Post-ACA Access to Care, Coverage Disparities Shifted in 2017

From 2016 to 2017, the uninsured rate rose by 1.2 percent and the number of persons who avoided care due to cost rose by 1.0 percent, demonstrating a shift in healthcare trends that started with the implementation of the Affordable Care Act, Health Affairs researchers found.

The ideological and political distinctions between the Obama administration and the Trump administration are, arguably, best reflected in their approach to healthcare. After Obama instituted the ACA in March 2010, he ushered it through its infancy. But starting in the Trump era, the bill began to come apart piece by piece, culminating most notably with the elimination of the individual mandate which was recently declared unconstitutional.

It can be difficult to accurately capture the effects of an administration change in general, but the researchers used the Behavioral Risk Factor Surveillance System (BRFSS) to examine access to care and uninsurance disparities between the Obama era and the Trump era.

“We assessed changes in health care access outcomes in the overall nonelderly US adult population and stratified by state Medicaid expansion status and household income. Because of the observational nature of our study design, our results should be considered descriptive; they do not enable us to make any direct connection between specific policy interventions and the study outcomes,” the researchers clarified.

Results from the 2.2 million respondents indicated that in the first quarter of 2017, the year that President Trump took office, the uninsurance rate fell to 23.2 percent, the number of patients avoiding care was at 23.1 percent, and 32.5 percent of respondents said they had no doctor. Each measure was on a downward trend, despite fluctuations of varying intensity since the ACA’s implementation in 2010.

By the final quarter of 2017, however, all three of these measures had risen with uninsurance hitting its highest apex since the third quarter of 2015 at 27.5 percent.

The study found that uninsurance saw the most increases in states that did not expand Medicaid. Affordability also took its hardest hits in these states. Individuals with incomes below 138 percent of the federal poverty line suffered the greatest decrease in uninsurance and affordability.

Medicaid expansion did not make a difference overall on whether or not a patient had a provider; the percentages suffered in both states that did and did not expand Medicaid. 

However, when the researchers drilled down into different subcategories, they found that one determining factor was income. Low-income respondents in expansion states were more likely to have a personal provider than those in nonexpansion states, which saw a two percent increase in low-income respondents without a personal provider between 2016 and 2017.

Specifically, when considering care avoidance due to cost, this disparity based on income did not exist in the four years prior to President Trump taking office.

Annual results proved to be similar to the quarterly results. Insurance dropped by 0.9 percent and care avoidance rose by 0.8 percentage points from 2016 to 2017. In comparing this to the quarterly changes, the Health Affairs researchers characterized this change as “highly significant, although slightly attenuated.”

Care avoidance for both high- and low-income groups fell by 8.5 percentage points between the end of 2013 and the end of 2016 in expansion states. 

Disparities in care avoidance arose in 2017, however. The absolute disparity between care avoidance in wealthy and poor participants in nonexpansion states rose 2.6 percentage points, from 23.4 percentage points to 26.0 percentage points. In contrast, expansion states saw a one percentage point decline in absolute disparity.

Ultimately, the researchers estimated that 17 percent of the adjusted change in healthcare coverage reversed by the end of 2017.

“The nature of our study design did not allow us to causally link changes in health care access with specific policy interventions. For instance, it is unclear whether the observed protective effects of Medicaid expansion are due to expansion per se or to other related state policies and activities,” the researchers admitted.

While they could not definitively link the changes in access to care back to the specific source, the study worked to eliminate non-policy factors such as the economy or demographic changes.

“The declines in coverage coincided with the implementation of federal policies that shortened enrollment periods and reduced advertising and outreach, as well as with general confusion about the ACA’s status after the repeal debate,” the researchers found.

Further study is needed to confirm whether these trends continued into 2018 and 2019. However, related studies have demonstrated that Medicaid expansion states continued enjoying lower uninsurance rates after 2017 and that expansion might even have the capacity to improve employment.