Affordable Care Act (ACA), which substantially expanded access to health insurance within the U.S., and richly detailed administrative tax data. We find that mother's relative post-childbirth employment increases by 12\% for births that occur after the insurance expansion. This labor supply response is pervasive across mother's pre-birth characteristics, and across the varied impact of the ACA expansion. Our analysis suggests that this response is likely driven by a combination of improved access to maternal health care, increased participation by mothers who do not work before birth, reduced exits among mothers who do work before birth, and a compositional changes in who gives birth following the ACA health insurance expansion.

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.

Health Policy by Litigation.

Since its enactment, the Affordable Care Act (ACA) has faced numerous legal challenges. Many of these lawsuits have focused on implementation of the law and the limits of executive power. Opponents challenged the ACA under the Obama Administration while supporters have turned to the courts to prevent the Trump Administration from undermining the law. In the meantime, Congress remains gridlocked over the ACA and many other critical health policy issues, leaving the executive branch to adopt its preferred policy approach and ultimately leading to lawsuits. This article briefly discusses the history of litigation over the ACA and some reasons why this litigation has been so enduring. The article then identifies other areas of health policy that are or could be future targets for litigation. Finally, the article comments on the potential impact of the courts on future health reform efforts.

Promoting Influenza Vaccination Among an ACA Health Plan Subscriber Population: A Randomized Trial.

To assess the effectiveness of an intervention to promote influenza vaccination among members of an Affordable Care Act (ACA) insurance plan. Randomized controlled trial. Messages were delivered by a community-based, nonprofit health insurance provider to its members in Central Texas. Adult subscribers for whom either a phone number or an e-mail address was available (n = 25 649). Participants were randomly assigned to be sent (1) no messages, (2) messages encouraging influenza vaccination via e-mails and texts, and (3) messages encouraging influenza vaccination through e-mails, texts, and postal mail. Messages were sent between September 12, 2017 and November 17, 2017. Influenza vaccination was determined using medical and pharmacy claims. Rate differences and 95% confidence intervals between each exposure condition were calculated for the overall population and by subgroups. The vaccination rate by December 31, 2017 was 16.9%. Those sent both electronic messages and postal mail were significantly more likely to be vaccinated than those who were not sent messages (rate difference: 2.5%; 95% confidence interval [CI]: 1.4-3.6) and those who were sent electronic messages only (rate difference: 1.6%; 95% CI: 0.5-2.8). A combination of messages delivered via text, e-mail, and postal mail generated a modest but significant positive effect on influenza vaccine rates in an ACA plan population. The postal mail component was essential for achieving this effect.

Diverse Stakeholder Perspectives on Rural Health Care Reform in a U.S. State That Rejected the Affordable Care Act: A Case Study

Purpose: This case study identifies rural health care stakeholder perspectives on the Affordable Care Act (ACA) and describes the health policy context in Idaho, the only state in the United States to reject Medicaid expansion yet develop a state-run health insurance exchange. Sample: The sample included 20 rural health care stakeholders, including clinicians, elected officials, state agency administrators, health care facility administrators, and interest group leaders. Method: A single-case study of stakeholder perspectives on the ACA and rural health care access in Idaho was conducted from 2014 to 2016. Data sources include qualitative interviews with 20 rural health care stakeholders and public documents relating to the ACA and rural health care from Idaho governmental and nongovernmental entities’ websites. Findings: Since the 2010 passage of the ACA, opposition to “Obamacare” became associated with a conservative stance on health care reform. However, in this case study, diverse health care stakeholders who criticized aspects of the ACA identified several components of the policy, including Medicaid expansion, as essential in ensuring access to rural health care. Some stakeholders called for federal legislation authorizing nurse practitioners to practice as independent primary care providers. However, the politics of medical sovereignty present challenges to this relevant strategy and to full implementation of Idaho’s Nurse Practice Act for increasing access to primary care in a rural state. Conclusions: The case study approach can be effective in illuminating stakeholder perspectives and policy strategies that may fall outside of polarized health care policy debates. Examination of the state-level political context of rural health care must consider concurrent battles about state sovereignty over health care policy and professional-clinical battles about sovereignty over primary care. Keywords: Affordable Care Act, case study, Idaho, rural health care policy, advanced practice nurses DOI: http://dx.doi.org/10.14574/ojrnhc.v18i2.514

How Did Affordable Care Act Exchanges Affect Individuals’ Willingness to Quit Their Jobs?

