People with disabilities benefited significantly from the Affordable Care Act through both expanded access to Medicaid and being able to purchase private insurance, a Washington State University study found.
The paper, published in late 2017 in the journal Inquiry, compared both health coverage and access to care among working-age adults with and without disabilities, drawing on responses to the National Health Interview Survey.
Researchers found people with disabilities were far more likely to have insurance through a public health insurance program. Among those who had private insurance, people with disabilities were more likely to have a plan purchased on a state exchange, rather than through work.
And even when they had insurance, many people with disabilities reported delaying or not receiving needed medical care due to high cost.
Jae Kennedy, the lead author and a professor in WSU’s School of Health Policy and Administration, said the ACA was important because many people with disabilities are unable to work full-time. Since most working-age Americans receive insurance through work, that made coverage difficult.
“Nobody really made a formal decision to link health insurance to employment. It just kind of happened,” he said.
Most part-time workers can’t get insurance through work, and buying private health insurance wasn’t an option because pre-existing conditions precluded many disabled people from coverage. The ACA required insurers to cover pre-existing conditions, opening up the health care marketplace.
“People with chronic illness and disability, for the first time, really, in the history of health insurance in this country, could get private health insurance,” Kennedy said.
Miriam Hertz, an independent living advocate with Disability Action Center Northwest in Moscow, Idaho, said she’s seen that in both her own experience and her work with clients. She signed up for an exchange plan shortly after the ACA’s markets were established and said she has seen many people benefit from the pre-existing conditions protection.
“There was a time when I was told that because of my stuttering I would have a hard time getting private health care coverage,” she said.
But the benefits of Medicaid expansion have left her clients behind, since Idaho opted not to expand the program.
“The biggest plus for people with disabilities coming out of the ACA era is actually the expansion of Medicaid which is on a state-by-state basis,” she said.
And access remains a concern, she said. Beyond the cost of care, people with disabilities often have trouble getting rides to appointments or needed accommodations at doctor offices, like accessible entrances or sign language interpreters.
Because the study is based on survey data, it doesn’t show whether people who newly enrolled in Medicaid would have been eligible before the expansion. And Kennedy notes that other factors, like recovery from the Great Recession, may also play a role in expanded coverage.
Kennedy is the head of a five-institution Collaborative on Health Reform and Independent Living, which is looking into the effect of health reform on people with disabilities.
Liz Wood, a WSU research professor who’s finishing her doctorate at the University of North Carolina in health services research, said the hope is to focus more discussion on health coverage on some of the highest users of the medical system, who often aren’t specifically written about in research.
“They spend so much more on health care, and they earn so much less, on average,” she said.
CHRIL has published prior research showing people with disabilities were more likely to be employed following the ACA’s implementation in states that expanded Medicaid. About 38 percent of people with disabilities were working in Medicaid expansion states in 2014-15, versus 32 percent in nonMedicaid expansion states.
Kennedy said access to Medicaid or other public programs can actually help people with disabilities stay in part-time jobs, because it doesn’t tie their insurance to disability benefits.
When people are covered through federal disability programs, they can fall into a trap where they lose benefits if they have outside income. That means someone who is only able to work part-time at jobs that don’t offer coverage has an incentive not to work at all.
“If you have other options for health insurance, you don’t have this kind of existential crisis where you have to drop out” of the labor force, Kennedy said.