The Affordable Care Act (ACA) improved health care access among people with certain disabilities, decreasing the share of people lacking insurance and increasing the likelihood they had a regular health care provider, according to new research published in the American Journal of Public Health. However, people with severe mental health conditions – a group with particularly high barriers to care – did not see such improvements.
“I came at this study from the perspective of, how did the ACA affect people with disabilities, and is there evidence that the particular provisions that seemed to me to be most targeted toward people with disabilities actually impacted them?” says H. Stephen Kaye, the study’s author and a professor at the Institute for Health & Aging and the Department of Social and Behavioral Sciences at the University of California, San Francisco.
While some might assume all people with disabilities are covered by Medicaid or Medicare, he explains: “This isn’t true — quite a few people don’t qualify for public coverage just by virtue of having a disability.”
Kaye explains that some adults with disabilities are eligible for Medicare or Medicaid because they can’t work. But some don’t qualify, either because they can work or because their inability to work is not recognized as such by the federal government. Those individuals can face challenges obtaining adequate, affordable insurance coverage if they are unemployed or work low-skill jobs that do not provide insurance benefits.
The Affordable Care Act is a federal statute signed into law by President Barack Obama in 2010. Prior to its passage, disabled individuals not eligible for Medicaid or Medicare saw challenges in obtaining insurance, including: reduced access to employer-provided coverage; exorbitant costs; and rejection by insurance companies on the basis of pre-existing health conditions.
The ACA expanded Medicaid coverage, eliminated insurance companies’ ability to decline coverage to those with pre-existing conditions and subsidized the cost of private insurance for moderate-to-low-income people.
To gauge whether these provisions had an impact on people with disabilities’ insurance status and access to care, Kaye looked at nationally representative interview data from the National Health Interview Survey, which asks 95,000 respondents yearly about topics including health conditions, insurance coverage and health care use.
Kaye analyzed six years of data from this survey – three years from the pre-ACA period (2008-2010) and three years from the post-ACA period (2015-2017). He focused on three outcomes in his study: rates of lack of insurance (measured by whether the respondent went without coverage at any point in the previous 12 months), delayed or forgone care (measured by whether respondents reported delaying or forgoing care because of cost concerns) and regular health care provider (as measured by whether respondents reported having a doctor’s office or clinic that they typically frequent for care).
Kaye measured disability through affirmative answers to survey questions about limitations in activities stemming from a physical, mental or emotional cause. Additionally, if respondents reported that mental health symptoms interfered “a lot” with activities, Kaye also classified those subjects as having disabilities.
Kaye subdivided the population of people with disabilities into four groups: people who need help with activities of daily living (these individuals have significant disabilities – they might qualify for an “institutional level of care,” and might have been eligible for Medicaid on this basis prior to the passage of the ACA); people whose disabilities prevent them from working (these individuals might also have been eligible for Medicaid or Medicare on these grounds prior to the passage of the ACA); other mental health disability (people who “either identify a mental health condition as causing activity limitation or who indicate that mental health interferes with their lives or activities ‘a lot.’”); and other physical or cognitive disability.
Here’s how the groups fared before and after the passage of the ACA:
Insurance
- People who needed help with activities of daily living, people whose disabilities prevented them from being able to work and people with other physical or cognitive disabilities were more likely to be insured after the ACA was enacted, as compared with before.
- Uninsurance rates, however, decreased almost entirely across the board after the ACA went into effect. The only group that had reductions in uninsurance levels beyond those seen in the nondisabled population was the “other” physical or cognitive disabilities population.
- After the ACA, people with other mental health disabilities saw increased rates of uninsurance as compared with before.
Delayed or forgone care
- People with disabilities saw across-the-board reductions in delayed or foregone care after the ACA was enacted as compared with before. However, both before and after the ACA was enacted, people in all categories of disabilities still were more likely to have delayed or forgone care than people without disabilities. “It’s always been a problem that people with disabilities have lots of foregone care, lots of trouble getting needed care,” Kaye says. “On average, people with disabilities have a lot more encounters with the health care system — they need more health care. There are more opportunities for people not to get the services they need because their coverage isn’t adequate, because they can’t find knowledgeable providers.”
Regular provider
- Before the ACA, people with work limitations and disabilities that severely limit their activity were more likely to have a doctor’s office or clinic that they typically went to for care than people without disabilities. People with other physical or cognitive disabilities were slightly more likely to have a regular provider. People with mental health disabilities were less likely to have a regular provider than those without any disabilities.
- After the ACA, people with other physical or cognitive disabilities were more likely to have a regular provider than the nondisabled.
Other mental health disabilities
- Of all the disability groups, this group was the worst off both before and after the passage of the ACA. “This population has substantially greater risk of uninsurance, very much greater likelihood of delayed or forgone care, and less likelihood of having a regular provider compared with the nondisabled group,” Kaye writes.
“The ACA can thus be regarded as an imperfect success,” Kaye concludes in the paper. “Gains in coverage for some segments of the disability population can be attributed to provisions prohibiting coverage denial or restriction based on preexisting conditions, promoting greater affordability, and increasing the availability of public coverage. These reforms must not be rolled back or weakened.”
Kaye adds that if states that have not yet expanded Medicaid chose to do so, that could help reduce disparities affecting people with disabilities. He also notes that Medicaid work requirements would harm people with disabilities who are on Medicaid and cannot work but still are not deemed exempt from such requirements. Other safeguards for people with disabilities include protecting subsidies for private health insurance, maintaining the prohibition against excluding people with pre-existing conditions and making sure that health insurance continues to provide comprehensive coverage, Kaye says.
For journalists hoping to cover the issue in more depth, Kaye suggests looking into the role disability advocates have played in protecting the ACA. He also recommends covering proposed rulemaking by the U.S. Department of Health and Human Services that would roll back part of the ACA — Section 1557, which currently provides nondiscrimination protections for people with disabilities and other minority groups in health care settings.