Keywords

Latino Health-Care Access and the Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (ACA) became law in 2010 and was nationally implemented in 2014 to make insurance more affordable and accessible. This comprehensive health insurance reform emphasizes community engagement and population health and has multiple provisions—insurance plans that are offered through marketplaces, Medicaid expansion, and incentives to improve cost and quality of care.

Racial and Ethnic Disparities in Health-Care Access and Utilization Under the ACA

Shortly after the roll out of the Affordable Care Act, our research team wanted to answer a simple question: What impact has the ACA had on health-care inequities, particularly for African Americans and Latinos? Using a pre-post study design, we analyzed combined data from the National Health Interview Survey (NHIS) and Medical Expenditure Panel Survey (MEPS) [1]. We found that all groups—non-Latino whites, African Americans, Latinos, and other race/ethnicity—experienced improvements in health-care access and utilization post-ACA, but that Latinos fared worse than all the other groups. For example, from 2011 to 2014, the probability of being uninsured dropped from 0.14 to 0.11 for non-Latino whites; from 0.24 to 0.17 for African Americans; and from 0.39 to 0.32 for Latinos. The other race/ethnicity category dropped from 0.18 to 0.14. The probability of delaying any necessary care also improved for every group; African Americans fared worse than Latinos (probability dropped from 0.17 to 0.14 and 0.18 to 0.12, respectively). The probability of having any physician visit increased post-ACA in all groups, but Latinos were consistently lower for all four years.

ACA’s Impact Among Latino Subgroups

Are these observed trends in health-care access and utilization consistent for all Latinos or for just some Latino subgroups? To answer this question, we performed a simple analysis of trends in Latinos by subgroups defined by heritage group (Puerto Rican, Mexican, Cuban, Central American, and other Latino), citizenship status, and interview language (Spanish or English) [2]. Measures of access to health care included health insurance status and forgoing necessary care because of cost; measures of utilization included any emergency department (ED) visit and any physician visit within the past 12 months. Our findings showed that the ACA, which was implemented in 2014, has reduced gaps in access and utilization of health care, and most reductions in disparities were experienced between Puerto Ricans and non-Latino whites; disparities remain for noncitizens [2].

Insurance Coverage

Central American and Mexican Latinos showed the lowest percentage of being insured currently (72.26% and 68.47% after the ACA, respectively); Puerto Ricans, who are citizens at birth, fared better (88.57%).

Forgoing Care

Results showed that Cubans and Mexicans were more likely to forgo necessary care in the past 12 months because of costs, and Puerto Ricans did better in forgoing care pre- and post-ACA.

Emergency Department Visit

We observed that emergency department utilization improved for all groups. Interestingly, while Puerto Ricans were much more likely to be insured and less likely to forgo seeking care, they had significantly higher percentage of visiting the emergency department in the last 12 months. We observed that ED use among other Latinos followed second to Puerto Ricans and that ED use among non-Latino whites did not change from 2011 to 2015.

Physician Visit

Trends were flat for any physician visits in the past 12 months; Mexican Latinos fared worse than the other heritage groups, followed by Cuban Latinos.

Citizenship and Language Use

We were also interested in knowing whether or not these associations were moderated by citizenship status or language use. We found that noncitizens had lower odds than US-born citizens of being insured (OR = 0.34; 95% CI, 0.31–0.37; P < .01), visiting an ED (OR = 0.78, 95% CI, 0.69–0.88; P < .01), and seeing a physician (OR = 0.74, 95% CI, 0.68–0.80; P < .01). Those whose interview language was Spanish had lower odds than those whose interview language was English of being insured (OR = 0.79; 95% CI, 0.71–0.87; P < .01), visiting an ED (OR = 0.62; 95% CI, 0.55–0.71; P < .01), and seeing a physician (OR = 0.80; 95% CI, 0.74–0.87; P < .01) [2].

ACA’s Impact on Reducing Disparities in Hypertension Treatment Among Mexican-Heritage Latinos

The cardiovascular literature shows that Latinos, in general, have lower rates of cardiovascular disease than other groups [3, 4]. Mexican-heritage Latinos, in particular, have lower rates of hypertension than non-Latino whites, but they are more likely to be undiagnosed; they are also more likely to be diagnosed later in disease, are much more difficult to treat, and are less likely to be on hypertensive medication.

