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PPACA Expands Coverage to More Patients, But Differences Remain

New study examines impact of Medicaid changes

Expansion of Medicaid coverage under the Patient Protection and Affordable Care Act (PPACA) has contributed to sizeable decreases in medical visits in which people were uninsured, according to a study in the Annals of Family Medicine. This is true across all racial and ethnic groups, although disparities remain.

Using electronic health record data from 10 states that expanded Medicaid and six states that did not, the study examined 359 community health centers and 870,319 patients with more than four million visits. Rates of Medicaid-insured visits increased in expansion states for all racial/ethnic groups immediately following PPACA Medicaid expansion, whereas no significant change was observed for Medicaid-insured visits for any racial/ethnic group in nonexpansion states.

Rates of uninsured visits decreased for all racial/ethnic groups in both expansion and nonexpansion states, but the declines were more immediate and pronounced in expansion states. Specifically, rates of Medicaid-insured visits in expansion states increased 60% from before the PPACA to after its implementation among non-Hispanic whites (rate ratio [RR], 1.60; 95% confidence interval [CI], 1.44–1.78), 77% for Hispanics (RR, 1.77; 95% CI, 1.56–2.02), and 40% for non-Hispanic blacks (RR, 1.40; 95% CI, 1.23–1.61).

The most notable changes in nonexpansion states were in private insurance visit rates: all racial/ethnic groups increased significantly in the post-implementation period, with Hispanics utilizing community health centers with private coverage at 3.6 times their rate prior to the PPACA. This suggests that fewer Hispanic patients were eligible for Medicaid and therefore sought private coverage to comply with the PPACA's individual mandate.

In spite of these improvements, disparities remain. For example, Hispanic patients had the highest uninsured visit rates before Medicaid expansion and, after Medicaid expansion, a significantly smaller decline in rates of uninsured visits than non-Hispanic whites and non-Hispanic blacks. Thus, gaps in Medicaid coverage appear to have continued for Hispanic patients while disparities have been reduced for non-Hispanic blacks. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.

The study, “Uninsured Primary Care Visit Disparities Under the Affordable Care Act,” was written by Heather Angier, MPH, of Oregon Health & Science University in Portland, Oregon, and colleagues.

Sources: American Academy of Family Physicians; September 12, 2017; Annals of Family Medicine; September/October 2017.


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