Racial/Ethnic and Gender Disparities in Health and Behavioral Health Care Utilization: Implications of the Affordable Care Act

Background and Purpose: The implementation of the 2010 Patient Protection and Affordable Care Act (ACA) offers new opportunities to improve the quality of care, reduce costs, and increase access to health care, in an effort to reduce disparities, including those related to race/ethnicity and gender. The majority of health care-related studies to date have explored racial and ethnic and gender differences separately. Minority groups of dual stratification systems such as race and ethnicity and gender may be at greater risk for disparities, yet few studies have examined the intersection of gender and race and ethnicity in the context of health service use and access. This study examines trends in race/ethnicity and gender disparities in health service utilization from 2006-2014, a 9-year period during which time the ACA was implemented. 

Methods: The analytic sample includes adult respondents aged 18 years and older surveyed from the 2006-2014 National Health Interview Survey (NHIS; N=257,560). Conducted annually, the NHIS is nationally representative of the civilian, non-institutionalized population in the United States. The NHIS uses a multistage area probability sampling design to select approximately 35,000 households including about 87,500 persons each year. Weighted linear probability models were used to estimate changes in service utilization under the ACA. Models controlled for key predisposing, need, and enabling factors.

Results:Results show modest improvement but also notable declines in health and mental health care use for specific racial/ethnic and gender groups. Significant improvement in office visits was found for all males, regardless of race/ethnicity, with the largest improvement (increase of 10.4 percentage points) among Asian males (p<.01). In adjusted models, there were significant increases in office visits for white and Asian males (increases of 2.2 and 7.2 percentage points, respectively; p<.01). Although Hispanic females experienced an increase in mental health visits during the study period, the magnitude of this difference was lower and not significant in the adjusted model. No other significant changes in mental health visits among the analytic groups were found. Adjusted models showed a significant reduction in emergency room visits was found among white males and females. However, a significant increase by 3 percentage points was found among black females (p<.01). Similar increases in unmet need were found among black males and females (increases of 2.1 and 2.5 percentage points, respectively; p<.01), controlling for observed changes in these groups from 2006 to 2014.

Conclusions and Implications: The current study found differential patterns of health and mental health service use based on race/ethnicity and gender. With few exceptions, little has changed in health care use and access over the 9-year study period. Although there were modest improvements in health care access for primarily white respondents, there were notable declines or no change at all in access for historically underserved groups. Ongoing research is needed to track both racial/ethnic-related and gender disparities to determine whether existing efforts under the ACA, such as insurance coverage, provider training, integrated care, care coordination, and other initiatives lead to reduction in these disparities.