In light of these disparities, we asked the question: Has the ACA made a difference in the treatment of hypertension in Mexican-heritage Latinos? Using data from the 2009–2014 California Health Interview Survey [5], we predicted trends in access, utilization, and hypertension control under the ACA for Mexican-heritage Latinos and non-Latino whites with hypertension. We found a significant initial uptake in insurance coverage for Mexican-heritage Latinos in 2013 followed by a slight decline in 2014, and there was a clear disparity in predicted insurance when compared to non-Latino whites even after implementation of ACA provisions. (These data reflect the fact that California adopted several provisions of the ACA before 2014.) Notably, the odds of taking hypertension medication increased among Mexican-heritage Latinos; that is, they were significantly more likely to report taking the medication after the ACA.

Impact of the ACA on Latino Children

Disparities Among Latino Children: Pre-ACA

About one in four US children under the age of 18 are Hispanic/Latino, making up the largest minority group among US children [6]. We thus had an interest in documenting disparities in health care among Latino children that existed before the ACA was implemented. Because family-centered care has been demonstrated to reduce disparities and improve the quality of health care, we examined racial and ethnic disparities in the receipt of family-centered care among the general pediatric population in the United States [7]. Using a linked dataset of MEPS and the NHIS from 2003 to 2006 (pre-ACA), we measured family-centered care using four questions adopted by the NHIS: “How often did your child’s doctors or other health providers (1) listen carefully to you, (2) explain things in a way you could understand, (3) show respect for what you had to say, and (4) spend enough time with you?” We found that compared to non-Latino whites, Latino youth experienced pediatric care with less of the four core processes of family-centered care—showing respect, sharing information, encouraging participation, and promoting collaboration. Their parents were less likely to say that their child’s doctors listened to them, explained things carefully, or spent enough time with them.

What is the source of the health-care disparities between Latino youth and other children? To identify explanatory factors, we used the Blinder-Oaxaca decomposition method to analyze the 2006–2011 NHIS (pre-ACA) data on parent-reported health-care access and utilization for white, Latino, and African American children in the United States [8]. We found that Latino children were less likely than non-Latino white children to have a usual source of care, receive at least one preventive care visit, and visit a doctor; Latino children were also more likely to have delayed care. These disparities could largely be explained by differences in socioeconomic status and health policy factors, such as having health insurance and having access to care.

Insurance Coverage and Latino Youth: Post-ACA

Did the ACA change the level of insurance coverage and health-care utilization or improve health-care disparities among Latino youth? Did Latino children show the same pattern of insurance coverage as Latino adults before and after implementation of the ACA? We analyzed national data from the 2011–2015 NHIS child component, which included parent-reported health-care utilization and access for youth aged 0–17 years. Using a pre-post study design, we found that insurance coverage and well-child visits improved for all youth post-ACA, but like their adult counterparts, Latino youth lagged significantly behind non-Hispanic whites, non-Hispanic blacks, and other race/ethnicity [9]. Even though Latino youth showed the largest gain in insurance coverage, they made up the highest proportion of uninsured post-ACA, largely because they had a much higher uninsured rate pre-ACA (Fig. 3.1). Although differences for well-child visits were minimal, Latino youth were also less likely to have a well-child visit.

Fig. 3.1
Two bar graphs depict Pre, Post-A C A on other, Latino, black, and white. 1. Currently uninsured exhibit high on Latino as Post and Pre-A C A is 0.08, 0.13. 2. The low measures for Latino as 0.75, 0.78. Values are estimated.

