Beyond Health Insurance: Remaining Disparities in US Health Care in the Post-ACA Era

Policy Points:

1. In a national survey of approximately 8,000 adults in 2015, we found large income‐ and race‐based disparities in perceived health care quality, affordability, and use of emergency departments.

2. Lack of health insurance is one factor that contributes to worse health care experiences among lower‐income Americans and racial/ethnic minorities, but it only explains a small to moderate portion of these disparities.

3. While the Affordable Care Act has led to significant improvements in health care access and affordability, large gaps remain. Repeal of the law would undo much of this progress, but even if the law remains in effect, policymakers need to address other social determinants that contribute to ongoing income‐ and race‐based disparities in health care.

Context: The Affordable Care Act (ACA) has reduced the US uninsured rate to a historic low. But coverage is only one of many factors contributing to race‐ and income‐based disparities in health care access, affordability, and quality.

Methods: Using a novel 2015 national survey of more than 8,000 Americans, we examined disparities between low‐income and high‐income adults and between racial/ethnic minorities and whites. We conducted a series of regression analyses, starting with models that only took into account income or race, and then sequentially adjusted for health insurance, state of residence, demographics, and health status. We examined self‐reported quality of care, cost‐related delays in care, and emergency department (ED) use due to lack of available appointments. Then we used multivariate regression to assess respondents’ views of whether quality and affordability had improved over the past 2 years and whether the ACA was helping them.

Findings: Quality of care ratings were significantly worse among lower‐income adults than higher‐income adults. Only 10%‐25% of this gap was explained by health insurance coverage. Cost‐related delays in care and ED use due to lack of available appointments were nearly twice as common in the lowest‐income group, and less than 40% of these disparities was explained by insurance. There were significant racial/ethnic gaps: reported quality of care was worse among blacks and Latinos than whites, with 16%‐70% explained by insurance. In contrast to these disparities, lower‐income and minority groups were generally more likely than whites or higher‐income adults to say that the ACA was helping them and that the quality and/or affordability of care had improved in recent years.

Conclusions: Our post–health reform survey shows ongoing stark income and racial disparities in the health care experiences of Americans. While the ACA has narrowed these gaps, insurance expansion alone will not be enough to achieve health care equity.