Sara R. Collins, Munira Z. Gunja, Michelle M. Doty, Sophie Beutel
S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on Their Own, The Commonwealth Fund, February 2017.
Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers’ experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people’s ability to buy health plans on their own following the passage of the ACA. For adults with family incomes less than $48,500, uninsured rates dropped about 17 percentage points below their 2010 peak. Lower-income whites, blacks, and Latinos have experienced drops this large, though Latinos are uninsured at higher rates. Among working-age adults who had shopped for plans in the individual market and ACA marketplaces over the prior three years, the percentage who reported it was very difficult to find affordable plans fell by nearly half from 2010, prior to the ACA reforms, to 2016. Coverage gains are helping working-age Americans get the care they need: the number of adults who reported problems getting needed health care and filling prescriptions because of costs fell from a high of 80 million in 2012 to an estimated 63 million in 2016.
Prior to the passage of the Affordable Care Act, the individual insurance market was a notoriously difficult place for consumers without employer-based health benefits to purchase insurance. It also was challenging for insurers to sell insurance without incurring large losses. As a result, insurers went to great lengths to exclude people with even mild health problems. In 2010, the Commonwealth Fund Biennial Health Insurance Survey found that more than one-third of people who tried to purchase health insurance in the individual market in the previous three years—an estimated 9 million people—had been turned down, charged a higher price, or had a condition excluded from their health plan.1
By January 2016, near the end of the ACA’s fourth open-enrollment period, things had changed. The size of the individual market has nearly doubled since 2010.2 As a result of changes that have made purchasing and affording coverage easier—and with consumer protections such as bans against insurers charging people more or denying coverage because of preexisting conditions—nearly 9 million people have signed up for a plan through HealthCare.gov, the federal marketplace website.3 This does not include enrollment in 11 states plus the District of Columbia that operate their own marketplaces. An additional 7 million are estimated to have purchased coverage in the individual market outside the marketplaces, where insurers must comply with the same regulations as the ACA.4 Further, more than 16 million people have enrolled in Medicaid and the Children’s Health Insurance Program.5 All told, more than 30 million people are currently insured as a result of the ACA’s insurance subsidies, expanded Medicaid eligibility, state and federal outreach efforts, and market regulations.
Members of Congress and the Trump administration are currently pursuing repeal of certain provisions of the ACA. In this time of uncertainty, the Commonwealth Fund Biennial Health Insurance Survey, fielded nearly every other year since 2001, examines long-term trends in the stability of insurance coverage, consumers’ experiences buying coverage, cost-barriers to timely health care, and problems paying medical bills. The current survey was conducted from July 12 to November 20, 2016, by Princeton Survey Research Associates International, with 4,186 adults ages 19 to 64 (see “How This Study Was Conducted” for more information).
The number of uninsured U.S. adults ages 19 to 64 declined to 23 million, or 12 percent of the population, in July to November 2016 from a high of 37 million, or 20 percent, in 2010 (Exhibit 1, Table 1).6,7 An estimated 18 million adults, or 10 percent, were insured at the time of the survey but had gaps in their insurance coverage in the past 12 months—about the same as in years prior to the ACA. About 147 million adults, or 78 percent, were insured continuously in 2016, up from a low of 70 percent, or 129 million, in 2012.
There have been broad coverage gains since passage of the law in 2010 across racial and ethnic groups, age ranges, and income. People with low and moderate incomes have experienced particularly dramatic gains. For adults with family incomes less than $48,500, the uninsured rates are now about 17 percentage points below their 2010 peak and 10 percentage points below 2001 levels (Exhibit 2). Whites, blacks, and Latinos in lower-income households have experienced drops this large. For lower-income Latinos, while the drops have been similar, they are uninsured at higher rates than whites and blacks. This is because Latinos had higher rates of uninsurance than other groups prior to the ACA, some states that have not expanded eligibility for Medicaid have large Latino populations, and undocumented immigrants are not allowed to enroll in the law’s coverage expansions.8 Young adults ages 19 to 34 have made the largest gains of any age group since 2010 (Exhibit 3).
