Medicaid Expansion and Racial-Ethnic Health Care Coverage Disparities Among Low-Income Adults With Substance Use Disorders
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Data Source
Participant Characteristics
Medicaid Expansion State Residence
Outcome Variables
Study Samples
Statistical Analysis
Results
Background Characteristics
Characteristic | White | Black | Hispanic | Omnibus group comparison (p) | Pairwise comparison (p) | |||||
---|---|---|---|---|---|---|---|---|---|---|
% | SE | % | SE | % | SE | White vs. Black | Black vs. Hispanic | White vs. Hispanic | ||
Age in years | <.001 | |||||||||
18–24 | 40.1 | .7 | 26.9 | .9 | 35.9 | 1.2 | <.001 | <.001 | .004 | |
25–34 | 23.2 | .6 | 25.6 | 1.1 | 28.6 | 1.3 | .070 | .065 | <.001 | |
35–44 | 14.2 | .6 | 16.7 | 1.0 | 20.1 | 1.3 | .024 | .035 | <.001 | |
45–64 | 22.5 | .8 | 30.8 | 1.4 | 15.4 | 1.4 | <.001 | <.001 | <.001 | |
Sex | <.001 | |||||||||
Male | 60.1 | .7 | 61.3 | 1.2 | 66.2 | 1.3 | .360 | .006 | <.001 | |
Female | 39.9 | .7 | 38.7 | 1.2 | 33.8 | 1.3 | ||||
Marital status | <.001 | |||||||||
Married | 13.9 | .6 | 13.4 | 1.0 | 27.1 | 1.4 | .630 | <.001 | <.001 | |
Separated, divorced, or widowed | 22.6 | .7 | 17.0 | 1.2 | 12.1 | 1.1 | <.001 | .002 | <.001 | |
Never married | 63.4 | .8 | 69.6 | 1.4 | 60.8 | 1.5 | <.001 | <.001 | .130 | |
Education | <.001 | |||||||||
Less than high school | 22.6 | .7 | 35.9 | 1.3 | 42.6 | 1.5 | <.001 | .001 | <.001 | |
High school graduate | 29.7 | .7 | 36.2 | 1.3 | 29.3 | 1.2 | <.001 | <.001 | .788 | |
Some college | 35.5 | .7 | 23.7 | 1.1 | 22.7 | 1.1 | <.001 | .526 | <.001 | |
College graduate | 12.2 | .5 | 4.2 | .5 | 5.4 | .6 | <.001 | .109 | <.001 | |
Employed | 52.6 | .8 | 42.5 | 1.3 | 62.0 | 1.4 | <.001 | <.001 | <.001 | <.001 |
Health status | <.001 | |||||||||
Excellent | 13.7 | .5 | 14.1 | .8 | 15.6 | 1.0 | .730 | .211 | .069 | |
Very good | 31.7 | .7 | 26.6 | 1.1 | 24.7 | 1.1 | <.001 | .211 | <.001 | |
Good | 32.6 | .7 | 31.3 | 1.2 | 35.4 | 1.4 | .337 | .027 | .081 | |
Fair or poor | 21.9 | .7 | 28.1 | 1.3 | 24.3 | 1.3 | <.001 | .041 | .112 | |
Substance use disorder, past year | <.001 | |||||||||
Alcohol | 78.8 | .6 | 73.0 | 1.1 | 83.5 | 1.0 | <.001 | <.001 | <.001 | <.001 |
Cannabis | 24.4 | .6 | 34.0 | 1.2 | 22.0 | 1.1 | <.001 | <.001 | <.001 | .040 |
Cocaine | 7.6 | .4 | 12.1 | .9 | 6.9 | .7 | <.001 | <.001 | <.001 | .400 |
Heroin | 6.0 | .4 | 2.5 | .4 | 3.4 | .6 | <.001 | <.001 | .242 | <.001 |
Expansion state | <.001 | |||||||||
No | 48.8 | .8 | 54.6 | 1.3 | 35.5 | 1.4 | ||||
Yes | 51.2 | .8 | 45.4 | 1.3 | 64.5 | 1.4 | <.001 | <.001 | <.001 |
Overall Trends in Coverage and Treatment After Expansion
Preexpansion | Postexpansion | Differenceb | Difference in disparitiesc | |||||
