Drilling Deeper on the Impact of the Affordable Care Act on Disability-Related Health Care Access Disparities

H. Stephen Kaye’s (p. 1015) demonstration of disability-related disparities in health care access makes a significant contribution to our knowledge about disabilities, health, and health care access. People with disabilities are a sizable segment of the population: 13% to 17% of the US population are identified with serious difficulties in one or more areas of functioning. By contrast to the earlier, diagnosis-based view, the current view of disability is defined by significant limitations in one or more functional domains. The World Health Organization advanced a functional view of disability in 2001 in its International Classification of Functioning, Disability and Health,¹ and the US Department of Health and Human Services (DHHS) codified this view in its guidelines for standard disability identification as called for by the Patient Protection and Affordable Care Act (ACA).² These identifiers include difficulties in hearing, seeing, cognition, mobility, self-care (e.g., bathing, dressing), and independent living (e.g., shopping, visiting doctor).²

This shift from a diagnostic to a functional definition allows disability to be disentangled conceptually from poor health and supports a view that people can have a disability and be healthy. Furthermore, it allows observed differences in health status to be examined as potential health disparities and allows health disparities to be seen as stemming from disparities in access to health care. Researchers are coming to understand the complex relationship between disability, health status, and health care utilization. Although people with disabilities are more likely to experience chronic conditions and therefore be high users of care, most people with chronic conditions do not report disability.³

SELECTION OF OUTCOME VARIABLES

Kaye examined three variables of health care access: (1) “uninsurance” indicates whether a third party will pay for health care expenditures, (2) “usual source of care” is an accepted indicator of quality health care with a known provider, and (3) “foregone or delayed health care” documents unmet need. The third is an especially important measure for people with disabilities. By contrast with utilization of care, foregone or delayed care accommodates varying levels of need for care and provides a closer measure of equity in health care access.

DISAGGREGATING BY DISABILITY SUBGROUPS

To make the case for considering people with disabilities as a health disparity population, researchers, including Krahn et al.,⁴ have aggregated all people with disabilities into a single group and compared them with people without disabilities. People with disabilities, however, are a highly heterogeneous group with diverse health status and health care needs. Effective interventions require precise information about which persons need which services. Kaye begins to do this, as he examines subgroupings of people with disabilities, while including the known correlates of age, gender, race/ethnicity, and family income in his analyses. By disaggregating people with disabilities into four groups, he is able to demonstrate the differential effect of the ACA on subgroups that differ in nature and severity of disability. These groups include people (1) who need help with activities of daily living, (2) whose disability prevents them from working, (3) with other mental health disability, and (4) with other physical or cognitive disability. Kaye’s analyses identify important differences among subgroups before versus after the ACA and gains among people with versus those without disabilities that are attributable to the ACA. His findings demonstrate the value of differentiation among disability subtypes.

MENTAL HEALTH DISABILITY

Kaye brings much needed attention to the health care access of people whose primary limitation is mental health. The standard disability question set established by DHHS and used in the American Community Survey and other surveys and the slightly different disability identification question set used in the National Health Interview Survey (NHIS; Washington Group questions) use a general question on cognition that is presumed to identify persons with a range of disorders, such as intellectual disability, dementia, brain injury, and mental difficulties. The use of the K6 question set in NHIS allows inclusion of people with serious limitations because of mental distress who would otherwise not have been identified by the standard identifier questions.

Mental and emotional difficulties are variable and dynamic, and their relationship with other disabilities is beginning to be understood with greater precision.⁵ Within a framework of primary disabilities and secondary conditions, mental disorders can be both primary and secondary conditions, when secondary conditions are defined as conditions with an increased likelihood of occurring related to having a primary disability. An example would be a mobility disability that leads to social isolation and cessation of activities that in turn leads to depression as a secondary condition. Understanding the interplay of mental health has been challenging for disability researchers using cross-sectional survey data. Bipolar disorder or psychosis are more likely to be considered primary disabilities, whereas depression can be a primary or secondary condition.

Kaye has navigated this concern by requiring that respondents (1) report significant limitations in functioning on the K6 questions and (2) not report needing activities of daily living assistance or having a disability that prevents work. This allows the study to identify people with other mental disability in addition to those whose mental health needs result in the need for activities of daily living support or work limitations. This other mental health disability group experiences the most severe access barriers among all disability subtypes. This important finding has significant implications for public health programs and policies.

IMPACT OF IMPLEMENTATION

Several ACA policies were premised on the notion that having health insurance and a usual source of care are critical components of health care access and parity. Kaye’s study reinforces the findings of others on the positive impact of the ACA on working age adults with disabilities.⁶ It also extends findings by providing greater specificity on which subgroups of people with disabilities benefit on which access indicators. Further, it documents the ongoing disparities in access after implementation of the ACA. Because Kaye dug deeper into disability subgroups and the nature of access disparity, his findings provide direction for ways to reduce health care access disparities and, potentially, health disparities. Because he used multiple indicators of outcomes, he was able to demonstrate that access to health insurance and a usual source of care are important but not sufficient for ensuring that people with diverse disabilities experience a reduction in unmet health care needs and that disability-related health care disparities are reduced.

Kaye notes as a limitation of his study that “newly acquired health coverage might have moved some population members out of the disability population before the interview” (p. 1020). Although potentially attenuating the measured impact of the ACA, this would truly be a positive effect of the ACA for people with disabilities. As noted by others,⁷ an intended benefit of the ACA and its expansion in some states was to allow people with disabilities to work to their potential by eliminating the need to remain eligible for public health care funding. In Kaye’s study, this effect might have resulted in shifting among subgroups of persons with disabilities. Research demonstrates the value of the ACA for persons with disabilities and identifies directions to reduce the disparities in access to care that persist even after ACA implementation. A next wave of research is needed that begins to disaggregate disability into conceptually meaningful and statistically justifiable subcategories, examines variables of access that are specifically meaningful, and documents improved health outcomes and reductions in health disparities.