Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act
Authors: Benjamin D. Sommers, Munira Z. Gunja, Kenneth Finegold, Thomas Musco
Journal: JAMA (2015)

Context:The Affordable Care Act (ACA) completed its second open enrollment period in February 2015.Assessing the law's effects has major policy implications.Objective: To estimate national changes in self-reported coverage, access to care, and health during the ACA's first two open enrollment periods, and to assess differences between lowincome 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 18-64 (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.We then compared pre-(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 in 28 states and Washington D.C.) versus non-expansion states (n=37,283 in 22 states) using differences-in-differences.Exposure: Beginning of the ACA's first open enrollment period (October 2013).Main Outcomes: Being uninsured, lacking a personal physician, lacking easy access to medicine, inability to afford needed care, self-reported health, and health-related activity limitations.Results: Among the 507,055 adults in this survey, pre-ACA trends were significantly worsening for all outcomes.Compared to the pre-ACA trend, the adjusted uninsured rate decreased 7.9 percentage points (95% CI -9.1, -6.7) by the first quarter of 2015; lacking a personal physician decreased 3.5 percentage points (95% CI -4.8, -2.2); lack of easy access to medicine decreased 2.4 percentage points (95% CI -3.3, -1.5); inability to afford care decreased 5.5 percentage points (95% CI -6.7, -4.2); the proportion reporting "fair" or "poor" health decreased 3.4 percentage points (95% CI -4.6, -2.2); and days with activities limited by health decreased 1.7 percentage points (95% CI -2.4,-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%, -8.5%) than white adults (-6.1 percentage points; 95% CI -7.3, -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, -2.6), lacking a personal physician, and difficulty accessing medicine. Conclusions:The ACA's first two 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 to adults in states that did not expand Medicaid.