Heterogeneous Effects of the Affordable Care Act on Emergency Department Visits and Payer Composition among Older Adults by Race and Ethnicity

We estimate the impact of the Affordable Care Act (ACA) on emergency department (ED) visits and the composition of insurance coverage for White, Black, and Hispanic older adults. Our estimation strategy uses changes in the discontinuity of health insurance coverage at age 65 and the variation in state decisions about Medicaid expansion under the ACA. We find that uninsured ED visits decreased for older adults in all three racial and ethnic groups in Medicaid expansion and non-expansion states. The magnitude of the decreases varied from four visits per 1,000 people among White older adults in non-expansion states to 23 visits per 1,000 people among Black and Hispanic older adults in expansion states. The insurance coverage gains came primarily from Medicaid in expansion states and private insurance in non-expansion states, regardless of race or ethnicity. We find suggestive evidence of increased ED visits for Black and Hispanic populations that had low insurance coverage rates before 2014.