Changes in insurance coverage associated with healthcare reform: do we see an extra benefit for adults with chronic health conditions?
Study design:We pooled data for non-institutionalized U.S. adults aged 21-64 years from the 2012-2014 National Health Interview Survey. Using information on family structure, family income as a percent of the federal poverty level (FPL), employment-related insurance offers, and current coverage, we assigned adults to six categories generally reflecting expanded Medicaid eligibility or subsidized private coverage: 1) income <100% FPL with dependent children [Medicaid expansion]; 2) income <100% FPL without dependent children [Medicaid expansion]; 3) income between 100-250% FPL, without alternative “affordable” coverage [marketplace premium subsidies and cost-sharing reductions]; 4) income between 250-400% FPL, without alternative “affordable” coverage [premium subsidies]; 5) income between 100-400% FPL, with ESI offers or Medicare [alternative coverage sources]; and 6) adults with income >400% FPL [elimination of health-status rating or exclusions only]. Indicators for a history of cancer, serious respiratory conditions, cardiac conditions, gastrointestinal or liver disease (GI), and diabetes were based on responses to questions about “whether a doctor ever told you that you had [condition]?” Bivariate analyses compared coverage (uninsured, Medicaid or SCHIP, private) pre- (2012-2013) and first year post (2014) ACA implementation. Linear probability difference-in-difference regressions examined pre-post coverage changes by category, and tested for differential effects by presence of chronic conditions, with controls for age, race, sex, marital status, educational attainment, and region.
Principle research findings:Prior to the ACA, 9.1% of working aged adults were Medicaid enrolled, with 3.0% other public, 66.3% private and 20.0% uninsured. Uninsured rates ranged from 4.7% among adults with income >400% FPL to 55.8% among adults with income 100-250% FPL, and from 12.7% among adults with cancer to 18.2% among adults with GI disease. Adjusted DID estimates indicate significant overall reductions in uninsured (3.9 percentage points) and increases in both Medicaid/SCHIP (2.1 points) and private coverage (1.8 points).The largest reductions in uninsured rates occurred for adults eligible for premium subsidies and cost sharing reductions (11.2 points). No coverage effects were found for the category with income>400% FPL. Interactions between chronic health conditions and the post-implementation period were uniformly small and not significant.
Conclusion:ACA implementation was associated with reductions in uninsurance targeted to particularly vulnerable populations. Adults with chronic conditions had lower uninsured rates prior to the ACA, and experienced Medicaid takeup or private insurance enrollment similar to adults without the conditions. Further stratification of eligibility categories by state Medicaid expansion policy is expected to further clarify coverage patterns.
Implications for policy or practice: Insurance coverage is essential to ensure adequate access to care for adults with chronic health conditions. The ACA included major provisions to reduce historic barriers to accessing coverage for affected adults. Further research is needed to assess implications for access and utilization for adults with chronic health conditions.