JANUARY 2016 Insight on the Issues Monitoring the Impact of Health Reform on Americans Ages 50–64: Access to Health Care Improved during Early ACA Marketplace Implementation Laura Skopec Jane Sung Timothy A. Waidmann Olivia Dean Urban Institute AARP Public Policy Institute This Insight on the Issues is the latest in a series that looks at the experience of 50- to 64-year- olds during implementation of the Affordable Care Act (ACA). New data from the Urban Institute and the AARP of Medicine 2009; Artiga et al. 2015). Our previous Public Policy Institute show improvements in paper in this series reported a 47 percent reduction key measures of access to health care for 50- to in the uninsured rate among 50- to 64-year-olds 64-year-olds over the first two open enrollment between December 2013 and March 2015 (Skopec periods of the Affordable Care Act (ACA). Between et al. 2015). Several measures of access to care December 2013 and March 2015, the share of 50- to improved alongside increases in coverage, as 64-year‑olds with a usual source of health care other examined in this paper. than emergency rooms increased. Concurrently, Access to health care and health insurance coverage the share who reported having a problem accessing are important to addressing health care needs health care decreased. and improving health outcomes among 50- to These measures of health care access improved 64-year‑olds. Prior research has shown that an most in states that chose to expand their Medicaid estimated 64 percent of adults ages 50–64 suffer programs under the ACA. However, despite these from a chronic condition (Collins, Doty, and Garber early improvements, certain vulnerable populations 2010). Uninsured adults with chronic conditions remain more likely to experience difficulties such as hypertension and diabetes are more likely accessing care. to have their conditions underdiagnosed or poorly controlled and are more likely to suffer poor HEALTH COVERAGE CORRELATED WITH IMPROVED outcomes than those with insurance (Institute of ACCESS AND BETTER HEALTH OUTCOMES Medicine 2009). Health coverage also increases the Health insurance coverage is associated with likelihood of having a usual source of care. One improved access to and use of health care (Institute JANUARY 2016 study found that adults with a usual source of care the same period, the share of 50- to 64-year‑olds and health care provider were more likely to receive reporting a problem accessing care dropped preventive care such as cancer screenings and flu from 16.8 percent to 14.5 percent, and the share shots (Blewett et al. 2008). Other studies found experiencing a delay in care due to difficulty that adults without a usual source of care are less getting an appointment dropped from 11.7 percent likely to receive treatment for hypertension or high to 9.4 percent (figure 2). These improvements cholesterol (Spatz et al. 2010) and are more likely to were concentrated in states that chose to expand have poorly controlled diabetes (Ali et al. 2012). eligibility for their Medicaid programs under the ACA (not shown), where the uninsured rate was RESULTS lowest in March 2015.1 Access to Care Improved for 50- to 64-Year-Olds Despite overall improvements in access between Between December 2013 and March 2015, over the December 2013 and March 2015, there was no first two ACA Marketplace open enrollment periods, change in some access measures. In March 2015, key measures of access to health care improved. The while 73.4 percent of 50- to 64-year-olds reported share of 50- to 64-year-olds with a usual source of having a routine medical checkup within the prior care other than emergency departments increased 12 months, this was not a significant change from from 78.9 percent to 82.4 percent (figure 1). Over December 2013 (not shown). Similarly, between FIGURE 1 FIGURE 2 50- to 64-Year-Olds with a Usual Source of 50- to 64-Year-Olds with Trouble Accessing Care in December 2013 and March 2015 Care in December 2013 and March 2015 December 2013 December 2013 March 2015 March 2015 82.4%** 78.9% 16.8% 14.5%** 11.7% 9.4%** Had a problem Delayed care because accessing care couldn’t get an appointment Had a usual source of care Source: HRMS-AARP Public Policy Survey, December Source: HRMS-AARP Public Policy Survey, December 2013 and March 2015. 2013 and March 2015. Note: Data are not adjusted for changes in the Note: Data are not adjusted for changes in the characteristics of the sample population over time. Both characteristics of the sample population over time. measures in the figure above are over the past 12 months. ** March 2015 estimate is significantly different from ** March 2015 estimate is significantly different from December 2013 estimate at the 0.01 level using two- December 2013 estimate at the 0.01 level using two-tailed tailed tests. tests. 