The Affordable Care Act (ACA) completed its second open enrollment period in February 2015. Assessing the law’s effects has major policy implications.
To estimate national changes in self-reported coverage, access to care, and health during the ACA’s first 2 open enrollment periods and to assess differences between low-income 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 through 64 years (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. Then, pre-ACA (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 among 28 states and Washington, DC) vs nonexpansion states (n = 37 283 among 22 states) were compared using a differences-in-differences approach.
Beginning of the ACA’s first open enrollment period (October 2013).
Main Outcomes and Measures
Self-reported rates of being uninsured, lacking a personal physician, lacking easy access to medicine, inability to afford needed care, overall health status, and health-related activity limitations.
Among the 507 055 adults in this survey, pre-ACA trends were significantly worsening for all outcomes. Compared with the pre-ACA trends, by the first quarter of 2015, the adjusted proportions who were uninsured decreased by 7.9 percentage points (95% CI, −9.1 to −6.7); who lacked a personal physician, −3.5 percentage points (95% CI, −4.8 to −2.2); who lacked easy access to medicine, −2.4 percentage points (95% CI, −3.3 to −1.5); who were unable to afford care, −5.5 percentage points (95% CI, −6.7 to −4.2); who reported fair/poor health, −3.4 percentage points (95% CI, −4.6 to −2.2); and the percentage of days with activities limited by health, −1.7 percentage points (95% CI, −2.4 to −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 to −8.5]) than white adults (−6.1 percentage points [95% CI, −7.3 to −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 to −2.6]), lacking a personal physician (−1.8 percentage points [95% CI, −3.4 to −0.3]), and difficulty accessing medicine (−2.2 percentage points [95% CI, −3.8 to −0.7]).
Conclusions and Relevance
The ACA’s first 2 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 with adults in states that did not expand Medicaid.