Insurance coverage and well-child visits for youth (0–17 years) in the United States pre-ACA (2011–2013) and post-ACA (2014–2015). (Reprinted from Ortega et al. [9]. © 2018 with permission from Elsevier)

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Since our original analysis of insurance coverage for youth and well-child visits post-ACA [9], there have been changes in the implementation of the ACA. In an effort to determine if insurance coverage and disparity levels are still improving, we reanalyzed our original data to include more recent 2018 NHIS data [10]. For the total of all youth, the prevalence of uninsured initially decreased from 6.6% in 2011–2013 (pre-ACA) to 4.8% in 2014–2015 (post-ACA); however, there was an uptick to 5.1% by 2016–2018. While these percentage differences may seem small, note that the denominator is in the millions—the 0.3% increase in uninsured from 2014–2015 to 2016–2018 is 196,000 uninsured children. The uninsured rate for non-Latino white and non-Latino black youth showed a similar pattern of change as the total of all youth, but Latino youth continued to improve over the three time periods (11.4%, 2011–2013; 8.4%, 2014–2015; 7.6%, 2016–2018). Significant disparities remain, however, as the uninsured rate for Latino youth is still higher than non-Latino white and non-Latino black youth. All the three groups continued to improve on well-child visits over the three time periods. We hypothesize that this is largely attributable to the mandatory preventive visits that are provided by the ACA, so children are going in for immunizations and screening well-child visits, which are covered regardless of insurance coverage.

It has been established that the effect of the ACA on health-care disparities between Latinos and non-Latino whites varies among Latino-heritage groups [2], and the question is whether the same disparity patterns exist among Latino youth. Using data from the 2011–2016 NHIS, we compared insurance coverage and health-care utilization by subgroups of Latino youth (Puerto Rican, Mexican, Cuban, Central or South American, and other subgroups) [11]. We found that the uninsured rate dropped significantly post-ACA for most Latino subgroups and non-Latino whites; children of Mexican heritage and Central or South American heritage experienced the greatest decline in uninsured rate (13.1% pre-ACA to 9.9% post-ACA and 12.4% to 9.1%, respectively)—a similar pattern to their adult counterparts [11]. However, disparities remained as both subgroups still experienced greater uninsured rates post-ACA than the other subgroups and non-Latino whites. Similarly, the proportion for a well-child visit in the past 12 months increased for most groups post-ACA, but the proportion of Mexican children going to a well-child visit still lagged behind all other groups both pre-ACA and post-ACA [11]. Interestingly and contrary to popular belief, Mexican-heritage children were very low utilizers of the emergency department [11]. This was true for both citizens and noncitizens.

Health-Care Access Among Undocumented Latinos

Are health-care disparities among Latinos in the United States associated with US citizenship and documentation status? In a pre-ACA study analyzing the 2003 data from the California Health Interview Survey (CHIS), we found that undocumented Mexicans and other Latinos have worse health-care access and utilization patterns than those born in the United States [12]. In a more recent post-ACA study, we compared health-care access and utilization among Latinos in California stratified by the continuum of documentation status—US-born citizen, naturalized citizen, permanent resident with a green card, and undocumented immigrant. An analysis of the 2011–2015 CHIS data showed significant health-care disparity along this continuum with undocumented Latinos faring the worst [13]. Interestingly, we also found that undocumented immigrants were the least likely to report having chronic disease, physical health problems or mental health issues than other immigrant groups, even though they were also the least likely to report excellent or very good health.

The Affordable Care Act holds the promise of ameliorating some of the health disparities that the Latino population experiences in the United States, but coverage needs to be extended to undocumented immigrants to narrow disparities and improve utilization and access to health care [14]. For example, California offers Medicaid to eligible children who are undocumented and also provides health benefits to adult undocumented immigrants through Medicaid, which is covered by state funds.

Conclusion

The ACA has positively impacted health-care disparities in the United States for both adults and children. While there have been gains in insurance coverage and primary health-care access and utilization across all racial and ethnic groups, disparities remain, especially for Latinos in states that have not expanded Medicaid. Moreover, among Latinos, disparities are particularly striking for Mexican and Central American subgroups and for noncitizen and undocumented immigrants. Any revision in the implementation of the ACA must consider these unremitting disparities, especially as the Latino population continues to grow and expand across the country. Some states, like California, are leading the way in implementing policies that ensure health care is a right afforded to all its citizens, which includes noncitizens who have been in the country for less than five years and undocumented immigrants, and this should be a model for national health-care reform.