Impact of the Affordable Care Act on Health Care Access and Utilization Among Latinos

Héctor E. Alcalá; Jie Chen; Brent A. Langellier; Dylan H. Roby; Alexander N. Ortega

doi:10.3122/jabfm.2017.01.160208

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Figure 1.
Rates of access and utilization measures, by heritage group. Data from the 2011 to 2015 National Health Interview Survey (N = 86,467).

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Table 1.

Sample Characteristics, by Heritage Group, 2011 to 2015 National Health Interview Survey (N = 86,467)

	Total (n = 86,467)		Non-Latino White (n = 65,703)		Puerto Rican (n = 1,995)		Mexican (n = 12,983)		Cuban (n = 871)		Central American (n = 3,592)		Other Latino (n = 1,323)		P Value
	n	%	n	%	n	%	n	%	n	%	n	%	n	%	P Value
Year															.304
2011	16,632	19.24	12,506	19.03	391	19.60	2,561	19.73	178	20.44	721	20.07	275	20.79
2012	17,325	20.04	13,153	20.02	395	19.80	2,648	20.40	169	19.40	705	19.63	255	19.27
2013	17,036	19.70	12,882	19.61	401	20.10	2,592	19.96	188	21.58	708	19.71	265	20.03
2014	18,656	21.58	14,285	21.74	412	20.65	2,736	21.07	192	22.04	752	20.94	279	21.09
2015	16,818	19.45	12,877	19.60	396	19.85	2,446	18.84	144	16.53	706	19.65	249	18.82
Citizenship status															<.001
US-born	71,176	82.32	62,683	95.40	1,151	57.69	5,836	44.95	269	30.88	587	16.34	650	49.13
Naturalized	6,492	7.51	1,949	2.97	813	40.75	1,899	14.63	317	36.39	1,125	31.32	389	29.40
Non–US citizen	8,799	10.18	1,071	1.63	31	1.55	5,248	40.42	285	32.72	1,880	52.34	284	21.47
Interview language															<.001
English	81,206	93.92	65,574	99.80	1,841	92.28	9,843	75.81	473	54.31	2,436	67.82	1,039	78.53
Spanish	5,151	5.96	38	0.06	153	7.67	3,131	24.12	396	45.46	1,149	31.99	284	21.47
Other	110	0.13	91	0.14	1	0.05	9	0.07	2	0.23	7	0.19	0	0.00
Age (years)															<.001
18–24	9,794	11.33	6,828	10.39	274	13.73	2,004	15.44	80	9.18	451	12.56	157	11.87
25–34	18,736	21.67	13,384	20.37	478	23.96	3,441	26.50	158	18.14	964	26.84	311	23.51
35–44	18,638	21.56	13,136	19.99	468	23.46	3,564	27.45	210	24.11	980	27.28	280	21.16
45–54	19,301	22.32	15,207	23.15	412	20.65	2,387	18.39	250	28.70	731	20.35	314	23.73
55–64	19,998	23.13	17,148	26.10	363	18.20	1,587	12.22	173	19.86	466	12.97	261	19.73
Female sex	45,998	53.20	34,556	52.59	1,189	59.60	7,047	54.28	451	51.78	1,959	54.54	796	60.17	<.001
Married	44,919	51.95	34,401	52.36	710	35.59	7,002	53.93	435	49.94	1,849	51.48	522	39.46	<.001
Family income															<.001
<100% FPL	14,647	16.94	8,672	13.20	664	33.28	3,796	29.24	204	23.42	912	25.39	399	30.16
100–200% FPL	15,534	17.97	9,536	14.51	430	21.55	3,980	30.66	210	24.11	1,057	29.43	321	24.26
>200% FPL	56,286	65.10	47,495	72.29	901	45.16	5,207	40.11	457	52.47	1,623	45.18	603	45.58
Education															<.001
Less than high school	11,520	13.32	4,400	6.70	474	23.76	5,108	39.34	103	11.83	1,133	31.54	302	22.83
High school	20,410	23.60	15,027	22.87	566	28.37	3,410	26.27	282	32.38	806	22.44	319	24.11
Some college education	17,496	20.23	13,900	21.16	400	20.05	2,187	16.85	110	12.63	613	17.07	286	21.62
College degree	27,919	32.29	24,053	36.61	458	22.96	1,934	14.90	302	34.67	826	23.00	346	26.15
More than college degree	9,122	10.55	8,323	12.67	97	4.86	344	2.65	74	8.50	214	5.96	70	5.29
US Census region															<.001
Northeast	13,989	16.18	11,211	17.06	1,051	52.68	312	2.40	51	5.86	788	21.94	576	43.54
Midwest	19,662	22.74	17,808	27.10	195	9.77	1,386	10.68	24	2.76	188	5.23	61	4.61
South	28,387	32.83	21,104	32.12	567	28.42	4,168	32.10	733	84.16	1,544	42.98	271	20.48
West	24,429	28.25	15,580	23.71	182	9.12	7,117	54.82	63	7.23	1,072	29.84	415	31.37
Self-reported health status															<.001
Excellent	25,933	29.99	20,164	30.69	474	23.76	3,420	26.34	339	38.92	1,138	31.68	398	30.08
Very good	28,818	33.33	23,012	35.02	547	27.42	3,607	27.78	240	27.55	1,046	29.12	366	27.66
Good	21,582	24.96	15,290	23.27	558	27.97	4,174	32.15	170	19.52	1,048	29.18	342	25.85
Fair	7,776	8.99	5,430	8.26	318	15.94	1,468	11.31	95	10.91	306	8.52	159	12.02
Poor	2,358	2.73	1,807	2.75	98	4.91	314	2.42	27	3.10	54	1.50	58	4.38
Chronic conditions
Hypertension	20,223	23.39	16,374	24.92	470	23.56	2,339	18.02	203	23.31	516	14.37	321	24.26	<.001
Coronary heart disease	2,093	2.42	1,749	2.66	60	3.01	184	1.42	22	2.53	48	1.34	30	2.27	<.001
Heart condition/disease	4,853	5.61	4,223	6.43	113	5.66	349	2.69	32	3.67	81	2.26	55	4.16	<.001
Asthma	11,190	12.94	9,038	13.76	480	24.06	1,089	8.39	113	12.97	296	8.24	174	13.15	<.001
Cancer	5,125	5.93	4,639	7.06	82	4.11	277	2.13	18	2.07	64	1.78	45	3.40	<.001
Diabetes	5,914	6.84	4,266	6.49	208	10.43	1,093	8.42	55	6.31	175	4.87	117	8.84	<.001
Any functional limitation	26,012	30.08	21,145	32.18	715	35.84	2,958	22.78	163	18.71	654	18.21	377	28.50	<.001

