Inequalities in hospitalizations for ambulatory care sensitive conditions in New York City before and after the affordable care act

The Patient Protection and Affordable Care Act (ACA) was signed into law by U.S. President Obama in 2010 and fully implemented in 2014. The ACA expanded health insurance by expanding the Medicaid program, creating health insurance exchanges (now called "marketplaces") in which people with incomes between 139% and 400% of the federal poverty level, could purchase subsidized insurance coverage, and by regulating health insurance to eliminate practices such as denying coverage to people with pre-existing conditions, or basing premiums on health status. We investigate the effects of the ACA's implementation on access to ambulatory health services in New York City by comparing rates of hospitalizations for ambulatory care-sensitive conditions (ACSC) before and after the full implementation of the law. Although the ACA was associated with a significant decrease in the rate of ACSC in NYC, we find that there continue to be systemic inequalities by gender, race, ethnicity, income, and insurance status. We argue that the broader social and economic inequalities at the national and state levels, including tax and spending policies that have led to increased income and wealth inequalities, help explain why we see persistent inequalities in hospitalizations for ACSC.