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AbstractThe 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.

In Manhattan, the rate of hospital discharges for avoidable hospital conditions (AHC), a measure of access to timely and effective ambulatory care, fell by nearly 50 percent between 1999 and 2013. Despite this remarkable improvement, there has been virtually no change in racial, ethnic, or neighborhood‐level differences in rates of AHC. This is surprising given New York City's emphasis on public health and its efforts to reduce health and health‐care inequalities. We discuss the policy implications of these findings and argue that growing income and wealth inequalities have limited the ability of New York City to address inequalities in population health and health‐care access. Unless there are substantial changes in federal and state policy, designed to reduce economic inequalities, it will be difficult to achieve the goal of eliminating health and health‐care inequalities.

Cet article présente un indicateur, les « hospitalisations sensibles aux soins de premier recours » (HSPR), utilisé aux États-Unis et dans d'autres pays de l'OCDE pour évaluer dans quelle mesure les soins de premier recours sont accessibles et permettent une prise en charge adaptée des pathologies avant qu'elles ne nécessitent des traitements à l'hôpital. Sur la base d'une étude conduite en Île-de-France à partir de données hospitalières et du Programme de médicalisation des systèmes d'information (PMSI), cet indicateur permet d'identifier les zones où les HSPR semblent particulièrement nombreuses et ces hospitalisations potentiellement évitables. Les facteurs susceptibles d'expliquer ces disparités (facteurs individuels et facteurs contextuels propres au lieu de résidence) sont analysés grâce à une régression logistique : les résidents des zones du dernier quartile de revenu et les patients hospitalisés dans des établissements publics rencontrent davantage de difficultés d'accès aux soins de premier recours, ce qui soulève une question importante pour les politiques de santé : faut-il imputer le nombre élevé de HSPR à un recours aux soins tardif ou au fait que le système de soins n'est pas organisé pour cibler les populations à risque ?