---|---|---|---|---|---|---|---|---|
Coverage and treatment | % | 95% CI | % | 95% CI | Percentage point | 95% CI | Percentage point | 95% CI |
No insurance | ||||||||
White | 37.6 | 35.4, 39.9 | 22.0 | 20.3, 23.9 | −15.6 | −18.4, −12.7 | Reference | — |
Black | 38.5 | 34.9, 42.1 | 24.2 | 21.4, 27.4 | −14.2 | −18.9, −9.5 | 1.3 | −4.1, 6.8 |
Hispanic | 51.2 | 46.9, 55.4 | 34.5 | 31.2, 37.9 | −16.7 | −22.1, −11.3 | −1.1 | −7.2, 4.9 |
Medicaid | ||||||||
White | 16.5 | 14.9, 18.2 | 31.5 | 29.4, 33.6 | 15.0 | 12.4, 17.6 | Reference | — |
Black | 29.3 | 26.2, 32.5 | 38.4 | 35.0, 41.9 | 9.1 | 4.4, 13.8 | −5.9 | −11.3, −.6 |
Hispanic | 22.4 | 18.9, 26.3 | 35.0 | 31.7, 38.5 | 12.6 | 7.6, 17.6 | −2.4 | −7.9, 3.2 |
Private insurance | ||||||||
White | 32.5 | 30.6, 34.4 | 33.7 | 31.9, 35.7 | 1.3 | −1.3, 3.8 | Reference | — |
Black | 18.9 | 16.2, 22.0 | 22.8 | 19.8, 26.1 | 3.9 | −.4, 8.2 | 2.6 | −2.4, 7.6 |
Hispanic | 17.0 | 14.7, 19.6 | 21.3 | 18.8, 24.0 | 4.3 | .8, 7.8 | 3.0 | −1.2, 7.3 |
Other insurance | ||||||||
White | 13.1 | 11.6, 14.7 | 12.6 | 11.1, 14.2 | −.5 | −2.7, 1.7 | Reference | — |
Black | 12.7 | 10.4, 15.5 | 13.8 | 11.6, 16.3 | 1.0 | −2.5, 4.5 | 1.5 | −2.7, 5.7 |
Hispanic | 9.1 | 6.8, 12.1 | 9.1 | 6.9, 11.8 | −.1 | −3.6, 3.5 | .5 | −3.7, 4.6 |
Substance use treatment, past year | ||||||||
White | 16.0 | 14.3, 17.9 | 14.6 | 13.3, 16.1 | −1.4 | −3.7, .9 | Reference | — |
Black | 12.0 | 9.8, 14.6 | 10.7 | 8.8, 13.0 | −1.3 | −4.4, 1.9 | .1 | −3.7, 4.0 |
Hispanic | 8.8 | 6.7, 11.6 | 9.0 | 7.1, 11.3 | .2 | −3.1, 3.4 | 1.5 | −2.3, 5.4 |
Insurance-eligible substance use treatment, past year | ||||||||
White | 14.6 | 12.8, 16.4 | 13.6 | 12.2, 15.0 | −1.0 | −3.2, 1.3 | Reference | — |
Black | 10.7 | 8.6, 13.2 | 9.5 | 7.7, 11.5 | −1.2 | −4.2, 1.8 | −.2 | −3.9, 3.5 |
Hispanic | 7.0 | 5.2, 9.4 | 7.9 | 6.1, 10.2 | .9 | −2.0, 3.8 | 1.9 | −1.7, 5.5 |
Trends in lack of coverage by expansion state and race-ethnicity.
Coverage and treatment | Expansion states | Nonexpansion states | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Preexpansion | Postexpansion | Difference estimatedb | Preexpansion | Postexpansion | Difference estimateb | Difference-in-differences estimatec | ||||||||
% | 95% CI | % | 95% CI | Percentage point | 95% CI | % | 95% CI | % | 95% CI | Percentage point | 95% CI | Percentage point | 95% CI | |
No insurance | ||||||||||||||
White | 32.9 | 30.2, 35.6 | 13.3 | 11.7, 15.2 | −19.5 | −22.8, −16.3 | 42.3 | 38.9, 45.7 | 31.8 | 28.8, 34.9 | −10.5 | −15.1, −6.0 | −9.0 | −14.5, −3.5 |
Black | 31.2 | 27.0, 35.8 | 13.0 | 9.9, 17.0 | −18.2 | −23.9, −12.5 | 44.7 | 39.4, 50.2 | 33.3 | 28.9, 38.0 | −11.4 | −18.6, −4.3 | −6.8 | −16.0, 2.4 |