Background: In October 2013, the Affordable Care Act (ACA) health insurance exchanges began offering access to subsidized community-rated plans previously unavailable to many non-elderly adults. This shock represents a decrease in the opportunity cost to employment for those with employer-sponsored insurance (ESI). Studies have examined labor participation, but not willingness to voluntarily quit as a result of expanded availability of guaranteed issue coverage. There is similarly little evidence on the reasons people quit or the activities that individuals pursue after quitting. Objective: To test the effect of the launch of ACA health insurance exchanges (late 2013) on individuals’ willingness to quit their current main job. Methods: Repeated panels (2006-2015) from the Medical Expenditure Panel Survey (MEPS) contain information on current employment and quitting in five survey rounds over a two-year period. Linear probability models (LPM) with standard errors clustered at the household level predict the probability of quitting, controlling for temporal and seasonal trends using panel/round fixed effects. Models include controls for demographic and socioeconomic characteristics and are weighted using the provided longitudinal weights. The main effect compares the first open enrollment period (Q4 2013-Q1-2014 [panel 17, round 5]) with the same seasonal period (round 5) in different panels (first difference), then controls for time trends by subtracting out the same comparison from a different round (e.g., panel 17, round 2) (second difference). Results: The sample contains 105,348 individuals, 2,782 of whom quit their current main job over 10 overlapping panels (10 years) of 4 rounds each (round 1 established current job). The unadjusted rate of voluntary quitting in round 5 across all pre-exchange panels was 3.1%. During the first open enrollment (panel 17, round 5), the predicted probability of voluntary quitting was nearly a full percentage point higher than the average of the prior panels [0.93 percentage points (95% CI: 0.01, 1.80)] and consistent for individual years (first difference). Controlling for temporal changes (second difference), using the second and third rounds as referent, the average effects are even stronger [2.01 (0.93, 3.11)] and [1.54 (0.37, 2.70)], respectively. We also observe a stronger effect in earlier panel years (pre-2010), suggesting the period of and following the Great Recession may have dampened willingness to quit. The largest change in reasons for voluntarily quitting a position between the first open enrollment and pre-exchange periods was ‘quit to take care of home/family’ (10.6%) followed by ‘quit to go to school’ (7.58%). Conclusions: These results show support for the job lock hypothesis, indicating that individuals may be willing to quit their jobs when access to other sources of affordable health insurance become available. The magnitude of this result is small, but generalizable to a sizable population, unlike other previous attempts to characterize the effects of the ACA on labor outcomes. Specifically, we describe the pathway where individuals may be willing to quit their current job differentially around the time of the first ACA open enrollment period. Affordable access to health insurance can improve flexibility to move in and out of the labor force.

Institutional Design of the Aca Health Insurance Exchanges: Factors Affecting Policy Implementation in State Administration

In state implementation of the Affordable Care Act (ACA) health insurance exchanges, sixteen states decided to create and administer their own exchanges, determining the institutional location of the exchanges. This institutional design of implementing organizations affects aspects of state policy implementation of the health exchanges, reflecting the intentions of state officials to exert control over the administration of operations and other decisions such as funding sources. This research examines whether state decisions regarding agency assignment of the ACA health exchanges were associated with political, economic, and historical-cultural explanations. This study provides evidence that, in the decision of the location of health insurance exchanges, state officials were influenced by the factors of state budget shortfalls and state histories of creating independent agencies, but not by divided government, compound divided government and state personnel capacity.

Individual Health Insurance Market with an Entrant – The ACA Health Insurance Exchange Observations

Abstract In this paper, a general framework is built up to model the dynamic of consumer health plan choice and individual health insurance market competition. A primary goal is to identify driving forces to individual health insurance equilibrium market coverage and premium. In the baseline model, we introduce plan quality information search cost as an additional determinant to consumer’s plan choice. Health insurers compete under the Hotelling’s game theory framework. Equilibrium solutions of the baseline model highlight the importance of budget limit and information search cost to health plan enrollment. The more important objective is to examine the impact of market entrants on equilibrium insurance market coverage and plan prices. In the model with market entry, we add an additional dimension to the baseline model. Equilibrium solutions and numerical studies show positive impact of higher insurance market coverage and lower health plan prices. The Affordable Care Act (ACA) brought multiple unprecedented changes to the health insurance market and provided opportunities to study market dynamics and driving forces. The ACA health insurance exchange market experience shows consistency with our model findings even at the early stage of implementation. More importantly, market observations suggest that entry barriers of claim costs and information search cost are high for entrants.

Leveraging health care reform to accelerate nurse practitioner full practice authority.

