Health Reform and Changes in Health Insurance Coverage in 2014
July 23, 2014DOI: 10.1056/NEJMsr1406753
Open enrollment under the Affordable Care Act (ACA), the most ambitious attempt to expand health coverage in the United States in decades, began October 1, 2013. The law offers Medicaid eligibility to citizens and qualified legal immigrants with incomes at or below 138% of the federal poverty level in participating states and tax credits for private insurance purchased via marketplaces for persons not eligible for Medicaid who have incomes between 100% and 400% of the federal poverty level.1The effect of these provisions on insurance coverage and access to care is of critical policy interest.
Preliminary reports from rapid-turnaround surveys have described a decline in the uninsured rate since the fall of 2013, when open enrollment began.2-5 However, numerous factors, including the economy, survey sampling error, and preexisting trends, can affect estimated rates of Americans without insurance. More generally, the systemic changes brought by the ACA pose a particular challenge for identifying the effect of the law, owing to the lack of a control group. Although to date 24 states have not expanded Medicaid, the ACA has major implications for these states, owing to subsidized marketplace coverage, the individual mandate, and a streamlined application process for uninsured persons who were previously eligible for Medicaid.6 An additional question is how quickly any coverage changes will lead to improved access to care. READ MORE…