ACA Medicaid Expansion Improves Access to Primary Care, Regardless of Race/Ethnicity Open Access

Singh, Katherine (2017)

Permanent URL:


The Affordable Care Act (ACA) of 2010 expanded Medicaid eligibility for low-income adults; yet, several states have chosen not to expand their Medicaid programs. Though research has been done on the effect of ACA Medicaid expansion on access to primary care, these studies were limited in their ability to specifically attribute their results to Medicaid expansion rather than other contemporaneous policy changes. In addition, none has looked specifically at how race/ethnicity may moderate the effects of ACA Medicaid expansion. The purpose of this study is to examine how Medicaid expansion under the ACA has affected access to primary care (measured by the likelihood of having a usual source of care and the likelihood of delaying care due to cost), and if race/ethnicity moderates that relationship. Survey data from the Behavior Risk Factor Surveillance System (BRFSS) for the years 2011-2015 and logistic regression models were used to test for effects on rates of having a usual source of care and delaying care following Medicaid expansion for a precisely targeted population in a difference-in-difference framework. In secondary models, a triple-difference interaction term measured the moderating effect of race/ethnicity in this relationship. Individuals in ACA Medicaid expansion states were 5.9 percentage points more likely to have a usual source of care and 3.6 percentage points less likely to delay care due to cost post-expansion. There were no statistically significant differences in access to primary care post-expansion by race/ethnicity. The findings of this study support the importance of Medicaid expansion as a step that can help improve access to primary care for low-income individuals, regardless of race/ethnicity. They also suggest that policies that decrease Medicaid coverage, such as ACA repeal or Medicaid block grants, may significantly reduce low-income individuals' ability to access primary care.

Table of Contents

Table of Contents

Chapter 1: Introduction 1 Chapter 2: Background and Literature Review 2 2A: Access to Primary Care--Measurement and Effects of Insurance 2 Measuring Access to Primary Care 2 Insurance Coverage and Access to Primary Care 4 2B: The Affordable Care Act and Medicaid Expansions 4 Medicaid and the Affordable Care Act 4 Systematic Differences Exist Between Expansion and Non-Expansion States 5 Pre-ACA Medicaid Expansions Have Improved Primary Care Access 6 Emerging Data on ACA Expansions Suggests Improved Primary Care Access 7 2C: Race/Ethnicity - A Key Moderator 8 2D: Gaps Filled and Policy Implications 9 Chapter 3: Methodology 12 3A: Conceptual Framework 12 Figure 1: Conceptual Framework 12 Focal Relationship 13 Confounders to the Focal Relationship 13 Minority Race/Ethnicity: A Moderator 14 3B: Hypotheses 15 3C: Data 15 3D: Analytic Sample 16 Figure 2: Analytic Sample 18 3E: Constructs and Measures 18 Access to Primary Care 18 ACA Medicaid Expansion 19 Predisposing Characteristics 19 Enabling Characteristics 20 Need Characteristics 20 Unmeasured Constructs 20 Table 1: Constructs and their Associated Measures 21 3F: Data Analysis 22 Model 1 22 Model 2 23 Chapter 4: Results 24 4A: Descriptive Statistics 24 Table 2: Characteristics of the Analytic Sample 24 4B: Descriptive Results 26 Figure 3: Changes in Percentage of People with a Usual Source of Care, by State Expansion Status and Year 26 Figure 4: Changes in Percentage of People who Did Not Delay Care Due to Cost, by State Expansion Status and Year 26 4C: Results of Model 1 27 Table 3: Difference-in-Difference Estimates for Impact of Medicaid Expansion on Access to Primary Care for Low-Income Non-Elderly Childless Adults 27 4D: Results of Model 2 29 Table 4: Difference-in-Difference Estimates for Impact of Medicaid Expansion on Access to Primary Care for Low-Income Non-Elderly Childless Adults, Moderated by Race/Ethnicity; Select Estimates 29 Chapter 5: Discussion 30 5A: Key Findings 30 5B: Strengths and Limitations 30 5C: Policy Implications 32 5D: Recommendations for Further Research 34 Chapter 6: Conclusion 34 References 36 Appendix 1: Full Results of Model 2 41 Table 5: Full Triple Difference Estimates for Impact of Medicaid Expansion on Access to Primary Care for Low-Income Non-Elderly Childless Adults 41

About this Master's Thesis

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
  • English
Research Field
Committee Chair / Thesis Advisor
Committee Members
Partnering Agencies
Last modified

Primary PDF

Supplemental Files