Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act

JAMA. 2015 Jul 28;314(4):366-74. doi: 10.1001/jama.2015.8421.

Abstract

Importance: The Affordable Care Act (ACA) completed its second open enrollment period in February 2015. Assessing the law's effects has major policy implications.

Objectives: To estimate national changes in self-reported coverage, access to care, and health during the ACA's first 2 open enrollment periods and to assess differences between low-income adults in states that expanded Medicaid and in states that did not expand Medicaid.

Design, setting, and participants: Analysis of the 2012-2015 Gallup-Healthways Well-Being Index, a daily national telephone survey. Using multivariable regression to adjust for pre-ACA trends and sociodemographics, we examined changes in outcomes for the nonelderly US adult population aged 18 through 64 years (n = 507,055) since the first open enrollment period began in October 2013. Linear regressions were used to model each outcome as a function of a linear monthly time trend and quarterly indicators. Then, pre-ACA (January 2012-September 2013) and post-ACA (January 2014-March 2015) changes for adults with incomes below 138% of the poverty level in Medicaid expansion states (n = 48,905 among 28 states and Washington, DC) vs nonexpansion states (n = 37,283 among 22 states) were compared using a differences-in-differences approach.

Exposures: Beginning of the ACA's first open enrollment period (October 2013).

Main outcomes and measures: Self-reported rates of being uninsured, lacking a personal physician, lacking easy access to medicine, inability to afford needed care, overall health status, and health-related activity limitations.

Results: Among the 507,055 adults in this survey, pre-ACA trends were significantly worsening for all outcomes. Compared with the pre-ACA trends, by the first quarter of 2015, the adjusted proportions who were uninsured decreased by 7.9 percentage points (95% CI, -9.1 to -6.7); who lacked a personal physician, -3.5 percentage points (95% CI, -4.8 to -2.2); who lacked easy access to medicine, -2.4 percentage points (95% CI, -3.3 to -1.5); who were unable to afford care, -5.5 percentage points (95% CI, -6.7 to -4.2); who reported fair/poor health, -3.4 percentage points (95% CI, -4.6 to -2.2); and the percentage of days with activities limited by health, -1.7 percentage points (95% CI, -2.4 to -0.9). Coverage changes were largest among minorities; for example, the decrease in the uninsured rate was larger among Latino adults (-11.9 percentage points [95% CI, -15.3 to -8.5]) than white adults (-6.1 percentage points [95% CI, -7.3 to -4.8]). Medicaid expansion was associated with significant reductions among low-income adults in the uninsured rate (differences-in-differences estimate, -5.2 percentage points [95% CI, -7.9 to -2.6]), lacking a personal physician (-1.8 percentage points [95% CI, -3.4 to -0.3]), and difficulty accessing medicine (-2.2 percentage points [95% CI, -3.8 to -0.7]).

Conclusions and relevance: The ACA's first 2 open enrollment periods were associated with significantly improved trends in self-reported coverage, access to primary care and medications, affordability, and health. Low-income adults in states that expanded Medicaid reported significant gains in insurance coverage and access compared with adults in states that did not expand Medicaid.

MeSH terms

  • Adult
  • European Continental Ancestry Group / statistics & numerical data
  • General Practice / statistics & numerical data
  • Health Services Accessibility / statistics & numerical data*
  • Health Services Accessibility / trends
  • Health Surveys
  • Hispanic Americans / statistics & numerical data
  • Humans
  • Insurance Coverage / statistics & numerical data*
  • Insurance Coverage / trends
  • Medically Uninsured / statistics & numerical data
  • Middle Aged
  • Patient Protection and Affordable Care Act / statistics & numerical data*
  • Regression Analysis
  • Self Report*
  • United States
  • Young Adult