2 JANUARY 2016 December 2013 and March 2015, the share of 50- to FIGURE 3 64-year-olds who reported having trouble finding Access to Care Measures for 50- to 64-Year-Olds a doctor with availability, who were told a doctor’s with Continuous Coverage as of March 2015 office was not accepting new patients, or who were Continuous Coverage (Insured all of the past 12 months) told a doctor’s office did not accept their insurance type also did not change significantly.2 Partial-Year Coverage (Insured 1–11 of the past 12 months) Uninsured (Not insured any of the past 12 months) Individuals with Continuous Health Insurance Coverage Have Better Access to Care 85.2% As of March 2015, 50- to 64-year-olds with 75.0%** 77.0% continuous coverage (insurance all year) were more likely than those with no insurance or insurance 59.5%** for only part of the year to have a usual source of 50.9%** care other than emergency rooms and to have had a routine checkup in the past 12 months (figure 3). 35.0%** However, even with continuous coverage, a sizable portion of 50- to 64-year-old adults still report difficulty accessing health care services. Nearly 14 percent (13.9 percent) of 50- to 64-year-olds with continuous coverage report having a problem Had a usual source Had a routine checkup in accessing care, and 9.3 percent report delaying of care the past 12 months care due to difficulty getting an appointment (not shown). Although these figures were higher for Source: HRMS-AARP Public Policy Survey, March 2015. those with no insurance coverage or insurance for Note: Data are not adjusted for differences in health status, only part of the year, these numbers suggest that income, or other characteristics across groups. health insurance coverage is not the only factor that affects access to care. ** Estimate is significantly different from estimate for “insured all of the past 12 months” at the 0.01 level using Some Groups Still Experience More Difficulty two-tailed tests. Accessing Care Certain subgroups of 50- to 64-year-olds remain less likely to have a usual source of care or are more likely to report having experienced a problem likely to report difficulty in accessing care. These accessing care than those with incomes over disparities exist even among those with continuous 138 percent of the FPL. health insurance coverage (appendix table 1). In our •• Individuals in fair or poor health: Nearly a March 2015 survey, we found these disparities: quarter (22.7 percent) of insured 50- to 64-year‑olds •• Hispanics: Insured Hispanics were less likely in fair or poor health reported having a problem than insured non-Hispanic whites and blacks to accessing care, compared with 9.8 percent of those report having a usual source of care other than in excellent or very good health. emergency rooms. In fact, between December •• Individuals with public coverage: 50- to 2013 and March 2015, the data showed no 64-year-olds with public coverage (Medicare significant improvements in this measure of and Medicaid) were more likely to report a access to care for Hispanic 50- to 64-year-olds. problem accessing care than those with private •• Individuals with family incomes at or below coverage. They were also more likely to report 138 percent of the Federal Poverty Level (FPL): a delay in care due to difficulty getting an Insured 50- to 64-year-olds with family incomes appointment than those with private coverage. at or below 138 percent of the FPL were more (Many individuals with private coverage are 3 JANUARY 2016 more likely to have higher incomes and fewer vulnerable populations understand and select health problems, so this disparity may in part be the most suitable coverage for their financial and attributable to other factors.) health needs and how to access care. Hispanics, low-income adults, and those in fair or •• Support education efforts to improve health poor health are still more likely to be uninsured and literacy among vulnerable populations and newly experience more difficulty affording care than their insured individuals. counterparts, as noted in other papers in this series. •• Encourage adoption of electronic health records and expand use of health information CONCLUSION AND POLICY RECOMMENDATIONS technology.3 As the uninsured rate among 50- to 64-year-olds fell by nearly half between December 2013 and March •• Improve and enforce requirements for health 2015, access to care among this group improved. plans to ensure timely access to care and access to Our findings are consistent with prior research an adequate number of in-network primary care among all adults showing that coverage increases physicians and specialists.4 access to care (Institute of Medicine 2009). •• Fund continual research to determine existing However, the gains in insurance coverage have not and emerging disparities in access to and translated into across-the-board improvements in affordability of care, and identify best practices in access to health care services. Disparities in access addressing these disparities. to