Trends in Access to Care Among Workers with Disabilities, 1997-2011, and Implications for the ACA Reforms

The Patient Protection and Affordable Care Act of 2010 fundamentally altered the avenues for obtaining health insurance in the United States, especially for those with low incomes or without insurance provided by an employer. These changes may be particularly salient for workers with disabilities, who may not have enough of an attachment to the labor force to obtain employer-sponsored benefits, yet potentially be ineligible for public benefits from Medicare or Medicaid due to earnings that exceed eligibility thresholds. A better understanding of the profile of workers with disabilities and the extent to which they might enroll in Medicaid expansions or private coverage through the health insurance exchanges now being established may help to ultimately tailor the package of benefits to meet their needs.

To best predict the likely effects of the ACA, we first need examine the situation for workers with disabilities prior to its enactment. In this study, we document disparities along multiple measures of cost-based and structural access to care between workers with disabilities and their nondisabled counterparts. We consider the 15-year period from 1997—2011 using data from the National Health Interview Survey (NHIS). During this time, changes from the Americans with Disabilities Act (ADA) were widely in place and policies stemming from the Ticket to Work and Work Incentives Improvement Act of 1999 were being implemented to encourage employment among adults with disabilities. Yet, at the same time, the employment rate of individuals with disabilities relative to their non-disabled counterparts fell.  Thus, workers with disabilities may have faced an ever-changing landscape of insurance coverage options and consequently, access to care.

Workers with disabilities differ from their peers along a number of dimensions; for example, they tend to be older, in worse health, and less often employed in full-time salaried positions. The relative differences between the two groups also changed during our period of study for the reasons described above. We consider the extent to which observable differences among workers by disability status and changes in those characteristics over time affected access disparities. Using predicted probabilities from logistic models, we document disparities in access to care for workers with disabilities and their peers based on income relative to the federal poverty line, insurance status, and firm characteristics. Each of these groups was selected to correspond as closely as possible to the policy changes enacted under the ACA.

Preliminary analysis indicates that disparities accessing care among workers with disabilities relative to their nondisabled counterparts persisted even after controlling for differences in individual characteristics. While reported rates of access difficulties are higher among certain subgroups (such as the uninsured and those with the lowest income), the relative size of the disparity remains approximately constant across subgroups. Future work will consider the extent to which access differentials reflect the volume of use and/or the types of services covered by insurance plans. Using this information, we intend to provide insight about the extent to which we can expect access to be improved among workers with disabilities in the years to come.