ACA: 10.3 Million Americans Newly Insured, Study Shows

Marcia Frellick

July 24, 2014

The number of uninsured adults in the United States has dropped by 5.2 percentage points from the beginning of open enrollment under the Affordable Care Act (ACA) in October 2013 through the second quarter of 2014, according to a New England Journal of Medicine special report published online July 23.

The drop represents a 26% relative decline from 2012 to 2013 and translates to 10.3 million adults gaining coverage, the report says.

Declines in the uninsured rate were significant (P < .001) for all subgroups defined by age, sex, and race or ethnic group, with the largest changes evident among Hispanics (down 7.7 percentage points), blacks (down 6.8 percentage points), and adults aged 18 to 34 years (down 6.5 percentage points).

Declines in the uninsured were highest in the states that expanded Medicaid. By the second quarter of 2014, the rate of uninsured among people with incomes at or below 138% of the poverty level dropped 6 percentage points (P = .006) in states with Medicaid expansion compared with a nonsignificant decline of 3.1 percentage points (P = .13) in the population among states without Medicaid expansion.

Among those in the next income range (139% - 400% of the federal poverty level), the uninsured rate dropped 9 percentage points in states with Medicaid expansion and 5.5 percentage points in those without Medicaid expansion (P < .001 for both comparisons).

Benjamin Sommers, MD, PhD, assistant professor in the Harvard School of Public Health, Boston, Massachusetts, and colleagues primarily used results from the largest national daily poll on health issues, the Gallup–Healthways Well-Being Index (WBI). The WBI is a daily telephone survey that asks US adults about health insurance, access to care, and health status. It is a rapid-turnaround survey with a much lower response rate (11%) than government-conducted surveys.

The authors looked at coverage changes in the fourth quarter of 2013 and the first 2 quarters of 2014, adjusting for the preexisting trend of coverage and potential confounders such as employment, income, and demographic characteristics.

Numbers Who Have Personal Physician Rise

The researchers also found a 2.2 percentage point increase in the likelihood of having a personal physician (P < .001) and a decrease of 2.7 percentage points in the number of people struggling to afford their care. They found that access to care increased quickly at the beginning of open enrollment.

"We found evidence that within the first 6 months of gaining insurance, more adults reported having a personal doctor and fewer had difficulties paying for medical care — even though the latter measure asked about the prior 12 months. These results are consistent with studies of previous insurance expansions that have shown that gains in coverage can lead to rapid improvements in access," the authors write.

The survey sample included more than 420,000 adults aged 18 to 64 years from January 1, 2012, through June 30, 2014. The average age was 41.1 years, and respondent percentages were 63% white, 15% Hispanic, and 10% black.

Among limitations were factors including economic climate and survey sampling error that can affect estimated rates of the uninsured. In addition, the lack of a control group presents challenges for determining the precise effect of the law.

26 States Have Expanded Medicaid

Open enrollment under the ACA began October 1, 2013. The law extended Medicaid eligibility to citizens and legal immigrants with incomes at or below 138% of the federal poverty level in participating states. So far, 26 states and the District of Columbia have expanded Medicaid. The act also offered tax credits for private insurance purchased through exchanges for people who do not qualify for Medicaid and who have incomes between 100% and 400% of the federal poverty level.

The authors note that their conclusions are observational and make assumptions about the relationships among the ACA, the number of uninsured, and access to care.

National estimates of coverage since October 2013 will not be available from federal surveys until late 2014, the report says, and state-level estimates will not be available until fall of 2015.

Dr. Sommers reports having received salary support from Agency for Healthcare Research and Quality, the National Institute for Healthcare Management, and the Commonwealth Fund and other support from the Georgia Budget & Policy Institute and the Healthcare Channel outside the submitted work. In addition, he is a senior adviser for the US Department of Health and Human Services. The other authors have disclosed no relevant financial relationships.

N Engl J Med. Published online July 23, 2014. Full text

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