care continue to exist among 50- to 64-year-olds. •• Improve access to health care in rural and Among those with continuous insurance coverage, underserved areas by those who are Hispanic, low-income, receiving ——Providing incentives and assistance in public coverage, or in fair or poor health are more recruiting and retaining health care personnel likely to face barriers in access to care. in underserved areas; Timely access to health care services may require ——Providing funding for and technical assistance more than health insurance coverage alone. to rural and community health centers;5 Other financial and nonfinancial barriers may affect access, such as lack of transportation ——Supporting development of alternative or time off work, poor coverage plan designs strategies to provide access to health care, such that make selecting the most appropriate plan as telemedicine and improved transportation difficult, language and literacy barriers, lack of resources; and information and resources for efficiently accessing ——Improving language access services and health care systems, provider unavailability and promoting cultural competency among unresponsiveness, and high out-of-pocket costs. providers. Barriers to accessing care could present major APPENDIX challenges for managing chronic conditions and coordinating care, particularly for those in fair or Data and Methods poor health. To build upon gains in access for 50- to This analysis uses data collected by the Urban 64-year-olds and to reduce disparities for vulnerable Institute’s Health Reform Monitoring Survey subgroups, federal and state policy makers should (HRMS), a quarterly Internet-based survey of adults consider the following policy ideas that have been under the age of 65 designed to provide rapid shown to improve health care access: feedback on implementation of the ACA before data from federal surveys are available. The survey data •• Support expansion of community-based used for this paper and other analyses in AARP initiatives that address social determinants of Public Policy Institute’s “Monitoring the Impact of health and integrate health and social services. Health Reform on Americans Ages 50–64” series •• Target education and outreach efforts to help are from oversamples of 50- to 64-year-old adults 4 JANUARY 2016 (HRMS-AARP Public Policy). The Urban Institute The HRMS-AARP Public Policy is weighted to be and GfK Custom Research conducted the survey, nationally representative. Results presented here and AARP Public Policy Institute provided funding were not adjusted for changes in the demographic to increase the sample size for this age group. GfK characteristics of the HRMS-AARP Public Policy Custom Research fielded the HRMS-AARP Public sample between December 2013 and March 2015. Policy oversample survey in December 2013, March Comparisons within subgroups were not adjusted 2014, December 2014, and March 2015 and included for socioeconomic, geographic, or health status approximately 8,000 adults ages 50 to 64 for each differences across groups. More information on the survey period. HRMS is available at http://hrms.urban.org/. APPENDIX TABLE 1 Access to Care in March 2015 for 50- to 64-Year-Olds with Continuous Coverage, by Demographic Characteristics, Insurance Type, and Self-Reported Health Status Delayed Had Any Care Due Had a Usual Problem to Difficulty Source of Had a Routine Accessing Getting an Indicator Care Checkup Care Appointment Male^ 83.9% 74.6% 13.2% 9.0% Gender Female 86.3%* 79.1%** 14.5% 9.6% At or below 138% FPL^ 82.6% 79.0% 21.0% 11.6% Family Income 139%–399% FPL 83.3% 76.0% 14.7%** 9.7% At or above 400% FPL 87.1% 77.0% 11.3%** 8.4%* White, non-Hispanic^ 85.7% 75.2% 14.0% 9.5% Race and Black, non-Hispanic 89.9%** 86.7%** 11.3% 7.1% Ethnicity Other, non-Hispanic 79.6%* 75.8% 14.1% 9.4% Hispanic 79.7%** 80.2%* 15.4% 10.0% Private^ 85.0% 75.6% 12.4% 8.8% Insurance Type Public 85.8% 84.0%** 21.2%** 11.8%* Excellent or very good^ 84.7% 73.4% 9.8% 6.8% Self-Reported Good 84.6% 77.8%** 14.8%** 9.7%** Health Status Fair or poor 87.5% 84.6%** 22.7%** 15.1%** Source: HRMS-AARP Public Policy Survey, March 2015. Note: Data are not adjusted for differences in health status, income, or other characteristics across groups. Continuous coverage is defined as insured for all of the 12 months prior to March 2015. All measures of access to care are over the past 12 months. ^ denotes reference population. */** Estimate is significantly different from estimate for reference population at the 0.05/0.01 level using two-tailed tests. 5 REFERENCES 1 There was no significant change in the share of 50- to Ali, Mohammed K., Kai McKevver Bullard, 64-year-olds with a change in their source of care or in the share of 50- to 64-year-olds who had trouble accessing care Giuseppina Imperatore, Lawrence Barker, and in states that did not expand Medicaid. Edward W. 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