Early Improvements in Access to Health Care and Equity after Affordable Care Act Enrollment in King County, Washington

BACKGROUND:  The Affordable Care Act (ACA) aims to transform the health insurance and health care landscape in the United States to drive progress towards the Triple Aim of better health and better quality of care at a lower cost. Public Health–Seattle & King County has developed a framework to measure the local impacts of ACA enrollment on health care and health equity to meet the information needs of multiple stakeholder groups, including local policymakers and the public.  

METHODS:  Multiple data sources and approaches were used to measure changes in access to health care after the ACA: i) pre-ACA (2008-2013) versus post-ACA (2014) non-elderly adult health insurance coverage using the American Community Survey, ii) pre-ACA (2000-2013) versus post-ACA (2013-2014) trends in non-elderly adult access to care, utilization of care, patient satisfaction, and population health measures using the Behavioral Risk Factor Surveillance System (BRFSS), iii) pre-ACA (2006-2013) versus post-ACA (2013-2014) trends in medical and dental uninsurance rates among clients of King County’s Federally Qualified Health Centers (FQHCs), and iv) pre-ACA (2013) versus post-ACA (2014-2015) availability of Medicaid-contracted primary care providers (PCPs) to accept new adult Medicaid members.  Changes were considered in both absolute and relative disparities. Logistic and linear regression were used to identify pre-ACA linear trends, an adjusted Wald test to identify significant pre-post changes in BRFSS-based measures and PCP availability, and a two-proportion z-test for the FQHC, insurance coverage, and disparity analyses. 

RESULTS:  In 2014, uninsurance rates dropped significantly in both the general non-elderly adult and FQHC patient populations in King County. The largest reductions in uninsurance rates were experienced by adults, Seattle residents, non-Hispanic adults, low-income adults, and unemployed adults. Among FQHC patients, place- and age-based medical and dental insurance disparities decreased; race-based disparities increased for medical insurance but decreased for dental insurance. The availability of PCPs accepting adult Medicaid members fell between 2013/2014 and 2015, but appointment wait times did not increase. 

CONCLUSIONS:  Although uninsurance rates and disparities dropped significantly in King County after 2014 ACA implementation, there are still eligible low-income residents. Race-based disparities in medical coverage worsened among FQHC patients, likely driven in part by system-level access to care barriers related to immigration and residency status. Fragmented data leading to limited data access continues to limit local health reform evaluation and measurement of progress towards equity, and highlights the need for increased data sharing and transparency, as well as cross sector and cross agency collaboration.