Gains in Coverage and Access to Care in Recent Years

A study by the Commonwealth Fund reports that uninsured rates have dropped in all states and fewer patients in most states report cost is a barrier to care. These improvements were observed in the years after the implementation of the Affordable Care Act (ACA).

Recent data have indicated that the rate of uninsured Americans under age 65 is currently at 11%, a record low. The Commonwealth Fund study reports that in 2013, before the ACA significantly expanded coverage, 17% of this population was uninsured. By 2015, all states saw their adult uninsured rates drop from their 2013 levels, and for 48 states and the District of Columbia, they decreased by 3 percentage points or more.

Unsurprisingly, the states that had expanded Medicaid eligibility saw the greatest improvements in the rates of uninsured adult residents. In 9 of these states, the uninsured rate was reduced by 10 to 13 percentage points, and 6 of these states cut their uninsured rates by at least half from 2013 to 2015. Improvements were observed even in states that had not expanded Medicaid, some of which saw their rates of uninsured adults drop by 7 to 9 percentage points. Medicaid expansion has particularly helped lower the rate of uninsured low-income adults from 38% in 2013 to 25% in 2015. All states saw reductions in these rates, but the greatest improvements were generally seen in states that had expanded Medicaid.

The expansion of coverage under the ACA also helped reduce the rates of uninsured children, which were already lower than those of adults prior to expansion due to federal initiatives like the Children’s Health Insurance Program (CHIP). The report’s authors theorize that these improvements in coverage among children reflect the “welcome mat effect,” which occurs when “people who were previously eligible but not enrolled for Medicaid or CHIP signed up, as a result of increased outreach efforts and awareness of insurance coverage.”

Another metric analyzed in the report was access to healthcare. In 38 states and DC, the proportion of adults who said they had not gone to the doctor when they needed to because of the cost declined by at least 2 percentage points from 2013 to 2015. These improvements are linked to the drop in uninsured rates for each state. Kentucky, which saw the largest decrease in the share of adults who could not afford necessary care, also had the largest decrease in adult uninsured rates.

Access to dental care, which is not a required component of coverage under ACA marketplace plans or state Medicaid programs, did not meaningfully improve from 2012 to 2014 (the years with available data). The nationwide rate of adults who reported they had not had a dentist visit in a year or more remained steady at 16%, and in 9 states this rate actually increased, indicating that access to dental care had worsened.

The report also detailed that access to care had improved for at-risk adults and that uninsured rates among black and Hispanic adults had decreased significantly since the ACA’s coverage expansions. The authors state that the US “is closer than it has ever been to achieving near-universal coverage,” citing the reductions in uninsured rates and cost-related access barriers since the implementation of the ACA. However, they caution that Republican lawmakers and President-elect Donald Trump could undo these accomplishments by repealing the ACA and cutting funding for CHIP and Medicaid.

“The ACA’s health insurance coverage expansions are working to get people covered and help them afford healthcare,” report coauthor Sara Collins, PhD, vice president for Health Care Coverage and Access at The Commonwealth Fund, said in a press release. “In this time of uncertainty about the ACA, it’s important to keep in mind the financial and health protection health insurance provides for families.”