Changes in Coverage, Access to Care, and Disparities in 2017

Importance: The Affordable Care Act (ACA) increased insurance coverage and access to care. However, since January 2017, the Trump administration has shortened enrollment periods, reduced outreach for the program, and attempted to repeal the law. It is unknown what effect these changes have had on overall coverage levels and access to care.

Objective: Assess changes in insurance coverage and access to care among U.S. adults before and after the change in administration in 2017, stratified by income and Medicaid expansion status.

Design: Interrupted time series.

Setting & Participants: Non-institutionalized U.S. residents aged 18-64 who responded to the Behavioral Risk Factor Surveillance System 2011-2017 (N=2,156,370).

Exposures: Change in administration in 2017, and whether a state chose to accept the Medicaid expansion.

Main Outcomes & Measures: Self-reported insurance coverage, access to a primary care physician, and avoidance of care due to cost.

Results: Between 2014 and 2016, the ACA was associated with large decreases in the proportion of adults who were uninsured, did not have personal doctor, or avoided care due to cost. However, this pattern began to reverse in 2017. From 2016Q4 to 2017Q4, the proportion of adults without health insurance increased by 1.4 percentage points (95% CI -2.4 to -0.4). The proportion of respondents indicating that they avoided medical care due to cost increased by 1.4 percentage points (95% CI 0.6 to 2.2). Declines in access were greater among respondents who were Black, rural, had household incomes under 138% of federal poverty level (FPL), or resided in states which opted not to expand Medicaid. As a result, absolute race- and income-based disparities increased in 2017, reversing earlier trends.

Conclusions: Health care coverage and access worsened in 2017, following several years of improvements after passage of the Affordable Care Act. These changes were largest among racial/ethnic minorities and those living in non-expansion states.