The impact of the Affordable Care Act on health care access and self-assessed health in the Trump Era (2017-2018).

Abstract

ObjectiveTo estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on health care access and self‐assessed health during the first 2 years of the Trump administration (2017 and 2018).Data SourceThe 2011‐2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self‐assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year.DesignWe estimate difference‐in‐difference‐in‐differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre‐2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self‐assessed health. We also examine differences by income and race/ethnicity.Principal FindingsDespite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018.ConclusionsWhile gains in access and self‐assessed health continued in the first 2 years of the Trump administration, the ongoing debate at both the federal and state level surrounding the future of the ACA suggests the need to continue monitoring how the law impacts these and many other important outcomes over time.