Hispanic | 46.2 | 40.9, 51.6 | 25.7 | 22.0, 29.7 | −20.5 | −27.1, −13.9 | 59.5 | 52.7, 65.9 | 51.8 | 45.7, 57.8 | −7.7 | −16.6, 1.3 | −12.8 | −24.0, −1.7 |
Medicaid | ||||||||||||||
White | 19.3 | 17.1, 21.8 | 41.0 | 38.0, 44.1 | 21.7 | 17.9, 25.5 | 13.7 | 11.7, 16.0 | 20.9 | 18.4, 23.6 | 7.2 | 3.8, 10.6 | 14.5 | 9.4, 19.6 |
Black | 36.4 | 31.6, 41.5 | 50.9 | 45.6, 56.1 | 14.5 | 7.2, 21.8 | 23.0 | 19.5, 26.8 | 28.4 | 24.5, 32.6 | 5.4 | −.1, 10.8 | 9.1 | .2, 18.0 |
Hispanic | 27.2 | 22.4, 32.6 | 44.2 | 40.1, 48.5 | 17.0 | 10.5, 23.6 | 14.3 | 10.4, 19.4 | 17.2 | 12.4, 23.3 | 2.8 | −4.2, 9.9 | 14.2 | 4.6, 23.8 |
Private insurance | ||||||||||||||
White | 32.9 | 30.6, 35.3 | 32.5 | 30.0, 35.1 | −.4 | −3.8, 3.0 | 32.0 | 29.3, 34.9 | 35.1 | 32.5, 37.8 | 3.1 | −.7, 6.8 | −3.5 | −8.4, 1.5 |
Black | 18.9 | 15.0, 23.5 | 21.8 | 17.6, 26.7 | 3.0 | −3.3, 9.2 | 18.9 | 15.3, 23.1 | 23.6 | 19.6, 28.0 | 4.7 | −1.1, 10.4 | −1.7 | −10.1, 6.7 |
Hispanic | 17.2 | 14.3, 20.6 | 20.8 | 17.7, 24.3 | 3.6 | −.9, 8.1 | 16.6 | 13.1, 20.9 | 22.3 | 18.3, 26.8 | 5.6 | −.1, 11.4 | −2.0 | −9.3, 5.3 |
Other insurance | ||||||||||||||
White | 14.7 | 12.6, 17.2 | 12.8 | 10.8, 15.1 | −2.0 | −5.1, 1.1 | 11.5 | 9.5, 13.8 | 12.3 | 10.3, 14.7 | .8 | −2.2, 3.9 | −2.8 | −7.2, 1.6 |
Black | 12.8 | 9.9, 16.4 | 13.5 | 10.3, 17.4 | .7 | −4.1, 5.5 | 12.7 | 9.4, 17.0 | 14.0 | 11.0, 17.6 | 1.2 | −3.8, 6.2 | −.5 | −7.5, 6.4 |
Hispanic | 9.2 | 6.4, 13.0 | 9.3 | 6.6, 13.0 | .1 | −4.4, 4.6 | 9.0 | 5.8, 13.8 | 8.6 | 5.4, 13.6 | −.4 | −6.0, 5.2 | .4 | −6.7, 7.6 |
Substance use treatment, past year | ||||||||||||||
White | 18.9 | 16.4, 21.7 | 14.4 | 12.6, 16.5 | −4.5 | −7.7, −1.2 | 13.2 | 10.9, 15.8 | 14.9 | 12.9, 17.1 | 1.7 | −1.5, 4.9 | −6.2 | −10.7, −1.7 |
Black | 14.9 | 11.4, 19.2 | 14.1 | 10.8, 18.3 | −.8 | −6.2, 4.6 | 9.4 | 6.9, 12.9 | 8.0 | 6.0, 10.6 | −1.4 | −5.2, 2.3 | .7 | −5.4, 7.0 |
Hispanic | 9.3 | 6.7, 12.7 | 9.9 | 7.4, 13.2 | .7 | −3.4, 4.8 | 8.0 | 4.8, 13.0 | 7.1 | 4.8, 10.4 | −.9 | −5.8, 3.9 | 1.6 | −3.7, 6.9 |
Insurance-eligible substance use treatment, past year | ||||||||||||||
White | 17.5 | 15.1, 20.3 | 13.5 | 11.7, 15.6 | −4.0 | −7.2, −.8 | 11.6 | 9.4, 14.3 | 13.6 | 11.7, 15.8 | 2.0 | −1.2, 5.1 | −6.0 | −10.5, −1.4 |
Black | 13.1 | 9.8, 17.3 | 12.4 | 9.4, 16.2 | −.7 | −5.8, 4.4 | 8.6 | 6.1, 11.9 | 7.1 | 5.2, 9.6 | −1.5 | −5.1, 2.2 | .8 | −5.5, 7.1 |
Hispanic | 7.9 | 5.5, 11.1 | 8.8 | 6.4, 11.9 | .9 | −3.0, 4.8 | 5.6 | 3.3, 9.3 | 6.2 | 4.1, 9.4 | .6 | −3.3, 4.5 | .3 | −5.1, 5.7 |
Trends in Medicaid by expansion state and race-ethnicity.
Other Trends During the Study Period
Discussion
Conclusions
Supplementary Material
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