Prior to the ACA, people without job-based health benefits had few affordable options. Because public insurance programs like Medicaid and the Children’s Health Insurance Program were available in most states only to children, pregnant women, and parents with very low incomes, people without job-based insurance were limited to purchasing coverage in the individual market and paying full premiums. States set their own rules for their markets; in most, people were charged premiums that reflected their health, gender, and age. They could be denied coverage because of a preexisting condition or have conditions excluded from their plan.9 Once insured, they could face annual and lifetime limits on what plans would pay and could have a policy cancelled retroactively (i.e., “rescinded”) if they developed a health problem.
One of the primary goals of the ACA was to reform the individual insurance market so that anyone without employer health benefits, regardless of their health status, could find and afford a plan that provided coverage at least as comprehensive as an employer plan. Under the ACA, insurers in the individual market now must offer a plan to all who apply, cannot charge people more based on health or gender, are limited in how much more they can charge an older person relative to someone younger, and are restricted from imposing lifetime or annual benefit limits and rescissions. To help consumers choose plans, all must be sold at four tiers of coverage that vary only by premium and cost-sharing amounts. The benefit package stays the same and must cover an essential set of services. Finally, people with incomes between $24,000 and $97,000 for a family of four are eligible for premium tax credits that reduce their share of premium costs.
These changes have made a dramatic difference. In 2010, an estimated 26 million people said they either had a plan or tried to buy a health plan in the individual market over the prior three years (Exhibit 4).10 In 2016, 44 million tried to purchase coverage either through the marketplaces or directly from an insurance company. In 2010, fewer than half (46%) of people who tried to buy a plan on their own, or 12 million people, ended up purchasing one. By 2016, two-thirds (66%), or 29 million people, ended up purchasing a health plan in the preceding three years.11
In 2010, 60 percent of adults who had a plan or tried to buy a plan on their own in the individual market found it very difficult or impossible to find one they could afford (Exhibit 4). By 2016, that percentage had fallen to about one-third (34%) of people. Among people with health problems, the share of those reporting difficulties finding an affordable plan dropped from 70 percent in 2010 to 42 percent in 2016. Among those with incomes less than 200 percent of poverty, the percentage who had trouble finding a plan they could afford dropped from nearly two-thirds (64%) in 2010 to one-third (35%) in 2016. Adults with higher incomes also found it easier to find an affordable plan in 2016 compared to 2010.
The law’s requirements for comprehensive health plans, along with bans on preexisting condition exclusions, appear to have made a significant difference in people’s ability to find plans that fit their health care needs. In 2010, 43 percent of people buying plans on their own said they found it very difficult or impossible to find a plan with coverage they needed; by 2016, the share had fallen to one-quarter (25%) (Exhibit 4). Among those with health problems, the share who reported difficulty finding a plan that met their needs fell from 53 percent in 2010 to 31 percent in 2016.
Expanded insurance coverage also is helping people get the care they need. The number of adults who did not get needed care in the past 12 months because of cost declined from a high of 80 million in 2012, or 43 percent of those surveyed, to 63 million, or 34 percent, in 2016 (Exhibit 5, Table 2). This is the lowest rate of cost-related access problems reported by adults since this measure was added to the survey in 2003.
There were declines in all four cost-related access problems asked about in the survey. The percentage of adults who said that because of cost they had not gone to the doctor when they were sick fell from 29 percent in 2012 to 20 percent in 2016; the percentage of those who said they had not filled a prescription because of cost dropped from 27 percent in 2012 to 19 percent in 2016; the share who said they skipped a recommended test, treatment, or follow-up visit because of cost fell from 27 percent to 18 percent; and the share who said they had not gotten needed care from a specialist fell from 20 percent to 13 percent (Table 2).
These population-wide declines in cost-related problems getting care are consistent with other recent federal surveys and reflect nationwide gains in insurance coverage.12 Fewer people are facing the full cost of their health care. We also found declines in cost-related problems getting care among the uninsured (Exhibit 6, Table 3), possibly explained by improved economic conditions as well as a significant shift in the demographic composition of the uninsured in the wake of the ACA’s coverage expansions.13
Still, as in past surveys, uninsured adults reported cost-related access problems at nearly two times the rate of those insured all year (Exhibit 6). In addition, cost-related access problems among people who had experienced gaps in coverage in the prior year were almost as high as those who were uninsured at the time of the survey.
