Changes In Health Insurance Coverage, Access To Care, And Income-Based Disparities Among US Adults, 2011-17.
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SUBMITTER: Griffith KN
PROVIDER: S-EPMC8139823 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportanceIt is unclear how the COVID-19 pandemic and its associated economic downturn have affected insurance coverage and disparities in access to health care among low-income families and people of color in states that have and have not expanded Medicaid.ObjectiveTo determine changes in insurance coverage and disparities in access to health care among low-income families and people of color across 4 Southern states and by Medicaid expansion status.Design setting and participantsThis random-digit dialing telephone survey study of US citizens ages 19 to 64 years with a family income less than 138% of the federal poverty line in in 4 states (Arkansas, Kentucky, Louisiana, and Texas) was conducted from October to December 2020. Using a difference-in-differences design, we estimated changes in outcomes by Medicaid expansion status overall and by race and ethnicity in 2020 (n = 1804) compared with 2018 to 2019 (n = 5710). We also explored barriers to health care and use of telehealth by race and ethnicity. Data analysis was conducted from January 2021 to March 2021.ExposuresCOVID-19 pandemic and prior Medicaid expansion status.Main outcomes and measuresPrimary outcome was the uninsured rate and secondary outcomes were financial and nonfinancial barriers to health care access.ResultsOf 7514 respondents (11% response rate; 3889 White non-Latinx [51.8%], 1881 Black non-Latinx [25.0%], and 1156 Latinx individuals [15.4%]; 4161 women [55.4%]), 5815 (77.4%) were in the states with previous expansion and 1699 (22.6%) were in Texas (nonexpansion state). Respondents in the expansion states were older, more likely White, and less likely to have attended college compared with respondents in Texas. Uninsurance rate in 2020 rose by 7.4 percentage points in Texas (95% CI, 2.2-12.6; P = .01) and 2.5 percentage points in expansion states (95% CI, -1.9 to 7.0; P = .27), with a difference-in-differences estimate for Medicaid expansion of -4.9% (95% CI, -11.3 to 1.6; P = .14). Among Black and Latinx individuals, Medicaid expansion was associated with protection against a rise in the uninsured rate (difference-in-differences, -9.5%; 95% CI, -19.0 to -0.1; P = .048). Measures of access, including having a personal physician and regular care for chronic conditions, worsened significantly in 2020 in all 4 states, with no significant difference by Medicaid expansion status.Conclusions and relevanceIn this survey of US adults, uninsured rates increased among low-income adults in 4 Southern states during the COVID-19 pandemic, but Medicaid expansion states, that association was diminished among Black and Latinx individuals. Nonfinancial barriers to care because of the pandemic were common in all states.
| S-EPMC8796874 | biostudies-literature
Project description:PurposePrevious work has demonstrated the Affordable Care Act (ACA) increased young adults' health care access during its first years. However, it is unclear if these trends continued through 2017; recent policies enacted by the Trump administration may have decreased the ACA's effectiveness. Our purpose was to determine changes in young adults' health care access during the transition from Obama to Trump administrations.MethodsData on noninstitutionalized U.S. young adults (18-24 years) was obtained from the Behavioral Risk Factor Surveillance System 2011-2017 (N = 173,848). We used interrupted time series and difference-in-differences analysis to quantify changes in self-reported insurance coverage, access to a primary care physician, and unmet care because of cost from 2013 to 2017.ResultsYoung adults' health care access continued to improve through 2016; for instance, the percentage of respondents experiencing uninsurance declined by 8.7 points from 2013 to 2016 (95% confidence interval [CI] -9.4 to -8.0). However, these trends began to reverse and from 2016 to 2017, the percentage of young adults who experienced uninsurance increased by 1.4 points (95% CI .6-2.1), not having a personal doctor increased by 1.1 points (95% CI .2-2.0), and unmet care because of cost increased by 1.0 points (95% CI .3-1.7). The 2017 declines in access were concentrated in states which did not expand Medicaid and in households earning above 138% of federal poverty level.ConclusionsHealth care access declined for young adults in 2017, after several years of improvements. These changes correspond with recent policy actions, which may have weakened the ACA's reforms.
