Coverage and Access for Americans With Chronic Disease Under the Affordable Care Act: A Quasi-Experimental Study

Ann Intern Med. 2017 Apr 4;166(7):472-479. doi: 10.7326/M16-1256. Epub 2017 Jan 24.


Background: Half of Americans have at least 1 chronic disease. Many in this group, particularly racial/ethnic minorities, lacked insurance coverage and access to care before the Patient Protection and Affordable Care Act (ACA) was enacted.

Objective: To determine whether the ACA has had an effect on insurance coverage, access to care, and racial/ethnic disparities among adults with chronic disease.

Design: Quasi-experimental policy intervention.

Setting: Nationally representative, noninstitutionalized sample in the United States.

Patients: 606 277 adults aged 18 to 64 years with a chronic disease.

Intervention: Implementation of ACA provisions on 1 January 2014.

Measurements: Self-reported insurance coverage, having a checkup, having a personal physician, and not having to forgo a needed physician visit because of cost.

Results: After the ACA was implemented, insurance coverage increased by 4.9 percentage points (95% CI, 4.4 to 5.4), not having to forgo a physician visit increased by 2.4 percentage points (CI, 1.9 to 2.9), and having a checkup increased by 2.7 percentage points (CI, 2.2 to 3.4). Having a personal physician did not change (0.3 percentage points [CI, -0.2 to 0.8]). All outcomes varied considerably by state, and coverage increased more in states that expanded Medicaid. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 1 in 5 black and 1 in 3 Hispanic persons with a chronic disease continued to lack coverage and access to care after ACA implementation.

Limitation: The study examined data from only the first year of the ACA's major coverage expansion provisions.

Conclusion: Although the ACA increased coverage and access for persons with chronic disease, substantial gaps remain, particularly for minorities and those in Medicaid nonexpansion states.

Primary funding source: None.

MeSH terms

  • Adolescent
  • Adult
  • Chronic Disease / ethnology*
  • Chronic Disease / therapy*
  • Female
  • Health Services Accessibility*
  • Healthcare Disparities
  • Humans
  • Insurance Coverage*
  • Insurance, Health*
  • Male
  • Medicaid / legislation & jurisprudence
  • Middle Aged
  • Patient Protection and Affordable Care Act*
  • United States
  • Young Adult