While there have been modest declines in cost-related access problems among insured adults, rates remain high: three of 10 adults (29%) who had coverage for the full year reported not getting care because of cost. People with individual market coverage continue to report cost-related access problems at higher rates than those with employer coverage (45% vs. 28%) (Table 3).
There has been modest but significant improvement in the percentage of adults who report medically related financial difficulties. In 2012, 75 million people, or 41 percent of those surveyed, said they had problems paying their medical bills in the past 12 months or were paying off medical debt. In 2016, this figure was 70 million, or 37 percent (Exhibit 7, Table 2).14
From 2012 to 2016, among the four areas of medical bill problems asked about in the survey, there was significant improvement among people’s ability to pay their bills and fewer reports of calls from collection agencies about unpaid bills. The percentage of adults who said they had problems paying or were unable able to pay their bills fell from 30 percent to 23 percent (Table 2). The percentage who reported they had been contacted by a collection agency about unpaid medical bills fell from 18 percent to 14 percent.
But there has been no improvement in the share of people who are paying off medical debt over time. Nearly a quarter (24%) of adults, or an estimated 46 million people, reported they had medical bills they were paying off over time, nearly the same as in 2012 (Table 2).
Lacking health insurance for even part of the year is associated with a much higher risk of medical bill problems, particularly among people with low incomes. Nearly two-thirds (63%) of adults with incomes of less than 200 percent of poverty who had experienced a gap in their insurance coverage in 2016 reported difficulties paying medical bills or were in medical debt compared to just over a third (36%) of people in that income group who had been insured continuously (Exhibit 8). Still, these rates are high even for insured adults.
Having health insurance coverage paves the way for people to have a regular doctor and get timely medical care. In the survey, continuously insured adults are more likely than those who were uninsured to have a regular source of care and to report receiving timely preventive care tests and cancer screenings (Exhibits 9 and 10, Table 3). Even gaps in health insurance is associated with disruptions in recommended care. For example, 72 percent of women ages 40–64 who had been insured continuously had received a mammogram in the past two years, compared to 55 percent of those who had a coverage gap and only 40 percent of those who were uninsured at the time of the survey.
This analysis indicates the Affordable Care Act has increased health insurance coverage for U.S. adults of all races, ages, and income groups. These coverage gains are allowing working-age adults to get the health care they need. In contrast, Americans who still lack health insurance are less likely to go to the doctor when they need to or get preventive care and cancer screenings. Even a gap in coverage is often associated with a lower likelihood that someone will get timely health care.
The Commonwealth Fund Biennial Health Insurance Survey highlights the strong growth in the use of the individual market by Americans since the ACA market reforms and subsidies went into effect in 2014. The market has evolved from being a place where mostly healthy people and those with sufficient income could buy plans to one where all are offered comprehensive plans, regardless of factors like gender or health status, with income-based financial assistance to offset costs for those eligible.
The survey does expose areas of weakness in the law and in U.S. health insurance coverage generally, including that offered by employers. The rates of people who cite problems affording plans in the individual market or finding plans that meet their needs have improved but remain high. These problems could be remedied by improving the generosity of marketplace subsidies as well as ongoing efforts to help people understand and compare health plans. Nearly 23 million working-age adults remained uninsured in 2016. To cover more people, all states could move to expand their Medicaid programs and increase outreach efforts to those potentially eligible. Immigration reform and lifting restrictions on ACA eligibility for undocumented immigrants could help lower uninsured rates among Latinos. Finally, rates of cost-related problems getting needed care and medical bill problems remain high even among insured people in all coverage types. Reducing deductibles and other cost-sharing in all private plans would help alleviate health care cost burdens for U.S. families whose incomes have barely kept pace with growth in medical costs.15 Repealing the Affordable Care Act’s insurance subsidies and Medicaid expansion without an effective replacement plan will only exacerbate these weaknesses in the marketplaces and leave problems in employer-based plans unaddressed.
