Issue: The Affordable Care Act’s (ACA) coverage provisions have extended health insurance coverage to millions of Americans. While the effects of the Medicaid expansion and marketplace establishments on coverage have been well studied, the resulting effects of coverage on access to health care remain unclear.
Goal: To examine how the 2014 coverage expansions affected health care access following the first open enrollment period of October 2013 to March 2014.
Methods: Analysis of data from the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS).
Findings and Conclusions: We find that gaining insurance coverage through the expansions decreased the probability of not receiving medical care by between 20.9 percent and 25 percent. Gaining insurance coverage also increased the probability of having a usual place of care by between 47.1 percent and 86.5 percent. These findings suggest that not only has the ACA decreased the number of uninsured Americans, but has substantially improved access to care for those who gained coverage.
One of the main goals of health reform like the Affordable Care Act (ACA) is to expand insurance coverage and, ultimately, to increase access to care. Among its reforms, the ACA expanded Medicaid coverage in participating states to all nonelderly adults with incomes below 133 percent of the federal poverty level (FPL), about $16,000 for an individual or $33,500 for a family of four, and provided subsidized insurance through the health care marketplaces for small businesses and individuals without access to employment-based insurance. Since the ACA’s first open enrollment period in the fall of 2013, the number of uninsured Americans has fallen from 41 million to 27 million.1
Many prior studies have examined the relationship between insurance coverage and access to care. Virtually all have found that people with health insurance, whether Medicaid or private coverage, have better access to services. However, studies that compare people with and without coverage can be biased; people who choose to participate in coverage may differ from those who do not.2 For instance, people in poorer health may be more likely to sign up for care than healthy people.
A few studies have examined how access to care at the population level has improved since ACA implementation.3,4 One study, using the Gallup-Healthways Well-Being Index, found that by the end of the second enrollment period in 2015, the proportion of Americans without a personal doctor decreased by 3.5 percentage points and the proportion reporting an inability to afford care decreased by 5.5 percentage points.5 These improvements were more pronounced in states that expanded Medicaid. Another study, using data from the Health Reform Monitoring Survey (HRMS), examined how various measures of access and affordability changed between the first and second open enrollment periods.6 Among all income groups, there were significant improvements, including increases in the proportion reporting a regular source of care and in those reporting decreases in unmet needs because of cost of care. A recent Commonwealth Fund survey found that 72 percent of those enrolled in a marketplace plan or in Medicaid had used their insurance to visit a doctor, hospital, or other health care provider. More than half said they would not have been able to access or afford care before getting coverage through the ACA.7 There is also evidence to suggest that the ACA has significantly reduced health disparities between racial and ethnic groups.8
While these studies avoid the problems of selection in the prior literature, they do not fully disentangle improvements in access resulting from the ACA and those resulting from other contemporaneous changes, such as slower growth in health care costs and an improving economy.
In this study, we used two datasets— the National Health Interview Survey (NHIS) restricted use data and the Behavioral Risk Factor Surveillance System (BRFSS)—to directly estimate the effect of the ACA’s first open enrollment on health care access. The initial rollout of the ACA varied across states during that period, depending on how well state websites and enrollment processes operated in the early months of 2014, as well as whether states chose to participate in the Medicaid expansion. We use this variation to more accurately identify the effects of new coverage and capture the impact of the ACA. We measured access to medical care in the past year and access to a personal doctor or usual place of care.
Effect of Increases in Marketplace Enrollment on Access to Care on a Population-Wide Basis
Before implementation of the ACA’s coverage expansions, many Americans had inadequate access to care. A substantial share of the nonelderly population—from 9 percent to 19 percent, depending on the question asked—went without care because of cost in the period before the ACA expansions were implemented. The percentage was somewhat higher among those in the income range that is eligible for marketplace subsidies and much higher among those with incomes in the Medicaid-eligible range (Exhibit 1). Many adults reported that they had no usual place of care.
We examined how increases in marketplace enrollment affected how people in a state accessed care, controlling for states’ decisions to expand Medicaid. In the NHIS data, we found that for each additional 1 percent of the nonelderly population enrolled in the marketplace, 0.23 percent fewer were likely to report not getting medical care because of cost. On average, 2.5 percent of the U.S. population was enrolled in the marketplaces in 2014. These data imply that enrollment in the marketplaces decreased the national rate of not getting medical care because of costs by 0.57 percentage points. Relative to the baseline level in Exhibit 1, this estimate suggests that marketplace enrollment in 2014 alone reduced the number of people facing cost-related barriers to access by 6 percent.
Similarly, for every 1 percent increase in the number of nonelderly people enrolled in the marketplaces, 0.51 percent more report having a usual place to get medical care (Exhibit 2). Given the national marketplace enrollment in 2014, this translates into a 1.3 percentage point increase in the rate of nonelderly adults who report a usual place to access medical care. The effects are larger in the BRFSS data. These estimates imply that enrollment in the marketplaces increased the rate of nonelderly population with a usual place of care by 2 percentage points.
Effects of Marketplace and Medicaid Coverage on Enrollees’ Access to Care
The population-level effects described above show how access to care changed across a state’s population. On an individual basis, gaining insurance coverage through the ACA decreases the probability that a person will report not receiving medical care because of costs by 20.9 percent (Exhibit 3), according to the NHIS data. In the BRFSS data, insurance coverage is associated with a 25 percent decrease in the probability of not receiving medical care because of cost. To put this figure in context, prior to implementation of the insurance expansions, about 47 percent of uninsured people reported that they were unable to access care because of cost. Gaining coverage cut that figure by half. Getting coverage through the ACA is also associated with very substantial increases in the probability of having a usual place of care—by 47.1 percent according to the NHIS data and 86.5 percent in the BRFSS data.9 These figures imply that people who gained coverage through the ACA’s expansions were just as likely to have a usual source of care as were those who had held insurance prior to the coverage expansions.
When the ACA was first introduced and debated, some opponents of the law argued that it was not needed because uninsured people already had adequate access to care.10 Since its passage, others have argued that the insurance coverage provided to people under the ACA provides insufficient protection against high costs or offers such limited networks that the newly insured cannot find care.11,12 These arguments imply that the ACA would not generate improvements in access to care.
Our analysis provides strong evidence that this implication is false. Expanding Medicaid coverage and establishing state marketplaces have not only decreased the number of Americans who are uninsured but has substantially improved access to care for those who gained coverage. People who are newly insured through the ACA are much less likely than uninsured people to report that they are unable to get care or delayed getting care because of cost. They are just as likely as those who have always been covered to report that they now have a usual place of care.