Friday, March 6, 2015

Affordable Care Act and Disparities in Access

A new research brief from the Commonwealth Fund focuses on the potential relationship between the Affordable Care Act and a variety of measures of disparities.  In short, the authors of the brief used data from the Behavioral Risk Factor Surveillance System to look at the relationship between insurance and several outcomes that may be expected to change after the affordable care act.  These outcomes were not having a usual source of care and foregoing care because of cost.  The Behavioral Risk Factor Surveillance System is a survey administered by the Centers for Disease Control in coordination with state departments of health to hundreds of thousands of respondents each year.

For the two outcomes of interest, the assumption is that having a usual source of care is better and that foregoing care because of cost is not a good thing.  Before we look at the implications of the Affordable Care Act it is worth thinking just a little more about those two issues.  

First, having a usual source of care is supposed to increase the provider's awareness of the conditions a patient has and, as a result, enable the provider to offer better care. That is important for chronic conditions.  It may not be as important for purely acute events. A key question is at what point it is useful/necessary to establish a relationship with a provider who will become a usual source of care, so that when a person has a chronic condition at some point they will get the best care possible.  Does one need to have a long-term and usual source of care before the incidence of the chronic condition or would it suffice to establish a usual source at the time of the incidence of the chronic condition.  In general, the expectation is that a longer relationship is better.  

As for going without care as a result of cost, that is an even more interesting question.  Specifically, as an economist, I would say that price is supposed to lead people to forego some services.  That is the role of price in a market economy.  Some people cannot afford some things and so they do not consume them.  The trick, of course, is whether the average person can ascertain whether the care that she went without was necessary care or was discretionary care.  We want people to think about the medical and health care resources they are using and to not assume that everything has zero opportunity cost.  But we don't want people to forego necessary care now that could potentially help to control costs later.  This is a tough question to address.  But, I am willing to accept that there is an issue if people feel they are not able to get care simply because of cost.  It is a signal of something important, although economists may debate just how important.

Not surprisingly people who have insurance are more likely to have a usual source of care and less likely to fail to get care because of cost.  Not only are the negative outcomes less likely but the disparity among individuals of different races and ethnicities decreases.  

There are also reports of the Affordable Care Act leading to more insurance--not surprisingly--and diminishing the racial disparities in insurance.

Thus, if the newly insured individuals behave and have success at accessing care that is similar to those who were already insured, we would expect to see the existing racial disparities diminish.  This would be a very positive outcome.  The key question is whether the rest of the system will adapt and evolve in ways to make finding a usual source of care and obtaining care as easy for the newly insured as for those who have historically had insurance.  Even the authors of the brief are careful to title their piece in a way that reflects that the past results may not reflect future outcomes. 

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