| S-EPMC8211364 | biostudies-literature
Project description:ObjectiveTo examine the effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions.Data sources/study settingNine years (2004-2012) of individual-level cross-sectional data from a restricted-access version of National Survey on Drug Use and Health.Study designA quasi-experimental difference-in-differences design comparing outcomes among residents in 14 states that implemented Medicaid expansions for low-income adults under the Section §1115 waiver with those residing in the rest of the country.Data collection/extraction methodsThe analytic sample includes low-income adult respondents with household incomes below 200 percent of the federal poverty level who have a behavioral health condition: approximately 28,400 low-income adults have past-year serious psychological distress and 24,900 low-income adults have a past-year substance use disorder (SUD).Principal findingsAmong low-income adults with behavioral health conditions, Medicaid expansions were associated with a reduction in the rate of uninsurance (p < .05), a reduction in the probability of perceiving an unmet need for mental health (MH) treatment (p < .05) and for SUD treatment (p < .05), as well as an increase in the probability of receiving MH treatment (p < .01).ConclusionsThe ongoing implementation of Medicaid expansions has the potential to improve health insurance coverage and access to care for low-income adults with behavioral health conditions.
| S-EPMC4693853 | biostudies-literature
Project description:ImportanceAn increasing diversity of children's health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Children's Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children.ObjectiveTo compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes.Design, setting, and participantsA repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Children's Health, comprising 80,655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015.ExposuresInsurance type was ascertained using a caregiver-reported measure of insurance status and each household's poverty status (percentage of the federal poverty level).Main outcomes and measuresCaregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care.ResultsAmong the 80,655 children, 51,123 (57.3%) had private insurance, 11,853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P < .01; CHIP, 88% [87%-89%]; P < .01) and dental (Medicaid, 80% [78%-81%]; P < .01; CHIP, 77% [76%-79%]; P < .01) visits than were privately insured children (medical, 83% [82%-84%]; dental, 73% [72%-74%]). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% [24%-32%]), problems obtaining a referral (23% [18%-29%]), and frustration obtaining health care services (26% [23%-28%]). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% [26%-33%]) and frustration obtaining health care services (36% [32%-41%]) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the child's needs (63% [60%-67%]) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% [75%-78%]) than were caregivers of children insured by Medicaid (26% [23%-28%]; P < .01) or CHIP (38% [35%-40%]; P < .01).Conclusions and relevanceThis examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.
| S-EPMC8011294 | biostudies-literature
Project description:BackgroundIn the USA, people with limited English proficiency (LEP) disproportionately experience gaps in health insurance coverage and access to care. The Patient Protection and Affordable Care Act (ACA) of 2010 included reforms that could improve these outcomes.ObjectiveTo describe changes in insurance coverage and access to health care by English language proficiency over 2006-2016.DesignWe used regression models to estimate changes in coverage and access after 2010 for adults with high vs. limited English proficiency, adjusting for socio-economic status, demographic characteristics, and health care needs. We used difference-in-differences models to assess adjusted changes in disparities by English proficiency after 2010. Supplemental analyses used nearest-neighbor propensity score matching to balance the characteristics of respondents.ParticipantsRespondents aged 18-64 in the Medical Expenditure Panel Survey over 2006-2016, with high (n = 174,214) or limited (n = 16,484) English language proficiency.Main measuresInsurance coverage was a binary variable indicating any health insurance coverage during the past 12 months. Access to care was measured using binary variables indicating whether the respondent had a usual source of care and received necessary medical, dental, and preventive care.Key resultsGains in health insurance coverage after 2010 were significant for adults with high English proficiency (1.7 percentage points, p < 0.001) and adults with limited English proficiency (4.6 percentage points, p = 0.007); gains did not significantly vary by English proficiency. Adults with LEP showed larger improvements than adults with high English proficiency in having a usual source of care (5 percentage points, p = 0.007) and receiving needed medical care and dental care (1.4 percentage points, p = 0.013, and 2.8 percentage points, p = 0.009, respectively). Findings remained similar when matching was used to balance the measured characteristics of respondents with high vs. limited English proficiency.ConclusionsDisparities in health care access by English proficiency narrowed after 2010, the year of passage of the ACA.
