Table 2. Outpatient Quality, Experience, Utilization, and Cost Before (2011-2013) and After (2014-2016) the ACA, by Annual Household Income.
| Outcome | Patients, mean (95% CI), % | Difference in differences | ||||||
|---|---|---|---|---|---|---|---|---|
| Annual household income <400% FPL | Annual household income ≥400% FPL | |||||||
| Before ACA (n = 45 811) | After ACA (n = 41 900) | Before ACA (n = 17 693) | After ACA (n = 17 767) | Unadjusted | P value | Adjusted | P value | |
| High-value care | ||||||||
| Cancer screening | 73 (72-74) | 73 (73-74) | 80 (79-81) | 79 (78-80) | 0.64 | .48 | 0.99 | .26 |
| Diagnostic and preventive testing | 70 (70-71) | 72 (72-73) | 84 (83-84) | 84 (83-84) | 2.18a | <.001a | 1.20a | .02a |
| Diabetes care | 62 (60-63) | 59 (58-61) | 72 (69-74) | 71 (68-74) | −1.34 | .58 | −0.97 | .67 |
| Counseling | 45 (44-46) | 45 (44-46) | 50 (48-51) | 49 (48-50) | 0.86 | .47 | −0.55 | .59 |
| Medical treatments | 34 (33-36) | 34 (33-35) | 41 (39-43) | 39 (37-41) | 2.06 | .16 | 0.54 | .67 |
| Low-value care | ||||||||
| Antibiotic use | 62 (59-64) | 56 (52-59) | 59 (56-63) | 54 (51-57) | −0.76 | .82 | −4.35 | .20 |
| Medical treatments | 13 (12-14) | 13 (12-14) | 8 (7-9) | 9 (8-10) | −0.40 | .63 | −0.99 | .28 |
| Imaging | 9 (8-10) | 10 (9-12) | 9 (8-10) | 9 (7-11) | 1.73 | .20 | 0.77 | .60 |
| Respondent experience | ||||||||
| Global rating of health care | 69 (68-70) | 73 (72-74) | 79 (78-81) | 81 (80-82) | 2.77a | .007a | 2.12a | .03a |
| Physician communication | 57 (57-58) | 63 (62-64) | 64 (63-65) | 67 (65-68) | 2.59a | .005a | 1.86a | .04a |
| Access to care | 50 (49-51) | 54 (53-55) | 59 (58-61) | 60 (59-62) | 3.20a | .01a | 2.58a | .047a |
| Utilization | ||||||||
| Encounters, mean (95% CI), No./year | ||||||||
| Office visits | 4.3 (4.2-4.5) | 4.7 (4.5-4.9) | 5.5 (5.3-5.8) | 5.8 (5.5-6.1) | 0.10 | .57 | 0.12 | .50 |
| Emergency department visits | 0.2 (0.2-0.2) | 0.2 (0.2-0.2) | 0.1 (0.1-0.1) | 0.1 (0.1-0.1) | −0.01 | .27 | 0.00 | .97 |
| Hospital admissions | 0.1 (0.1-0.1) | 0.1 (0.1-0.1) | 0.1 (0.1-0.1) | 0.1 (0-0.1) | 0.00 | .84 | 0.01 | .26 |
| Prescribed medicines, mean (95% CI), total fills/year | 10.2 (9.8-10.7) | 10.5 (10-11) | 9.0 (8.5-9.4) | 8.6 (8.2-9) | 0.67 | .09 | 0.34 | .29 |
| Preventive visit within past year | 58 (57-59) | 60 (59-61) | 69 (68-70) | 69 (68-71) | 1.81 | .07 | 0.70 | .48 |
| Has primary care | 65 (64-66) | 66 (65-67) | 80 (78-81) | 77 (76-78) | 3.33a | <.001a | 2.97a | .001a |
| Cost, $ | ||||||||
| Totalb | 3871 (3678-4063) | 4309 (4010-4607) | 4401 (4120-4683) | 4591 (4315-4867) | 248.53 | .25 | 195.67 | .37 |
| Office-basedb | 867 (824-911) | 954 (900-1009) | 1206 (1146-1265) | 1327 (1248-1406) | −34.36 | .52 | 0.28 | >.99 |
| Hospital outpatient department–basedb | 327 (296-357) | 411 (345-477) | 531 (452-610) | 566 (481-652) | 49.26 | .43 | 81.31 | .20 |
| Inpatient-basedb | 1170 (1069-1270) | 1160 (1012-1307) | 1061 (876-1246) | 933 (769-1097) | 118.40 | .40 | 193.15 | .21 |
| Prescriptionsb | 944 (830-1057) | 1126 (1016-1237) | 957 (863-1052) | 1045 (930-1161) | 94.38 | .32 | −41.86 | .70 |
| Out of pocket | ||||||||
| Total | 504 (477-530) | 439 (416-461) | 757 (719-794) | 769 (734-804) | −77.26a | .008a | −105.50a | .001a |
| Office-based | 126 (118-134) | 131 (119-142) | 239 (220-257) | 278 (260-296) | −35.05a | .006a | −45.39a | .002a |
| HOD-based | 29 (24-35) | 23 (20-26) | 46 (38-54) | 52 (45-59) | −12.20a | .04a | −14.59a | .03a |
| Inpatient-based | 49 (36-61) | 28 (23-33) | 50 (33-67) | 38 (31-45) | −8.79 | .44 | −0.75 | .95 |
| Prescriptions | 156 (145-167) | 127 (116-138) | 200 (187-213) | 159 (147-171) | 12.17 | .23 | 3.14 | .76 |
Abbreviations: ACA, Patient Protection and Affordable Care Act; FPL, federal poverty level.
Denotes P < .05. Regression was adjusted for each year, age, sex, race, ethnicity, US Census region, partner status, education status, health status, employment status, smoking status, activities of daily living, instrumental activities of daily living, Short Form–12 Physical Component Score, Short Form–12 Mental Component Score, body mass index, Kessler index, hypertension, dyslipidemia, diabetes, chronic obstructive pulmonary disease, coronary artery disease or myocardial infarction, cancer, asthma, arthritis, frequency of chronic disease, and primary care. Adjustment did not include primary care for the “has primary care” outcome. See eTable 5 in the Supplement for all measures.
Includes out-of-pocket expenditures.