Over the course of 2017, positive trends in insurance coverage and healthcare access from the Affordable Care Act reversed, particularly for low-income residents of states that did not expand Medicaid.

A new Boston University School of Public Health (BUSPH) study finds that two million more Americans avoided health care because of inability to pay, and/or did not have health insurance, at the end of 2017 compared to the end of 2016.

Published in the February issue of Health Affairs, the study examines the period from 2011 to 2017, showing positive trends in healthcare coverage and access following implementation of the Affordable Care Act (ACA, also known as Obamacare), and a reversal of those trends when newly-elected President Trump and Congressional Republicans began working to dismantle the ACA.

“We hear a lot about the ACA being ‘undermined.’ While we found the ACA isn’t unravelling, there are real consequences to some of the policies that have been put in place. We see that you have these policy changes that are affecting millions of peoples’ ability to get insurance, and millions of people forgoing care because they can’t afford it,” says Mr. Kevin Griffith, a doctoral candidate at BUSPH and the study’s lead author.

Griffith and colleagues used data on a nationally-representative sample of 2.2 million U.S. residents between the ages of 18 and 64 years old from the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System.

The researchers note that this did not give them the ability to directly analyze the causal effects of specific policies, but the quarterly data did allow them to see that trends reversed coinciding with these changes. “This is a time when additional states are implementing Medicaid expansion, and the economy’s improving, so you wouldn’t traditionally think that access would be declining,” Griffith says.

The researchers note several policy changes in 2017 that could have had effects immediate enough to see within the same year, such as shortened enrollment periods, cuts in advertising and navigator funding, and reductions in payments to hospitals. They also note widespread confusion during the “repeal and replace” battle, when a quarter of Americans believed the ACA had been at least partially repealed.

The researchers estimated that uninsurance rates fell by 7.1 percentage points from 2013 to 2016 before rising by 1.2 points during 2017. After a similar downward trend, they found a 1.0-percentage-point increase in adults who avoided health care because of costs in 2017.

They found that low-income residents of states that did not expand Medicaid were the hardest hit by the reversal, while those affected in expansion states were mostly middle-income residents who were eligible for the exchanges. In non-expansion states, the decrease in insurance coverage and healthcare access was four to five times greater than in expansion states.

They also found that the gap in healthcare access between higher- and lower-income people shrank from 2013 to 2016 by about 8.5 percentage points in expansion and nonexpansion states. Then, from the fourth quarter of 2016 to the fourth quarter of 2017, the gap increased by 2.6 percentage points in nonexpansion states (a relative increase of 11 percent) but continued to decrease by another 1.0 point in expansion states (a relative decrease of 8 percent).

“Medicaid expansion seemed to be a really great way for states to insulate themselves from some of the damage of these federal policies,” Griffith says. “For states considering Medicaid expansion, this shows that it’s a good way to take care of your residents, even regardless of what’s going on in Congress.”

The researchers are now looking through 2017 into 2018 and beyond, to see how federal policy changes and more states expanding Medicaid have affected these trends. Griffith says the results of the 2017-focused study are likely an indicator of worse to come.

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