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Work Remains for ACA to Fully Address Disparities Linked to Disabilities, Study Says


For people with disabilities, the Affordable Care Act (ACA) helped to reduce uninsurance and healthcare that was delayed or never received, but it did not totally eliminate disparities, according to new research.

For people with disabilities, the Affordable Care Act (ACA) helped to reduce uninsurance and healthcare that was delayed or never received, but it did not totally eliminate disparities, according to new research published in The American Journal of Public Health.

Using nationally representative data from the National Health Interview Survey (NHIS), Stephen Kaye, PhD, a professor at the Institute for Health and Aging, University of California San Francisco, examined the landmark health law’s effect on disparities in access to healthcare based on disability status, as well as age, income, race, and ethnicity. He called the law “an imperfect success” and said steps should be taken to strengthen it to help this population, such as expanding Medicaid.

“Access to healthcare for people with disabilities has been a problem for a long time, especially for people who don’t have the kind of disability that qualifies them for public coverage,” Kaye said in an interview with The American Journal of Managed Care®. “I had been curious to see if the Affordable Care Act improved that access or not.”

The NHIS sample, consisting of 128,000 respondents, covered the years from 2008 to 2010, the period before the law, and from 2015 to 2017, after the law was fully implemented.

Access to healthcare was measured by uninsurance over the previous 12 months, delayed or forgone healthcare for reasons of cost, and having a regular provider.

“People with disabilities that are deemed significant enough that they are deemed unable to work get public insurance often,” Kaye said. That happens through 1 of 2 ways: access to Medicaid, or access to Medicare if receiving Social Security Disability Income (SSDI).

His study used 4 disability levels: the top 2 included those whose highly activity-limiting disabilities might qualify them for public health coverage through Medicaid or SSDI. One category was comprised of people needing help in activities of daily living (ADL), such as dressing, bathing, and eating. The other category, those who don’t need ADL help, included people who report that “a physical, mental, or emotional problem” keeps them out of the workplace.

These 2 groups have no guarantee of public coverage, however. According to the National Alliance on Mental Illness, most claims are rejected, although most are also appealed.

And not everyone with a disability is covered, either because the disability is not considered severe enough to qualify or they may never apply. This applies to the 2 other categories in the study, those with “other mental health disability,” or people who report that they have a mental health condition that limits activity or who indicate that mental health interferes with their lives or activities “a lot.” The category “other physical or cognitive disability” made up the rest of the population.

At the same time, the “other” category is the one that most often suffers from some of the highest rates of uninsurance, for the typical reasons that people lack insurance, Kaye said: being underemployed, not being employed at all, or working part-time jobs that don’t offer coverage.

Even for those with insurance, other healthcare access issues remain; delayed or forgone care “has been a problem for people with disabilities, kind of across the board, for a long time,” he said. “The more healthcare you need, the more likely you are, I think, to go without services that you need, especially if you’re not wealthy.”

His study found that before the ACA, the highest uninsurance rates were seen among people with incomes below twice the federal poverty level (FPL), with adjusted odds ratios of 8.09 and 7.92 for 2 categories of income just below and above the FPL (P < .001). Rates were also significantly higher among those aged 19 to 25 years, Latinos, American Indians and Alaska Natives, and people with other mental health disabilities.

Those in the highest income category, people needing ADL help (and thus more likely to have public coverage), and people in the highest age group (55 to 64 years), had the lowest rates of uninsurance.

After the ACA was implemented, those aged 19 to 25 years no longer had high rates of uninsurance rates. Although Latinos and individuals under twice the FPL all achieved gains, these groups continued to experience high uninsurance, as did American Indians and Alaska Natives.

What worked? The ACA increased coverage for some of those considered disabled through its protections around pre-existing conditions; although having a disability is separate and distinct from having a pre-existing condition, there is overlap between the two, the study noted. The law also promoted greater affordability and increased the availability of public coverage.

The law reduced disparities based on income, age, and disability status, but substantial disparities remain, the study said. Disability status remains associated with much greater risk of delayed or forgone care, and mental health disability is associated with greater likelihood of uninsurance.

“People with disabilities really have benefitted from the prohibitions against charging them more,” said Kaye. Although his study did not touch on the issue directly, he also noted that they also benefitted from the Medicaid expansion.

“I think weakening the pre-existing condition prohibitions, the prospect of that, to the extent that it’s been done already, is a real danger for the gains that people with disabilities have experienced,” he said. "Not expanding Medicaid at all, or expanding it only with work requirements, is really dangerous for people with disabilities,” Kaye said.


Kaye HS. Disability-related disparities in access to health care before (2008—2010) and after (2015–2017) the Affordable Care Act [published online May 16, 2019]. Am J Public Health. doi: 10.2105/AJPH.2019.305056.

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