| S-EPMC7210354 | biostudies-literature
Project description:ObjectiveMultiple studies have detailed the relationship between Medicaid expansion under the Affordable Care Act and various health and financial outcomes. However, fewer studies have examined Medicaid expansion's effects on individuals with psychiatric diagnoses. This study sought to determine the relationship between Medicaid expansion and various health and financial outcomes among low-income adults with depression.MethodsThis quasi-experimental study used a random-digit-dial survey of U.S. citizens ages 19-64 with incomes below 138% of the federal poverty level. Surveys were conducted in three southern states (two expansion states, Arkansas and Kentucky, and one nonexpansion state, Texas) between 2013 and 2016. The study sample consisted of those with a positive screen for depression-score of ≥2 on the two-item Patient Health Questionnaire (N=4,853). Survey-weighted difference-in-differences regressions were conducted with insurance status, health care access and utilization, and affordability of care as outcomes of interest. Subgroup analyses stratified the sample on the basis of the respondent's residence in a health professional shortage area (HPSA) in mental health and severity of depression.ResultsMedicaid expansion was associated with a significant reduction in the proportion of adults with depression who lacked health insurance (-23 percentage points, 95% confidence interval=-32 to -14, p<.001). Medicaid expansion was also associated with significant reductions in delaying care and medications because of cost. These changes were similar regardless of residence in a mental health HPSA and severity of depression.ConclusionsMedicaid expansion was associated with improved access to care and medication among persons with depression, even in areas with relative shortages of mental health professionals.
| S-EPMC6395562 | biostudies-literature
Project description:ObjectiveTo test the impact of the dependent coverage expansion (DCE) on insurance disparities across race/ethnic groups.Data sources/study settingSurvey data from the National Survey of Drug Use and Health (NSDUH).Study designTriple-difference (DDD) models were applied to repeated cross-sectional surveys of the U.S. adult population.Data collection/extraction methodsData from 6 years (2008-2013) of the NSDUH were combined.Principal findingsFollowing the DCE, the relative odds of insurance increased 1.5 times (95 percent CI 1.1, 1.9) among whites compared to blacks and 1.4 times (95 percent CI 1.1, 1.8) among whites compared to Hispanics.ConclusionsHealth reform efforts, such as the DCE, can have negative effects on race/ethnic disparities, despite positive impacts in the general population.
| S-EPMC5867154 | biostudies-literature
Project description:ImportanceThe Affordable Care Act created 2 new coverage options for uninsured adults: Medicaid expansion, which in most states provides comprehensive coverage without premiums and deductibles; and private marketplace coverage, which requires a premium contribution and cost-sharing, though with generous federal subsidies at lower incomes. How enrollment rates compare in the marketplace vs Medicaid is an important policy question as states continue to weigh alternative coverage options such as Medicaid buy-in programs, enrolling Medicaid-eligible populations into marketplace plans, or creating a public option.ObjectiveTo assess the association between income eligibility for Medicaid vs marketplace coverage and insurance enrollment among low-income adults in Colorado.Design setting and participantsUsing 2014 and 2015 all-payer claims data from Colorado and detailed income eligibility information, we used a regression discontinuity design to assess the difference in Medicaid and marketplace enrollment just below and just above 138% of the federal poverty level (FPL), the eligibility threshold between the 2 programs. The sample included nonpregnant adults aged 19 to 64 years with incomes between 75% to 400% FPL. We stratified our analysis by age, sex, chronic condition status, and urban vs rural residence. Analysis was conducted from January to October 2020.Main outcome and measuresThe main outcome was total enrollment in either Medicaid or marketplace coverage during marketplace's Open Enrollment period. Income-based health insurance eligibility was assessed as a percentage of FPL at the time of initial application for coverage.ResultsThe primary analytical sample included 32 091 enrollees in 2014 and 55 451 in 2015, with incomes