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Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults

Low-income adult has better health care now


Low-income adults in Arkansas and Kentucky who obtained coverage under the Affordable Care Act’s Medicaid expansion had better access to primary care and preventive health services, lower out-of-pocket costs, improved medication compliance, and improved self-reported health status than did low-income adults in Texas, which did not expand Medicaid. Among adults with chronic conditions, ACA coverage was associated with better disease management and medication compliance and a significant increase in self-reported health status.

The Issue

Congress is currently weighing the future of the Affordable Care Act. Since becoming law, the ACA has helped more than 20 million Americans enroll in health insurance coverage, and national studies have noted improvements in coverage, consumer satisfaction, and access to care. In this Commonwealth Fund–supported study, researchers compared Kentucky, which expanded Medicaid as prescribed by the ACA; Arkansas, which obtained a waiver to use federal Medicaid funds available through the ACA to purchase private marketplace insurance for low-income adults; and Texas, which did not expand Medicaid coverage. Looking at these three states, the authors assessed ongoing changes in health care use and self-reported health among low-income adults, including those with chronic conditions, after three full years of the ACA’s coverage expansions.

Data indicate that the ACA’s coverage expansion to low-income adults was associated with significant improvements in access to primary care and medications, affordability of care, preventive visits, screening tests, and self-reported health.

Key Findings

  • By the end of 2016, the uninsured rate in Arkansas and Kentucky—the two expansion states—had dropped by more than 20 percentage points compared to Texas, the nonexpansion state. In 2016, the uninsured rate was 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas.
  • Low-income adults in Kentucky and Arkansas who gained coverage experienced a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket costs, and a 23-point increase in the share of those who reported they were in “excellent” health.
  • Results were similarly positive for people with chronic illnesses who gained coverage because of the ACA. Low-income patients with diabetes, heart disease, hypertension, and stroke who gained coverage were 56 points more likely to report having regular care for their condition than were chronically ill adults in Texas, 51 points less likely than those in Texas to skip medications because of the cost, and 20 points more likely to report being in excellent health.

The Big Picture

The study suggests a strong link between insurance coverage, quality of care, and health. It also shows that two traditionally vulnerable populations have made significant gains from the ACA’s expansion of health coverage: low-income adults and people with chronic illnesses.

The study’s results also offer insights into alternative state approaches to expanding coverage, as the two expansion states experienced similar gains. “Coverage expansion is quite important for patients,” the authors conclude, “but the type of coverage obtained is less critical.”

About the Study

Researchers used survey data from Arkansas, Kentucky, and Texas, gathered yearly from 2013 through 2016, to compare the experiences of low-income adults—those with incomes below 138 percent of the federal poverty level—with respect to health care access, affordability, utilization, and quality, as well as health status.

The Bottom Line

Expanding health care coverage significantly improves the ability of low-income adults to access health care services and leads to improved self-reported health status. The benefits of having health care coverage are especially pronounced for individuals with chronic illness.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


Benjamin D. Sommers et al., “Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults,” Health Affairs, published online May 17, 2017.