Disparities in Utilization of Preventive Care: Does the Elimination of Cost-Sharing in the Affordable Care Act Have a Differing Effect on Certain Populations?

Approximately one in every three children is overweight or obese, which predisposes them to chronic disease, and almost one out of every two adults in the U.S. has a chronic illness, many of which are preventable. Preventive care is a particularly high-value health care service in the realm of public health; increased focus on prevention will not only improve health outcomes, but will also reduce health care costs and improve quality of care. However, utilization of preventive services is a complex issue. In general, access measured in terms of utilization depends on availability of services, affordability, mobility (i.e. physical accessibility) and community-level attitudes and values. A population is often defined as “having access” to health care if services are available in adequate supply (i.e. individuals have an opportunity to obtain health care). Whether a population can actually “gain access” also depends on financial, organizational and social or cultural barriers that limit the utilization of services. Thus, in addition to increasing availability of preventive services, it is equally important to understand whether “access” has a differing effect on specific populations, and how these differences may translate into disparities in health care utilization.

This study uses the Patient Protection and Affordable Care Act (ACA) and Medical Expenditure Panel Survey (MEPS) data to examine preventive health care utilization both before and after the act was implemented. Cost-sharing, one aspect of utilization, creates an economic dis-incentive to access services, such that use of preventive services will likely decline when cost-sharing is imposed. Evidence from several studies that focus on mammography, colorectal cancer screening, and other types of preventive services suggests that cost-sharing for preventive services may discourage use; thus, it also seems reasonable to suspect that the reverse may also be true (i.e. use may increase when cost-sharing is eliminated). Other research has demonstrated cost-sharing-related disparities among certain groups. For instance, increased cost-sharing has been associated with adverse health outcomes in vulnerable groups such as low-income populations. This study builds upon existing research using MEPS data to look at the relationship between implementation of the ACA and preventive service utilization by examining whether this exogenous policy change had a differing effect on utilization by certain groups. Ten types of preventive services are evaluated across five specific group types, and the extent to which existing disparities were impacted is analyzed.

Preliminary results indicate differing utilization of preventive services pre- and post-ACA by race, income (percentage of federal poverty level, FPL), education and type of insurance. For instance, likelihood of receipt of blood pressure screening, cholesterol testing, the influenza vaccine and a wellness exam was particularly significant for whites (vs. non-whites), high-income individuals (>400% of the FPL), well-educated individuals, and individuals with private insurance (vs. public/ no insurance). Results for disparities are mixed; for example, a reduction in disparities is more often observed among income and education groups, while race and insurance differences remain large. A differing impact of the ACA on certain groups, in particular for vulnerable populations, has important implications for future policy.