Differential Effects of the ACA by Age, Gender, and Ethnicity/Race
After controlling for potentially confounding variables such as gender, age group, race, and zip code income, patients who were younger (younger than 26 years: OR, 9.4 [95% CI, 7.5-12.0]; 26-64 years: OR, 6.6 [95% CI, 6.0-7.3]; 65+ years: OR, 0.8 [95% CI, 0.6-1.1]; p < 0.001), men (women/men: OR, 0.7; 95% CI, 0.5-0.8; p < 0.001), white (white/nonwhite: OR, 2.5; 95% CI, 2.1-3.0; p < 0.001), and who lived in the highest income quartile zip code (level 1 [lowest income]: OR, 5.6 [95% CI, 5.1-6.2]; level 2: OR, 8.5 [95% CI, 6.7-10.7]; level 3: OR, 8.5 [95% CI, 6.0-12.0]; level 4: OR, 18.3 [95% CI, 9.9-33.8]; p < 0.001) were more likely than their counterparts to become insured during this time.
Of the 792 patients (9%) who were seen multiple times and changed their insurance status between visits, 621 (78% of those who switched) became insured, whereas 171 patients (22%) became uninsured. Beginning in January 2014, after implementation of the major provisions of the ACA, the increase in patients newly insured was higher than it was before (18 patients per month versus 8.7 patients per month, or 4.8% and 2.4% of monthly visits) (Fig. 1). Of the approximately 370 patients seen monthly, this fraction of current patients who became insured was relatively small. Therefore, the majority of the decrease in uninsured clinic visits was the result of new patients who presented to the clinic with insurance rather than those who switched between visits.
The primary objective of the ACA was to “make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured” . Federal, state, and local governments have used numerous policy levers to achieve this objective, including establishing and expanding insurance marketplaces, providing premium tax credits and other cost-sharing assistance, expanding Medicaid coverage, empowering organizations to provide outreach and enrollment assistance, mandating the purchase of insurance coverage, and more . We aimed to examine the effect of the ACA on orthopaedic care for uninsured, low-income patients on the state level. Specifically, we asked: (1) did the ACA result in a decrease in the number of uninsured patients at one safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in Rhode Island, and (2) did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state. We found that there was a substantial increase in the proportion of patients seen at our clinic who had insurance after passage of the ACA. After controlling for potentially confounding variables such as gender, age group, race, and zip code income, patients who were younger (younger than 26 years), men, white, and who lived in the highest (level 4) income quartile zip code were more likely than their counterparts to become insured during this time.
There are some limitations to this study. First, although our clinic is the safety net clinic in the state that provides a dominant majority of all aspects of orthopaedic care, there is no obligation to seek care here, and our database is not an all-inclusive registry. Therefore, there inevitably will be loss to followup. This data loss is potentially most serious as patients may become insured and seek care elsewhere, although this may be mitigated because the total number of annual visits was relatively consistent, which suggests that the number of available appointments was the limiting factor. Furthermore, Rhode Island has the lowest Medicaid reimbursement rate in the United States . Given that ACA is a Medicaid expansion, ACA policies offer similar reimbursement rates, which substantially discourages provider acceptance of the patients with these polices . This is another factor that likely caused our clinic population to remain captured even after the patients obtained ACA insurance. Second, although our study examines the effect of the ACA on orthopaedic care for low-income, uninsured patients in our state, it is not possible to definitively say that our results are generalizable to other states. Each state has a considerable influence on the access to care afforded by insurance made available through the ACA depending on reimbursement rates and the extent to which providers participate. Third, our database does not track patient outcomes, but rather insurance status as a process measure of ACA success. Therefore, we did not examine the effect of increased access to health insurance on outcomes of orthopaedic interventions. Currently, there is no consensus regarding the effect of access to health insurance on health outcomes. Although a previous study  showed that improving access to health care is not associated with improve health outcome, other studies suggest otherwise [1 , 11]. Fourth, it is impossible to know the precise fraction of income that patients spend on health care and therefore to determine who is “underinsured” . A counterintuitive result from our study is that patients residing in the wealthiest zip codes were the least likely to be insured before implementation, although these patients benefitted disproportionately, eventually having a higher proportion of insured than those in the lowest three quartiles. Further study is needed regarding the effect of the ACA on the financial viability of such safety net clinics, especially given the changing funding mechanisms and their abilities to change capacity to meet patient demand.
Studies regarding the ACA have shown improved access to care, with up to an 11% decrease in the likelihood of being uninsured, and suggested the possibility of health improvements [7 , 20]. The US Census Bureau’s Small Area Health Insurance Estimates showed that the proportion of uninsured people decreased from 13% in 2009 to 7% in 2016, a 7% absolute reduction (and 50% relative reduction) . From 2013 to 2014, across the period of ACA implementation, the fraction of uninsured patients in Rhode Island declined from 13% to 9%, representing an almost 30% decrease . After the ACA was implemented, more patients were likely to become insured after a visit at our clinic, despite the similar volume of appointments. Although patient financial advocates and education programs helped connect patients with insurance, these programs became more successful after ACA implementation. Interestingly, after implementation of the ACA, the fraction of uninsured patients continued to decrease, suggesting the full effects had not been realized by the end of 2015. The proportion of our clinic’s uninsured patient visits decreased more dramatically, with a 36% absolute reduction and 73% relative reduction. A previous study showed improving access to health care is associated with improved health outcomes in patients with nonorthopaedic conditions like HIV . Future studies should examine the effect of increased access to care on health outcomes of orthopaedic interventions.
Although evidence generally suggests that the ACA led to a higher proportion of patients with insurance coverage, the effect of the ACA on health insurance may vary with socioeconomic status and other demographic characteristics [3 , 5 , 15]. For example, Hispanics may be less likely to have employer-sponsored health insurance, which may be associated with lower income, immigration status, and a higher likelihood of having a part-time job in which the employer did not offer an insurance plan . Although the ACA specifically sought to address these disparities, the effect of the ACA remains mixed. An investigation examining the effect of the ACA revealed that young Hispanic adults (ages 19-25 years) did not benefit from implementation of the ACA at the rate at which they obtained dependent insurance coverage in comparison to young white adults . In our study, patients who were 26 years old or younger, men, and English speakers were more likely to be insured across all times, and patients who were young, white, men, and lived in a wealthier zip code became insured disproportionately higher during the time of ACA implementation as compared with their counterparts. There are numerous possible reasons for these differences between groups, including financial, logistic, language, and educational barriers [3 , 6 , 10 , 13 , 14 , 19]. Although increasing insurance access is only one component of efforts to improve the incredibly complex system of health care in the United States, other aspects of the ACA seek to overcome barriers and improve the quality of and access to care.
The direction of health policy and insurance markets in the United States remains unclear. Although the ACA resulted in a dramatic reduction in uninsured patients in the United States, legislators have highlighted the limitations of the ACA, and want reform of the ACA . Regardless of the perceptions of the quality of the insurance policies that stemmed from the ACA, a previous study showed that improving access to health care is associated with improved health outcomes in patients . We recognize that these benefits may not translate to surgical specialty care. However, we believe that improved access to care is a step in the right direction and must be recognized as discussion regarding healthcare reform ensues. Future investigations should examine the effect of the ACA on the quality of orthopaedic care that is supported by ACA insurance. If the ACA is repealed, studies regarding its effect on the proportion of patients who can access healthcare should be evaluated.
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