Since development of the nurse practitioner (NP) role, NPs have been advocating for policy allowing them to practice to the full extent of their training. The aim of this research was to determine whether passage of the Affordable Care Act (ACA) had an impact on expansion of NPs' scope of practice. This was a retrospective descriptive study of NPs' scope of practice legislation from 1994 to 2016 using regulatory theory. Data sources included annual reports on NP legislation and state-level legislative and media coverage. Eight states adopted full practice authority (FPA) from 2011 to 2016, representing a two-fold increase compared with the previous 10 years. Seven states adopted Medicaid expansion. Nursing interest groups and politicians shaped their argument in favor of FPA around the increasingly insured population because of the ACA, provider shortages, and rural health care access issues. Shaping the discourse of FPA beyond the benefits to the NP profession makes way for broader political interest and participation. Although the future of the ACA is unknown, as the 28 states without FPA continue to advocate for legislative change, they could benefit from the strategies of these newly adapted FPA states.

Lower barriers to primary care after the implementation of the Affordable Care Act in the United States of America.

ABSTRACTObjectiveTo examine short-term changes in perceived barriers to access to primary care before and after implementation of the Affordable Care Act (ACA) among adults in the United States of America.MethodsThe ACA was approved in 2010. We used the National Health Interview Survey (NHIS) for the years 2011-2014 to compare the main reported problems in accessing primary care among adult respondents in 2011-2013 (before implementation of mandatory ACA health insurance for individuals) and in 2014 (after that implementation). A multivariate logistic stepwise regression analysis was used to identify trends with primary care barriers.ResultsWe found that from 2010 through 2014, individuals were progressively less likely to report challenges to accessing care, such as having trouble finding a provider, getting accepted as new patients, and health care providers not accepting their health insurance. In addition, adults were less likely to report inconveniences linked to waiting times for an appointment and with provider's office hours.ConclusionsInforming policymakers, providers, and system administrators about the short-term changes in perceived barriers to care offers a baseline for evaluating policies and programs linked to implementing the ACA, as well as assessing how prepared primary care networks were for the influx of newly insured patients. Nevertheless, the abolition of the ACA health insurance mandate through legislation approved in December 2017 has put into question whether patients’ perceptions of improved access to care will be sustained in the future.

Impact of ACA Health Reforms for People With Mental Health Conditions.

This brief report explores the impact of health reform for people with mental illness. The Health Reform Monitoring Survey was used to examine health insurance, access to care, and employment for 1,550 people with mental health conditions pre- and postimplementation of the Affordable Care Act (ACA) and by state Medicaid expansion status. Multivariate logistic regressions with predictive margins were used. Post-ACA reforms, people with mental health conditions were less likely to be uninsured (5% versus 13%; t=-6.89, df=50, p<.001) and to report unmet need due to cost of mental health care (17% versus 21%; t=-3.16, df=50, p=.002) and any health services (46% versus 51%; t=-3.71, df=50, p<.001), and they were more likely to report a usual source of care (82% versus 76%; t=3.11, df=50, p=.002). These effects were experienced in both Medicaid expansion and nonexpansion states. Findings underscore the importance of ACA improvements in the quality of health insurance coverage.

Development of a Rural Family Practice Rotation in an Athletic Training Residency Program

Context: Postprofessional residency (PPR) programs continue to gain popularity as athletic training education prepares for a paradigm shift. The Commission on Accreditation of Athletic Training Education has established didactic and clinical infrastructure for PPRs seeking accreditation. Accredited programs provide athletic trainers (ATs) with an advanced level of knowledge in a focused area of clinical practice. Objective: A case study report to introduce a novel PPR general medical rotation to illustrate the skills and knowledge of ATs, evaluate the impact of the athletic training residents in the rural family practice (FP) setting, and to discuss how employing an AT in this setting aligns with the triple aim of the Affordable Care Act (ACA). Background: Currently, there is very little literature regarding PPRs. Additionally, very little research exists describing how ATs function within the ACA model of health care delivery. Description: The PPR developed a rotation for a rural FP outpatient clinic. Athletic training residents completed 3-week rotations in this setting working with multiple providers. Learning objectives were created to emphasize the evaluation, diagnosis, and management of general medical conditions. Objectives were assessed at the conclusion of the rotation. Finally, data were collected to evaluate the impact of athletic training residents in the ACA model of health care delivery. Clinical Advantage(s): The athletic training residents improved their clinical evaluation and diagnosis skills in a FP clinic through this educational opportunity. This rotation cultivated and fostered interdisciplinary education and interprofessional collaboration. Finally, the observational findings of this rotation revealed the impact of ATs appear to align with the objectives of the ACA health care model, supporting the use of ATs in this role. Conclusion(s): This rotation highlights an area of clinical practice future ATs could pursue. Accredited PPR programs must consider the evolution in health care delivery and the shift in athletic training education standards to develop strong PP programs.

