Without Obamacare 18.1 million would be Uninsured

Health care reform under President Obama aimed to decrease the number of uninsured in the United States via passage of the Affordable Care Act (ACA).  Though the political implications of the ACA will largely be determined by the outcomes of the upcoming elections, analysis of insurance rates in the U.S. can be used to assess the effectiveness of the ACA in providing access to health care to the American uninsured.

Both political parties have used the ACA for personal advantage, often identifying factoids and statistics that support their position or provide political gains. Few debate whether insurance rates have risen since implementation of the ACA began in 2010. However, no studies have compared trends in the number of uninsured individuals against counterfactual scenarios where forces in health care present prior to 2010 continued to current day. Comparison with this counterfactual reality is necessary to assess whether changes in insurance rates in the U.S. are due to provisions within the ACA or due to the persistence of existing trends within health care.

Employer-based insurance has been the standard source of healthcare coverage since the early 20th century. The decline in employer-based insurance, coupled with a Great Recession that saw unemployment rates peak above 9%, lead to a spike in the rate of uninsurance in the mid-2000s. The economic recovery and legislative trends towards increasing coverage for children would have increased insurance rates from nadirs in the mid-2000s irrespective of the ACA. Despite these existing trends, analysis of insurance rates from 2000-2015 show a reduction in the number of uninsured by 46% attributable to the ACA. These 18.1 million individuals, who are no longer uninsured, are found in middle-income groups aged 19-25 and 45-64 years old; many gained coverage due to expansions in Medicaid in the 26 states and the District of Columbia which implemented the ACA’s coverage expansion. This number will increase when more states expand.

With a focus on demographic shifts and insurance trends within age and socioeconomic classes, the analysis confirms estimates by the Congressional Budget Office in 2010. The clarity provided by academic analysis of health care trends has the potential to help referee what is shaping to be an election cycle full of partisan myths and political group-speak.

commentary by Orlando Sola

Abstract

Time lags in receiving data from long-standing, large federal surveys complicate real-time estimation of the coverage effects of full Affordable Care Act (ACA) implementation. Fast-turnaround household surveys fill some of the void in data on recent changes to insurance coverage, but they lack the historical data that allow analysts to account for trends that predate the ACA, economic fluctuations, and earlier public program expansions when predicting how many people would be uninsured without comprehensive health care reform. Using data from the Current Population Survey (CPS) from 2000 to 2012 and the Health Reform Monitoring Survey (HRMS) data for 2013 and 2015, this article develops an approach to estimate the number of people who would be uninsured in the absence of the ACA and isolates the change in coverage as of March 2015 that can be attributed to the ACA. We produce counterfactual forecasts of the number of uninsured absent the ACA for 9 age-income groups and compare these estimates with 2015 estimates based on HRMS relative coverage changes applied to CPS-based population estimates. As of March 2015, we find the ACA has reduced the number of uninsured adults by 18.1 million compared with the number who would have been uninsured at that time had the law not been implemented. That decline represents a 46% reduction in the number of nonelderly adults without insurance. The approach developed here can be applied to other federal data and timely surveys to provide a range of estimates of the overall effects of reform.

PMID: 27076474 Blumberg, LJ, et al. Inquiry. 2016 April 13; 53.