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ACA’s Biggest Winners: Long-Term Uninsured

The long-term uninsured were most likely to gain coverage from Affordable Care Act. (Volume 9, Issue 28)

The Affordable Care Act (ACA) created the largest expansion of health insurance coverage in the United States in the roughly fifty years since the creation of Medicare and Medicaid. However, the ACA differs from prior expansions which largely targeted specific patient populations such as the elderly, disabled, and children. Instead, the law sought to fill the gaps largely through a combination of and new . However, exactly who would sign up for these new insurance programs became a source of speculation prior to implementation of these reforms.

Source: National Center for Health Statistics

In a recent article, Decker and Lipton sought to answer this “who” question. Specifically, “How long were individuals uninsured prior to gaining new insurance coverage?” The authors utilized data from 106,651 adult Americans between ages 19 and 64 in the National Health Interview Survey. By comparing the responses from 2013 to those in 2014, they were able to examine the changes in the uninsured population in the years immediately before and after ACA implementation.

Overall, they found that the rate of uninsured fell from 18% to 13.9% in a single year. Similar to prior research, coverage gains were significantly more pronounced in . For the individuals who gained coverage, over half came from those who were categorized as long-term uninsured (greater than three years). Amongst this population, the gains were dramatic.  In a single year, the rate of long-term uninsured dropped by 24.5%.

These findings offer some clues as to the greater impact of the coverage expansion on patients and health systems. The authors wisely point out that doctors may see a temporary increase patient volume due to pent-up demand from the long-term uninsured. Many of these patients likely will need to catch up in preventive care treatments and may have undiagnosed medical conditions. For patients and healthcare providers alike, this may prove challenging in the short-term.

Of course, these findings are especially pertinent in the current Congressional environment that has pledged to “repeal and replace” the ACA. While it still remains unclear if this is even politically or logistically feasible, the stakes are high. If current coverage availability is disrupted, millions of Americans will be at risk for prolonged periods without insurance. Unfortunately, those who might lose coverage under a repeal situation might find themselves uninsured for years at a time.

commentary by Kyle Fischer


In 2014-after the implementation of most of the Affordable Care Act provisions, including Medicaid expansions in some states and subsidies to purchase Marketplace coverage in all states-adults who had been uninsured for more than three years represented a larger share of the newly insured, compared to adults who had been insured for shorter periods of time.

PMID: 28069842 Decker, SL and Lipton, BJ. Health Affairs. 2017; 36(1): 16-20.

Kyle Fischer, MD, MPH
About Kyle Fischer, MD, MPH

Kyle Fischer is a practicing emergency physician in Maryland. He received a combined MD/MPH from the University of Wisconsin School of Medicine and subsequently completed an emergency medicine residency at Drexel University. Dr. Fischer possesses legislative health policy experience in both the Wisconsin and Maryland state legislatures and the United States House of Representatives. Broadly, his interests lie in health system and payment reform, integration of public health measures into emergency care as well as targeted interventions of high-risk populations, particularly victims of violent injury. Of note, he participates as the policy liaison for the National Network of Hospital-Based Violence Intervention Programs. He is currently a health policy fellow in the University of Maryland Department of Emergency Medicine and tweets at @KBFischer. Contact: Website | Facebook | Twitter | Google+ | More Posts