ranging from 120% to 156% FPL. Most enrollees were women (59.26% in 2014, 59.20% in 2015), resided in urban areas (70.36% in 2014, 73.08% in 2015), and had no chronic conditions (74.66% in 2014, 76.11% in 2015). For age, in 2014 and 2015, respectively, 13.22% and 13.93% were aged 19 to 25 years, 27.85% and 28.54% were aged 26 to 34 years, 23.58% and 24.34% were aged 35 to 44 years, 18.35% and 17.75% were aged 45 to 54 years, and 17.00% and 15.44% were aged 55 to 64 years. Marketplace enrollment was 81.3% (95% CI, -86.0% to -75.0%) lower than Medicaid enrollment in 2014 and 88.6% (95% CI, -90.8% to -86.0%) lower in 2015 among those close to the 138% FPL eligibility threshold. The drop-off in marketplace enrollment was largest among younger adults, aged 26 to 34 and 35 to 44 years: relative drop off -88.7% (95% CI, -93.3% to -80.8%) and -87.8% (95% CI, -90.8% to -83.9%) in 2014, and relative drop off -91.9% (95% CI, -94.5% to -87.9%) and -93.0% (95% CI, -94.5% to -91.1%) in 2015, respectively.Conclusions and relevanceIn this cross-sectional study using a regression-discontinuity analysis, meaningful gaps in insurance enrollment may have existed for those with incomes just above the eligibility threshold for Medicaid expansion, especially among younger adults. Policies expanding Medicaid income eligibility or zero-dollar premium marketplace plans are likely to be more effective at inducing enrollment than subsidized private plans with premium requirements.
| S-EPMC8796906 | biostudies-literature
Project description:OBJECTIVE:To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on disparities in insurance coverage after three years. DATA SOURCE:The 2011-2016 waves of the American Community Survey (ACS), with the sample restricted to nonelderly adults. DESIGN:We estimate a difference-in-difference-in-differences model to separately identify the effects of the nationwide and Medicaid expansion portions of the ACA using the methodology developed in the recent ACA literature. The differences come from time, state Medicaid expansion status, and local area pre-ACA uninsured rates. In order to focus on access disparities, we stratify our sample separately by income, race/ethnicity, marital status, age, gender, and geography. PRINCIPAL FINDINGS:After three years, the fully implemented ACA eliminated 43% of the coverage gap across income groups, with the Medicaid expansion accounting for this entire reduction. The ACA also reduced coverage disparities across racial groups by 23%, across marital status by 46%, and across age-groups by 36%, with these changes being partly attributable to both the Medicaid expansion and nationwide components of the law. CONCLUSIONS:The fully implemented ACA has been successful in reducing coverage disparities across multiple groups.
| S-EPMC6341207 | biostudies-literature
Project description:ObjectiveTo examine Medicaid expansion (ME) effects on health insurance coverage (HIC) and cost barriers to medical care among people with asthma.MethodWe analyzed 2012-2013 and 2015-2016 data from low-income adults with current asthma aged 18-64 years in the Behavioral Risk Factor Surveillance System Asthma Call-Back Survey (state-level telephone survey). We calculated weighted percentages and 95% confidence intervals from ME and non-ME jurisdictions (according to 2014 ME status). Outcomes were HIC and cost barriers to buying asthma medication (MED), seeing a health care provider for asthma (HCP), or any asthma care (AAC). Using SUDAAN, we performed survey-weighted difference-in-differences analyses, adjusting for demographics. Subgroup analyses were stratified by demographics.ResultsOur study population included 6445 participants from 25 states plus Puerto Rico. In 2015-2016 compared to 2012-2013, HIC was more common in ME jurisdictions (P < 0.001) but unchanged in non-ME jurisdictions. Adjusted difference-in-differences analyses showed ME was associated with a statistically significant 13.36 percentage-point increase in HIC (standard error = 0.053). Cost barriers to MED, HCP, and AAC did not change significantly for either group in descriptive and difference-in-differences analyses. In subgroup analyses, we noted variation in outcomes by demographics and 2014 ME status.ConclusionsWe found ME significantly affected HIC among low-income adults with asthma, but not cost barriers to asthma-related health care. Strategies to reduce cost barriers to asthma care could further improve health care access among low-income adults with asthma in ME jurisdictions.
| S-EPMC8842503 | biostudies-literature