The Commonwealth Fund Biennial Health Insurance Survey, 2016, was conducted by Princeton Survey Research Associates International from July 12 to November 20, 2016. The survey consisted of 25-minute telephone interviews in either English or Spanish and was conducted among a random, nationally representative sample of 6,005 adults age 19 and older living in the continental United States. A combination of landline and cellular phone random-digit dial samples was used to reach people. In all, 2,402 interviews were conducted with respondents on landline telephones and 3,603 interviews were conducted on cellular phones, including 2,262 with respondents who live in households with no landline telephone access.
The sample was designed to generalize to the U.S. adult population and to allow separate analyses of responses of low-income households. This report limits the analysis to respondents ages 19 to 64 (n=4,186). Statistical results are weighted to correct for the stratified sample design, the overlapping landline and cellular phone sample frames, and disproportionate nonresponse that might bias results. The data are weighted to the U.S. adult population by age, sex, race/ethnicity, education, household size, geographic region, population density, and household telephone use, using the U.S. Census Bureau’s 2016 Annual Social and Economic Supplement.
The resulting weighted sample is representative of the approximately 187.4 million U.S. adults ages 19 to 64. The survey has an overall margin of sampling error of +/– 1.9 percentage points at the 95 percent confidence level. The landline portion of the survey achieved a 14 percent response rate and the cellular phone component achieved a 10 percent response rate.
We also report estimates from the 2001, 2003, 2005, 2010, 2012, and 2014 Commonwealth Fund Biennial Health Insurance Surveys. These surveys were conducted by Princeton Survey Research Associates International using the same stratified sampling strategy that was used in 2016, except the 2001, 2003, and 2005 surveys did not include a cellular phone random-digit dial sample. In 2001, the survey was conducted from April 27 through July 29, 2001, and included 2,829 adults ages 19 to 64; in 2003, the survey was conducted from September 3, 2003, through January 4, 2004, and included 3,293 adults ages 19 to 64; in 2005, the survey was conducted from August 18, 2005, to January 5, 2006, among 3,352 adults ages 19 to 64; in 2010, the survey was conducted from July 14 to November 30, 2010, among 3,033 adults ages 19 to 64; in 2012, the survey was conducted from April 26 to August 19, 2012, among 3,393 adults ages 19 to 64; and in 2014, the survey was conducted from July 22 to December 14, 2014, among 4,251 adults ages 19 to 64.
1 S. R. Collins, M. M. Doty, R. Robertson, and T. Garber, Help on the Horizon: How the Recession Has Left Millions of Workers Without Health Insurance, and How Health Reform Will Bring Relief—Findings from The Commonwealth Fund Biennial Health Insurance Survey of 2010 (The Commonwealth Fund, March 2011).
2 The number of people ages 19 to 64 with individual coverage climbed from an estimated 11.4 million people in 2010 to 22.7 million in 2015; analysis of the Current Population Survey by Sherry Glied and Ougni Chakraborty for The Commonwealth Fund.
3 Centers for Medicare and Medicaid Services, Biweekly Enrollment Snapshot: Weeks 10 and 11, Jan. 1–Jan. 14, 2017, News release (CMS, Jan. 18, 2017).
4 Office of the Assistant Secretary for Planning and Evaluation, About 2.5 Million People Who Currently Buy Coverage Off-Marketplace May Be Eligible for ACA Subsidies, ASPE Data Point, (ASPE, Oct. 4, 2016).
5 Centers for Medicare and Medicaid Services, Medicaid and CHIP November 2016 Application, Eligibility, and Enrollment Data (CMS, Jan. 18, 2017). This includes people eligible for both expanded eligibility for coverage under the ACA and the existing Medicaid and CHIP programs.
