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 64 years 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.
KEY WORDScardiovascular Affordable Care Act insurance health care minority
All authors contributed to the project design, data analysis, and manuscript write-up processes.
This study received financial support from the National Heart, Lung and Blood Institute (NIH), grant number 1U01HL105342-01 (Drs. Kressin and McCormick).
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 13.Pool LR, Ning H, Lloyd-Jones DM, Allen NB. Trends in Racial/Ethnic Disparities in Cardiovascular Health Among US Adults From 1999-2012. J Am Heart Assoc. 2017;6(9).Google Scholar
- 16.2014 National HealthCare Quality and Disparities Report. Agency for Healthcare Research and Quality. Available at http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/2014nhqdr.pdf. Accessed 26 April 2019.
- 19.U.S. Department of Health and Human Services. Strategic goal 1: strengthen health care. 2016. Available at https://www.hhs.gov/about/strategic-plan/strategic-goal-1/index.html. Accessed 26 April 2019.
- 21.The Henry J. Kaiser Family Foundation. Health reform implementation timeline. 2016. Available at http://kff.org/interactive/implementation-timeline. Accessed 26 April 2019.
- 22.Patient Protection and Affordable Care Act. 111th Congress. Public Law 148. 2010. Available at: https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm. Accessed 26 April 2019.
- 24.Cohen RA, Zammitti EP, Martinez ME. Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2017. National Center for Health Statistics. 2018. Available at : https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201711.pdf. Accessed 26 April 2019.
- 29.Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS). 2018. Available at: https://www.cdc.gov/brfss/index.html.. Accessed 26 April 2019.
- 33.Calonico SCM, Farrell M, Titiunik R. Regression Discontinuity Designs Using Covariates. Ann Arbor: University of Michigan; 2016.Google Scholar
- 37.Ku L,Steinmetz E, Bruen B, Bysshe T. Effects of the Affordable Care Act on Health Insurance Coverage of Americans at Risk for Cardiovascular disease. Report. Milken Institute School of Public Health. 2016. Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_480864.pdf. Accessed 26 April 2019.
- 41.The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention for 2020. Department of Health and Human Services. 2008. Available at: https://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf. Accessed 26 April 2019.
- 42.Americans’ Experiences with ACA Marketplace Coverage: Affordability and Provider Network Satisfaction. 2016. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2016/jul/americans-experiences-aca-marketplace-coverage-affordability-and. Accessed 26 April 2019.
- 44.Collins SR, Gunja MZ, Doty MM, Bhupal H. First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse. The Commonwealth Fund. May 1, 2018. Available at: http://www.commonwealthfund.org/blog/2018/first-look-health-insurance-coverage-2018-finds-aca-gains-beginning-reverse?redirect_source=/publications/blog/2018/apr/health-coverage-erosion. Accessed 26 April 2019.
- 45.Congressional Budget Office. Federal Subsidies for Health Insurance Coverage for People under Age 65, 2017–2027. Washington DC: Congressional Budget Office, 2016. Available at: https://www.cbo.gov/system/files?file=115th-congress-2017-2018/reports/53091-fshic.pdf. Accessed 26 April 2019.Google Scholar