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Financial Barriers to Care Among the Insured in Massachusetts after Healthcare Reform: Disparities by Race and Income
Massachusetts’ 2006 healthcare reform, the model for the Affordable Care Act (ACA), aimed to increase coverage and access to healthcare by making care affordable – particularly for minorities and low-income individuals. Little is known about the post-reform prevalence of cost-barriers to care among the insured in Massachusetts (MA).
Methods:
We analyzed data from the Behavioral Risk Factor Surveillance System on insured MA residents, ages 18-65, pre-reform (2004-2005) and post-reform (2009-2010). We considered respondents to have a cost-barrier to care if they indicated that within the last 12 months they needed to see a doctor but could not because of cost. We assessed rates of cost-barriers to care overall and by racial/ethnic and income groups using bivariate analysis. We also conducted a multivariate logistic regression to determine the independent effects of race and income on cost-barriers to care after adjusting for other covariates. We determined if there was an improvement in cost-barriers in MA compared to nearby control states using a difference-in-difference analysis with linear probability regression. Lastly, we examined the association between cost-barriers and receiving certain routine health services.
Results:
Post-reform, financial barrier rates varied by race and income group - with the highest rates in low-income minority individuals. Among persons with incomes below $15,000, 24.9% of Blacks and 24.2% of Hispanics reported cost-barriers versus 9.8% of Whites (p=0.011). In multivariate analyses, lower-income individuals reported more cost-barriers than those with incomes over $50,000 (<$15,000: OR=4.23; 95%CI=2.73-6.56, $15,000-$34,999: OR=4.06; 95%CI=3.05-5.40) as did Hispanics compared to Whites (OR=1.47; 95%CI=1.06-2.04). Relative to control states, cost-barriers to care among people with insurance in MA improved by 1.1% (p=0.025). Women reporting cost-barriers were less likely to receive a pap smear (OR=0.42; 95%CI=0.24-0.72) and women over 50 were less likely to receive a mammogram (OR=0.32; 95%CI=0.17-0.62).
Conclusion:
Although there was a small improvement in cost-barriers to care for insured individuals after implementation of healthcare reform in MA, among insured minorities and insured low-income residents cost-barriers are common. Furthermore we found that cost-barriers are associated with lower odds of receiving some health services. While we know that insurance improves access to care and health outcomes, high cost-sharing can make physician visits unaffordable. We predict that high cost-sharing under the ACA and new cost-sharing in some state Medicaid plans is likely to perpetuate disparities in access to care nationwide.
Learning Areas:
Provision of health care to the publicPublic health or related laws, regulations, standards, or guidelines
Public health or related public policy
Learning Objectives:
Analyze cost-barriers to care among insured minorities and insured low-income individuals in Massachusetts after state healthcare reform?
Compare cost-barriers to care among insured individuals in Massachusetts to control states before and after Massachusetts healthcare reform?
Keyword(s): Health Care Access, Low-Income
Qualified on the content I am responsible for because: I am a general internal medicine fellow at Harvard Medical School and the Cambridge Health Alliance doing research in health disparities and access to care. After completing my residency in internal medicine and because interested in public health so now I am also a graduate student at the Harvard School of Public Health.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.