Over the course of 2017, positive trends in insurance coverage and healthcare access from the Affordable Care Act were reversed, particularly for low-income residents of states that did not expand Medicaid.
A new Boston University School of Public Health study finds that two million more Americans avoided healthcare because of inability to pay, and/or did not have health insurance, at the end of 2017 compared to the end of 2016.
Published in the February issue of Health Affairs, the study examines the period from 2011 to 2017, showing positive trends in healthcare coverage and access following implementation of the ACA, and a reversal of those trends when newly-elected President Trump and Congressional Republicans began working to repeal and replace the ACA.
WHAT'S THE IMPACT
Researchers used data on a nationally-representative sample of 2.2 million U.S. residents between the ages of 18 and 64 years old from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System -- but cautioned this didn't give them the ability to directly analyze the causal effects of specific policies. Rather, the quarterly data allowed them to see that trends reversed coinciding with these changes.
There were several policy changes in 2017 that could have had effects immediate enough to see within the same year, such as shortened enrollment periods, cuts in advertising and navigator funding, and reductions in payments to hospitals. There was also widespread confusion during the "repeal and replace" battle, when a quarter of Americans believed the ACA had been at least partially repealed.
Based on the new estimates, uninsurance rates fell by 7.1% from 2013 to 2016 before rising by 1.2% during 2017. After a similar downward trend, they found a 1% increase in adults who avoided healthcare because of costs in 2017.
Low-income residents of states that did not expand Medicaid were the hardest hit by the reversal, while those affected in expansion states were mostly middle-income residents who were eligible for the exchanges. In non-expansion states, the decrease in insurance coverage and healthcare access was four to five times greater than in expansion states.
Meanwhile, the gap in healthcare access between higher- and lower-income people shrank from 2013 to 2016 by about 8.5% in expansion and non-expansion states. Then, from the fourth quarter of 2016 to the fourth quarter of 2017, the gap increased by 2.6% in non-expansion states (a relative increase of 11%) but continued to decrease by another 1% in expansion states (a relative decrease of 8%).
THE LARGER TREND
The primary goal of the ACA was to expand access to insurance coverage, and in that measure it largely succeeded. The law established a Health Insurance Exchange, or marketplace, that offers varying degrees of insurance and at least a semblance of a safety net for those in danger of falling through the cracks.
Even with low unemployment figures, the numbers of people signing up for marketplace plans has remained relatively stable. This year, a total of 8,303,850 individuals enrolled, compared to 8,454,882 in 2018. That's a 1.7% drop in the number of people enrolling, but there are factors that may help explain the dip.
The Centers for Medicare and Medicaid Services, which administers ACA policy, recently said open enrollment is influenced by a number of factors. This year, the unemployment rate is at the lowest it has been in 50 years. And states such as Maine have expanded Medicaid, so that an estimated 12,000 people are now eligible for Medicaid in that state instead of tax credits.