6 All reported differences are statistically significant at the p≤0.05 level or better unless otherwise noted.
7 These estimates are in the range of those found in other recent surveys. The federal government and a number of private organizations including The Commonwealth Fund have used different surveys and methodologies aimed at measuring the change in insurance coverage as a result of the coverage expansions under the Affordable Care Act. Most recently, the Center for Disease Control’s National Health Interview Survey found that in the first six months of 2016, 8.9 percent of the U.S. population, or 28.4 million people, and 12.4 percent of adults ages 18 to 64, or 24.4 million people, were uninsured (https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201611.pdf). Data from the U.S. Census Bureau’s Current Population Survey (CPS) showed that 12.6 percent of adults ages 19 to 64, or 24.3 million people, were uninsured in 2015 (http://www.census.gov/library/publications/2016/demo/p60-257.html; analysis of 2015 Current Population Survey by Sherry Glied and Ougni Chakraborty of New York University for The Commonwealth Fund). The Commonwealth Fund reported in May 2016 using its ACA Tracking Survey that the uninsured rate among adults ages 19 to 64 had declined from 19.9 percent in July–September 2013 to 12.7 percent in February–April 2016, or an estimated 24 million people (http://www.commonwealthfund.org/publications/issue-briefs/2016/may/aca-tracking-survey-access-to-care-and-satisfaction).
8 The survey finds that low-income Latinos born outside the United States are uninsured at significantly higher rates (42 percent) than are Latinos born in the United States (15 percent). This distinction should only be viewed as a loose approximation of immigration status.
9 M. M. Doty, S. R. Collins, J. L. Nicholson, and S. D. Rustgi, Failure to Protect: Why the Individual Insurance Market Is Not a Viable Option for Most U.S. Families (The Commonwealth Fund, July 2009); K. Swartz, Reinsuring Health: Why More Middle Class People Are Uninsured and What Government Can Do (Russell Sage Foundation, 2006); S. R. Collins, C. Schoen, K. Davis, A. Gauthier, and S. Schoenbaum, A Roadmap to Health Insurance for All: Principles for Reform (The Commonwealth Fund, Oct. 2007); N. C. Turnbull and N. M. Kane, Insuring the Healthy or Insuring the Sick? The Dilemma of Regulating the Individual Health Insurance Market—Findings from a Study of Seven States (The Commonwealth Fund, Feb. 2005).
10 S. R. Collins, M. M. Doty, R. Robertson, and T. Garber, Help on the Horizon: How the Recession Has Left Millions of Workers Without Health Insurance, and How Health Reform Will Bring Relief—Findings from The Commonwealth Fund Biennial Health Insurance Survey of 2010 (The Commonwealth Fund, March 2011).
11 Of this group, some people who shopped for plans in the marketplaces may have ended up enrolling in Medicaid. By the time of the survey in 2016, of this group 15 percent had a Medicaid plan, 30 percent were enrolled in an employer plan, and 43 percent had a plan through the individual market.
12 S. L. Hayes, S. R. Collins, D. C. Radley, D. McCarthy, and S. Beutel, A Long Way in a Short Time: States’ Progress on Health Care Coverage and Access, 2013–2015 (The Commonwealth Fund, Dec. 2016); and B. W. Ward, T. C. Clarke, and J. S. Schiller, Early Release of Selected Estimates Based on Data from the January–June 2016 National Health Interview Survey (National Center for Health Statistics, Nov. 2016).
13 In particular, Latinos make up a significantly greater share of the uninsured in 2016 than they did in 2010 (31% vs. 42%) (data not shown). As a group, Latinos report less use of health care overall than do whites (M. M. Doty, Hispanic Patients’ Double Burden: Lack of Health Insurance and Limited English, The Commonwealth Fund, Feb. 2003). In addition, uninsured Latinos have consistently reported significantly lower rates of cost-related problems getting needed care than whites over the duration of the survey (data not shown).
14 While this is slightly higher than the rate in 2014, the change is not statistically significant.
15 S. R. Collins, D. C. Radley, M. Z. Gunja, and S. Beutel, The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch (The Commonwealth Fund, Oct. 2016).
The authors thank David Blumenthal, Kathleen Regan, Don Moulds, Barry Scholl, Eric Schneider, Dana Sarnak, Arnav Shah, Deborah Lorber, Chris Hollander, Christine Haran, Paul Frame, and Jen Wilson of The Commonwealth Fund for helpful comments, data checking, and editorial support and design.