Falling through the Coverage Cracks: How Documentation Status Minimizes Immigrants' Access to Health Care.

Recent policy debates have centered on health reform and who should benefit from such policy. Most immigrants are excluded from the 2010 Affordable Care Act (ACA) due to federal restrictions on public benefits for certain immigrants. But, some subnational jurisdictions have extended coverage options to federally ineligible immigrants. Yet, less is known about the effectiveness of such inclusive reforms for providing coverage and care to immigrants in those jurisdictions. This article examines the relationship between coverage and health care access for immigrants under comprehensive health reform in the Boston metropolitan area. The article uses data from interviews conducted with a total of 153 immigrants, health care professionals, and immigrant and health advocacy organization employees under the Massachusetts and ACA health reforms. Findings indicate that respondents across the various stakeholder groups perceive that immigrants' documentation status minimizes their ability to access health care even when they have health coverage. Specifically, respondents expressed that intersecting public policies, concerns that using health services would jeopardize future legalization proceedings, and immigrants' increased likelihood of deportation en route to medical appointments negatively influenced immigrants' health care access. Thus, restrictive federal policies and national-level anti-immigrant sentiment can undermine inclusive subnational policies in socially progressive places.

Effects of Affordable Care Act Marketplaces and Medicaid Eligibility Expansion on Access to Cancer Care.

The aim of this study was to inform oncologists about how repealing the Affordable Care Act (ACA) may affect their ability to provide cancer therapies for people with cancer enrolled in ACA health plans and why proposals to change Medicaid funding may make it even more difficult for Medicaid beneficiaries to access cancer treatments. We examined the regulations and provisions of the ACA related to how health insurance impacts access to diagnostic testing and treatments for people with cancer, including access to clinical trials. Similarly, we examined federal and state rules affecting Medicaid beneficiaries' access to cancer treatments. Repealing various provisions of the ACA will restrict who has access to both current and new cancer treatments. Such changes also will impact oncology research that depends on having heterogeneous people in clinical trials. Significant changes to the ACA will affect oncology treatment choices of everyone with health insurance-not only the 10 million people newly covered by ACA health plans and the 70 million people with Medicaid coverage.

Increased Emergency Department Use in Illinois After Implementation of the Patient Protection and Affordable Care Act

We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state. Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation. Average monthly ED visit volume increased by 14,080 visits (95% confidence interval [CI] 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI -27,037 to -21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI -11.1 to -6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged. ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation.

Interpretive policy analysis: Marshallese COFA migrants and the Affordable Care Act

BackgroundSince the enactment of the Affordable Care Act (ACA), the rate of uninsured in the United States has declined significantly. However, not all legal residents have benefited equally. As part of a community-based participatory research (CBPR) partnership with the Marshallese community, an interpretative policy analysis research project was conducted to document Marshallese Compact of Free Association (COFA) migrants’ understanding and experiences regarding the ACA and related health policies. This article is structured to allow the voice of Marshallese COFA migrants to explain their understanding and interpretation of the ACA and related polices on their health in their own words.MethodsQualitative data was collected from 48 participants in five focus groups conducted at the local community center and three individual interviews for those unable to attend the focus groups. Marshallese community co-investigators participated throughout the research and writing process to ensure that cultural context and nuances in meaning were accurately captured and presented. Community co-investigators assisted with the development of the semi-structured interview guide, facilitated focus groups, and participated in qualitative data analysis.ResultsContent analysis revealed six consistent themes across all focus groups and individual interviews that include: understanding, experiences, effect on health, relational/historical lenses, economic contribution, and pleas. Working with Marshallese community co-investigators, we selected quotations that most represented the participants’ collective experiences. The Marshallese view the ACA and their lack of coverage as part of the broader relationship between the Republic of the Marshall Islands (RMI) and the United States. The Marshallese state that they have honored the COFA relationship, and they believe the United States is failing to meet its obligations of care and support outlined in the COFA.ConclusionWhile the ACA and Medicaid Expansion have reduced the national uninsured rate, Marshallese COFA migrants have not benefited equally from this policy. The lack of healthcare coverage for the Marshallese COFA migrants exacerbates the health disparities this underserved population faces. This article is an important contribution to researchers because it presents the Marshallese’s interpretation of the policy, which will help inform policy makers that are working to improve Marshallese COFA migrant health.