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Insurance Loss in the Era of the Affordable Care Act

Association With Access to Health Services

Mojtabai, Ramin MD, PhD, MPH

doi: 10.1097/MLR.0000000000001150
Brief Report

Background: Every year, millions of Americans lose their health insurance and remain uninsured for various reasons, potentially impacting access to medical services.

Objective: To examine trends in health insurance loss in the periods shortly before and after implementation of Patient Protection and Affordable Care Act (ACA) and to assess the association of past-year health insurance loss with access to health services and medications.

Research Design and Subjects: Trends in health insurance loss were examined in 176,961 nonelderly adult participants of the National Health Interview Survey 2011–2017—a representative cross-sectional annual survey of US general population. Multivariable logistic regression models were used to examine access to health services and medications.

Measures: Loss of private insurance or Medicaid in the past year; use of emergency room services and hospitalizations; contact with medical providers; affording medical care or medications; cost-related medication nonadherence.

Results: Private health insurance loss decreased from 3.9%–4.0% in 2011–2013 to 2.7% to 3.1% in 2014–2017 (P<0.001); Medicaid loss decreased from 8.5%–8.9% to 4.6%–6.4% in this period (P<0.001). Nevertheless, as late as 2017, ∼6 million uninsured adults reported having lost private insurance or Medicaid in the past year. Loss of either type of health insurance was associated with lower odds of accessing medical providers, but higher odds of not affording medical care and poor adherence to medication regimens to save costs.

Conclusions: Implementation of ACA was associated with lower risk of health insurance loss. Nevertheless, health insurance loss remains a major barrier to accessing health services and prescribed medications.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

The author declares no conflict of interest.

Reprints: Ramin Mojtabai, MD, PhD, MPH, 624 North Broadway, Room 797, Baltimore, MD 21205. E-mail:

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