FPL, federal poverty level.

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Table 2.

Odds of Access and Utilization of Health Care as a Function of Year, Heritage Group, Citizenship Status, and Interview Language, 2011 to 2015 National Health Interview Survey (N = 86,467)

	Insured		Delay in Care		Forgo Care		ED Use		Physician Visit
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Year
2011
2012	1.03	0.96–1.10	0.91	0.85–0.98	0.97	0.90–1.05	0.96	0.89–1.03	0.97	0.92–1.03
2013	1.02	0.95–1.10	0.81^*	0.75–0.87	0.90^{^†}	0.82–0.98	0.95	0.89–1.02	1.01	0.96–1.07
2014	1.43^*	1.32–1.55	0.75^*	0.69–0.81	0.77^*	0.70–0.85	0.92^{^†}	0.86–0.99	1.13^*	1.06–1.20
2015	1.82^*	1.68–1.98	0.63^*	0.58–0.69	0.67^*	0.61–0.73	0.93	0.86–1.01	1.03	0.97–1.09
Heritage group
Non-Latino white
Puerto Rican	1.05	0.90–1.22	0.86	0.72–1.03	0.94	0.78–1.14	1.42^*	1.24–1.63	0.90	0.79–1.02
Mexican	0.68^*	0.63–0.73	0.83^*	0.77–0.91	0.96	0.87–1.06	0.83^*	0.77–0.91	0.87^*	0.82–0.93
Cuban	0.98	0.75–1.29	1.08	0.88–1.34	1.33^{^†}	1.02–1.73	1.15	0.88–1.51	0.96	0.82–1.13
Central American	0.66^*	0.59–0.74	1.08	0.94–1.24	1.28^*	1.10–1.49	1.07	0.94–1.22	1.01	0.91–1.11
Other Latinos	1.01	0.84–1.22	0.92	0.75–1.13	0.99	0.79–1.24	1.25^{^†}	1.07–1.46	0.90	0.78–1.02
Citizenship status
US-born
Naturalized	0.86^*	0.78–0.95	0.96	0.86–1.07	1.03	0.90–1.17	0.92	0.83–1.01	1.09^{^†}	1.01–1.17
Non–US citizen	0.34^*	0.31–0.37	1.10	0.99–1.24	1.12	1.00–1.26	0.78^*	0.69–0.88	0.74^*	0.68–0.80
Interview language
English
Spanish	0.79^*	0.71–0.87	1.05	0.93–1.18	0.86^{^†}	0.75–0.98	0.62^*	0.55–0.71	0.80^*	0.74–0.87
Other	0.55^{^†}	0.31–0.98	0.61	0.29–1.31	0.53	0.27–1.04	0.80	0.35–1.82	0.80	0.55–1.17

Models also control for age, sex, marital status, family income, education, US Census region, self-reported health status, chronic conditions, and functional limitations.
↵* P < .01.
↵† P < .05.
CI, confidence interval; ED, emergency department; OR, odds ratio.

