Health and Health Care Use Among Individuals at Risk to Lose Health Insurance With Repeal of the Affordable Care Act

Approximately 20 million individuals have gained health insurance under the Affordable Care Act (ACA),¹ including young adults covered under parental insurance, those purchasing private insurance on exchanges, and those covered through state Medicaid expansion. As of mid-2016, 10.4 million individuals had private insurance policies through the exchanges, of whom 84% had incomes below 400% of the federal poverty level (FPL) and received premium tax credits.² Enrollment is projected at 13.8 million by the end of the open enrollment period in 2017.³ State Medicaid expansion covered individuals with incomes below 138% FPL and included childless adults who were ineligible for Medicaid prior to the ACA. By 2016, over 14.6 million adults were enrolled in Medicaid under the “new adult” category, of which 11 million were newly eligible under the ACA.⁴ Results of the 2016 US election suggest that the ACA may be repealed or modified. Health and health care use by individuals at risk of losing health insurance should be better understood.

Using the Integrated Health Interview Series⁵ of the 2015 National Health Interview Survey (NHIS), we identified 3 groups of adults younger than 65 years at risk to lose health insurance if premium tax credits are eliminated and Medicaid expansion is rolled back. The first group included adults with incomes below 400% FPL who purchased insurance through exchanges. If premium tax credits were to be removed, this group could experience substantial premium increases. The second group included childless adults with incomes below 138% FPL who are covered through Medicaid and who do not receive Social Security income due to disability. This group represents newly eligible Medicaid adults under the ACA. The third group included Medicaid-enrolled parents or adults in families with children who did not receive disability income and whose income was 50% to 138% FPL. Before the ACA, the median eligibility threshold across states was 61% FPL for parents or adult caretakers,⁶ so a large portion of this group could lose coverage. We characterized sociodemographic characteristics, rates of chronic disease, and health care utilization, and compared the 3 groups with adults younger than 65 years with employer-sponsored insurance, a group unlikely to be affected by changes in subsidies on exchanges or to Medicaid. We used NHIS survey weights to produce nationally representative estimates. We used χ² tests for statistical comparisons between groups. Because we used publically available, previously collected, deidentified data, this study was exempt from institutional review board review.

The NHIS was representative of 112 787 040 adults with employer-sponsored insurance, 6 799 679 adults in exchanges, 4 367 348 Medicaid childless adults, and 4 630 117 Medicaid parents or adult caretakers. Adults in the 3 groups at risk to lose insurance were significantly more likely to be minorities, poor, and unemployed than adults in the employer-sponsored insurance group, and had significantly less educational attainment (Table 1). As compared with the employer-sponsored insurance group, adults in the 3 groups at risk to lose insurance had significantly higher rates of self-reported poor health and in many cases, but not all, were more likely to have certain chronic diseases, have visited the emergency department at least once, been hospitalized, and have 10 or more physician office visits in the past 12 months (Table 2).

Our analysis highlights the socioeconomic vulnerability and rates of chronic diseases and health care utilization of individuals at risk to lose health insurance if the ACA is modified or repealed such that premium tax credits are eliminated and Medicaid expansion is rolled back. We did not include children who obtained coverage through exchanges, which accounts for approximately 16% of those with insurance through exchanges, nor considered the impacts of other possible ACA modifications, including changes to plan affordability, protections against preexisting conditions, or changes to state Medicaid block grant programs. Nevertheless, the serious consequences for those at risk to lose coverage if premium tax credits and Medicaid expansion are rolled back are striking.

These consequences point to the challenges Congress should address before enacting new health care legislation.

Corresponding Author: Pinar Karaca-Mandic, PhD, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455 (pkmandic@umn.edu).

Correction: This article was corrected on April 3, 2017, for a missing conflict of interest disclosure for Dr Karaca-Mandic.

Published Online: January 20, 2017. doi:10.1001/jamainternmed.2016.9541

Author Contributions: Dr Karaca-Mandic had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Karaca-Mandic, Ross.

Drafting of the manuscript: Karaca-Madic, Jena.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Karaca-Mandic, Jena.

Administrative, technical, or material support: Karaca-Mandic.

Study supervision: Karaca-Mandic.

Conflict of Interest Disclosures: Dr Karaca-Mandic serves as a consultant to Precision Health Economics and Tactile Medical. Dr Jena receives consulting fees from Pfizer, Hill Rom Services, Bristol Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals, and Precision Health Economics. Dr Ross receives support through Yale University from Johnson and Johnson, Medtronic, the Centers of Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), the Blue Cross Blue Shield Association, and the Laura and John Arnold Foundation.

Funding/Support: This work was funded in part by the Office of the Director, National Institutes of Health NIH Early Independence Award (grant 1DP5OD017897-01 to Dr Jena).

Role of the Funder/Sponsor: The funder/sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Ross is an associate editor of JAMA Internal Medicine, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: We would like to acknowledge the Minnesota Population Center and the State Health Access Data Assistance Center at the University of Minnesota for access to data from the Integrated Health Interview Series.