ACA Expanded Insurance, Access for Women 18-44

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The Affordable Care Act (ACA) was associated with expanded insurance coverage and improvements in access to care for women of reproductive age, particularly for those with lower incomes.

The Affordable Care Act (ACA) was associated with expanded insurance coverage and improvements in access to care for women of reproductive age, particularly for those with lower incomes, according to a study published Thursday.

Rates of uninsurance have historically been higher among women compared with the general population for 2 reasons: they are less likely to be insured through work and younger adults are less likely to have coverage than older adults. Before the ACA, public coverage options for women not old enough for Medicare were limited, and Medicaid was narrow, as well. By 2009, the year before President Obama signed his landmark health law, 1 in 4 women of reproductive age and 1 in 8 pregnant women reported being currently uninsured.

In a national study of the first 3 years of the ACA’s major coverage expansions, researchers found significant reductions in uninsurance and increases in nongroup private insurance and Medicaid among reproductive-aged women aged 18 to 44. They also found significant decreases in women reporting not having a usual source of care and cost-related barriers to medical care.

Additional analysis showed the changes were larger among lower-income women. However, outcomes for pregnant women did not show a significant change.


The authors said these findings showing reductions in cost and improvements in access to care extends previous research demonstrating how the ACA improved insurance coverage to women of reproductive age. Previous research has shown that the ACA caused the rate of the uninsured to fall to 10% in 2016, down from 17% in 2013, and even more in states that expanded Medicaid.

This was an observational analysis of the 2010 to 2016 panels of the National Health Interview Survey (NHIS), a nationally representative survey of US households conducted by the CDC.

Researchers compared current insurance type, cost-related barriers to medical care, and no usual source of care among women aged 18 to 44 (n = 128,352) and pregnant (n = 2179) NHIS respondents. Time frames before (2010-2013) and after (2015-2016) the ACA were examined.

The law was associated with a 7.4 percentage-point decrease in the probability of uninsurance (95% CI = —8.6 to –6.2), a 3.6 percentage-point increase in Medicaid (95% CI = 2.5, 4.7), and a 3.1 percentage-point increase in nongroup private coverage (95% CI = 2.1, 4.1).

The ACA was also associated with a 1.5 percentage-point decline in cost-related barriers to medical care (95% CI = —2.6 to –0.5) and a 2.4 percentage-point reduction in lacking a usual source of care (95% CI = –4.5 to –0.3).

In the first year of implementation, there was an 18% drop in uninsured women, growing to a 33% decline in the second and third years of implementation.

In addition, the improvements were concentrated among women earning less than 185% of the federal poverty level, the median state income threshold to qualify for pregnancy-related Medicaid coverage when the ACA was implemented. Women in this income range are more likely to experience inadequate prenatal care and severe maternal illness. Increasing insurance rates may improve outcomes among Medicaid-covered births by increasing access to family planning services and interventions to reduce risk factors for adverse pregnancy outcomes before conception.

Increases in Medicaid coverage rates among women may also improve postpartum health outcomes for low-income women, as more women will be able to maintain Medicaid long term rather than losing it when pregnancy-related Medicaid coverage expires 60 days after delivery.


Daw JR, Sommers BD. The Affordable Care Act and access to care for reproductive-aged and pregnant women in the United States, 2010—2016 [published online February 21, 2019]. Am J Public Health. doi:10.2105/AJPH.2018.304928.