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Table 3.

Odds of Access and Utilization of Health Care as a Function of Year and Heritage Group Interaction Citizenship, 2011 to 2015 National Health Interview Survey (N = 86,467)

	Insured		Delay in Care		Forgo Care		ED Use		Physician Visit
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Heritage
Non-Latino white
Puerto Rican	1.05	0.88–1.26	0.97	0.78–1.19	1.16	0.93–1.44	1.59^*	1.36–1.85	0.94	0.81–1.09
Mexican	0.67^*	0.62–0.73	0.89^{^†}	0.81–0.98	1.00	0.89–1.12	0.81^*	0.74–0.89	0.85^*	0.79–0.91
Cuban	0.91	0.71–1.17	1.22	0.94–1.58	1.52^{^†}	1.10–2.10	1.32^{^†}	1.05–1.65	1.01	0.83–1.22
Central American	0.63^*	0.55–0.72	1.10	0.93–1.29	1.35^*	1.14–1.60	1.10	0.94–1.28	0.92	0.81–1.04
Other Latinos	1.14	0.90–1.43	0.82	0.63–1.07	0.92	0.70–1.20	1.25^{^†}	1.04–1.50	0.91	0.76–1.08
Time period
Before ACA
After ACA	1.56^*	1.46–1.67	0.78^*	0.74–0.84	0.78^*	0.72–0.84	0.96	0.91–1.01	1.07^*	1.02–1.12
Heritage group × time period
White × after ACA
Puerto Rican × after ACA	0.98	0.72–1.32	0.71^{^†}	0.52–0.98	0.53^*	0.35–0.79	0.76^{^†}	0.60–0.97	0.88	0.70–1.11
Mexican × after ACA	1.03	0.92–1.16	0.82^{^†}	0.71–0.95	0.90	0.76–1.06	1.07	0.94–1.22	1.07	0.97–1.17
Cuban × after ACA	1.21	0.85–1.73	0.70	0.43–1.15	0.64	0.39–1.06	0.67	0.38–1.17	0.90	0.70–1.17
Central American × after ACA	1.15	0.94–1.40	0.94	0.74–1.21	0.86	0.65–1.14	0.94	0.74–1.20	1.25^{^†}	1.04–1.49
Other Latino × after ACA	0.73	0.54–1.00	1.32	0.86–2.04	1.22	0.78–1.90	1.01	0.75–1.34	0.97	0.73–1.30

Models also control for citizenship status, interview language, age, sex, marital status, family income, education, US Census region, self-reported health status, chronic conditions, and functional limitations.
↵* P < .01.
↵† P < .05.
ACA, Patient Protection and Affordable Care Act; CI, confidence interval; OR, odds ratio.

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Table 4.

Odds of Access and Utilization of Health Care as a Function of Year and Citizenship Status or Interview Language Interactions, 2011 to 2015 National Health Interview Survey

	Outcome
	Insured		Delay in Care		Forgo Care		ED Use		Physician Visit
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Citizenship × time period^* (n = 20,764)
US-born × after ACA
Naturalized × after ACA	0.98	0.82–1.17	1.05	0.83–1.32	1.09	0.84–1.40	1.02	0.84–1.24	1.10	0.94–1.28
Non–US citizen × after ACA	1.03	0.81–1.30	0.80	0.62–1.03	0.83	0.62–1.12	0.94	0.76–1.16	1.15	0.96–1.36
Interview language × time period^{^†} (n = 20,745)
English × after ACA
Spanish × after ACA	1.02	0.87–1.20	0.97	0.79–1.19	0.92	0.74–1.14	0.96	0.76–1.22	1.17^{^‡}	1.01–1.37

↵* Models also control for race, interview language, age, sex, marital status, family income, education, US Census region, self-reported health status, chronic conditions, and functional limitations.
↵† Models also control for race, citizenship, age, sex, marital status, family income, education, US Census region, self-reported health status, chronic conditions, and functional limitations. These analyses excluded individuals who completed the National Health Interview Survey in a language other than English or Spanish.
↵‡ P < .05.
ACA, Patient Protection and Affordable Care Act; CI, confidence interval; ED, emergency department; OR, odds ratio.