Another day, another study on the benefits of the Affordable Care Act and the gains we risk losing if the Trump administration succeeds at undermining the law.
This one, published this month in Health Affairs, focuses on the impact of the ACA insurance marketplace on people who were previously uninsured. Overall, researchers found that the ACA led to a dramatic decline in the uninsured rate, a decrease in barriers to medical care, increased use of outpatient services and prescription drugs, and increases in hypertension diagnoses. Those changes were most pronounced among people who previously went without insurance and were living on incomes of 138 percent to 250 percent of the poverty level, which makes them eligible for the ACA’s cost-sharing subsidies.
“These result demonstrate that despite initial challenges in the rollout of the (ACA) marketplaces, they were successful in improving coverage among many long-term uninsured adults,” the study stated. “However, even after expansion of coverage availability, more than half of this group remained uninsured at the end of 2014, which indicates that significant outreach efforts are still needed.”
To conduct the study, researchers used longitudinal data spanning 2011 to 2014 from the federal Medical Expenditure Panel Survey, comparing previously uninsured, nonelderly adults with incomes making them eligible for marketplace subsidies to people who had employer-sponsored insurance prior to the ACA. The data included represented more than 9,600 adults, of which about 5,700 had continuous employer-based coverage and about 3,800 people who were uninsured for six months or more in 2013. Researchers found that the uninsured group experienced both a decrease in uninsurance of more than 10 percentage points by the end of 2014 and an increase in the likelihood of having private health coverage.
Previously uninsured adults also experienced a decline in being unable to get necessary medical care, an increase in the rate of inpatient admissions of 2.5 percentage points, and an increase in the number of prescriptions filled. The likelihood of receiving a hypertension diagnosis also went up among the previously uninsured. However, researchers did not detect significant differences in emergency department visits, rates of preventive visits, and poor or fair self-reported health status.
Parsing out the results by income, the study found that low-income people — with incomes 138-250 percent of the federal poverty level — and middle-income adults — at 251-400 percent of poverty — experienced increases in coverage of about 11 percent and 13 percent, respectively, when compared to those with employer-sponsored coverage. Among the lower-income group, rates of being unable to access care went down significantly and use of outpatient services went up. The lower-income group also reported a large increase in the number of prescriptions filled and in receiving a hypertension diagnosis. The middle-income group experienced a decrease in the likelihood of delaying medications as well as an increased likelihood of being diagnosed with hypertension.
Researchers attributed the majority of gains to ACA marketplace coverage. They also noted that the lack of changes detected in preventive care use and self-reported health status may be because the study only included data on the first year after ACA implementation. However, they also said it’s possible that ACA marketplace coverage and its cost-sharing requirements may be less effective at moving the needle on those indicators than the ACA’s accompanying Medicaid expansion.
Still, researchers warned that policy and regulatory moves at the federal level, like repeal of the individual mandate, could bring back pre-ACA numbers. Study authors Anna Goldman, Danny McCormick, Jennifer Haas and Benjamin Sommers write:
The Trump administration’s decision to cease payments for cost-sharing subsidies to insurers, as well as the elimination of the individual mandate penalty, could further erode marketplace coverage and undo some of these gains. However, despite notable improvements, we also found that many barriers to care remain for this population. Legislative changes to marketplace plans that increase the generosity of subsidies and boost enrollment might produce greater progress on a range of outcomes related to health care.
For a copy of the new study, visit Health Affairs.