Two Million Americans Lost Health Coverage/Access in Trump’s First Year

Posted on: February 3, 2020 Topics: ACA, access to care, affordable care act, health care, health insurance, healthcare, healthcare costs, healthcare disparities, healthcare system, insurance, medicaid, obamacare, politics and health, underinsurance

Worried couple looking at billsA new School of Public Health 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,” says Kevin Griffith, a doctoral candidate in the Department of Health Law, Policy & Management and the study’s lead author.

“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.”

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.

Percent of low-income households that were uninsured, had no personal doctor, or avoided care because of cost, 2011–17. Kevin N. Griffith, David K. Jones, Jacob H. Bor, and Benjamin D. Sommers. “Changes In Coverage, Access, And Income-Based Disparities Among US Adults, 2011–17.” Health Affairs, February 2020.

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 ACA exchanges. In non-expansion states, the decrease in insurance coverage and healthcare access was four to five times greater than in expansion states.

The researchers 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.”

Differences between rich and poor households in rates of avoided care because of cost in the fourth quarters of 2013, 2016, and 17, by whether or not states expanded eligibility for Medicaid. Kevin N. Griffith, David K. Jones, Jacob H. Bor, and Benjamin D. Sommers. “Changes In Coverage, Access, And Income-Based Disparities Among US Adults, 2011–17.” Health Affairs, February 2020.

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.

“We had this narrowing of disparities in access and coverage, but that’s reversing,” he says. “Since 2017, the split between white and black, between rich and poor, urban and rural, renters and homeowners—all of these disparities are getting wider again. That’s concerning.”

The study was co-authored by: Jacob Bor, assistant professor and Peter T. Paul Career Development Professor of global health and epidemiology; David Jones, associate professor of health law, policy & management; and Benjamin Sommers of the Harvard T. H. Chan School of Public Health and Brigham and Women’s Hospital.

Michelle Samuels

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  1. Rural hospital bankruptcy is the other manifestation of the same process. The lies during the State of the Union make this a frustrating topic!

  2. Study does not address the effect on these numbers from the individual mandate and therefore brings the objectivity of the entire study into question.

  3. I agree with Dr. Insaf (I am assuming he is a doctor). A drop from 2013 to 2014 would be expected when people are forced to buy health insurance or pay a penalty.

    Studying the chart from 2014 2nd quarter through 4th quarter 2017 is a better representation of what was going on at that time under the individual mandate which was not ended until 2019 by dropping the IRS penalty to $0. The real argument here should turn to how do we fix it without forcing low-income households to pay for the over priced health care our system generates and not bankrupting the country. Perhaps if congress had not wasted the last 3 years trying to unseat the President we would have the answer.

  4. Patients have chosen no insurance due to the extraordinary deductibles and the monthly premiums that are too costly for their incomes; many patients who have insurance choose not to use it for prescriptions and testing since good rx and similar plans are an affordable alternative

  5. Millions more people are out of the shadows and now in the work force. These folks are now being counted. Of course the numbers will skew because of this and the fact that the ridiculous mandate is gone. Let’s find a way to get all insured while lowering cost, premiums, copays, coinsurance and deductibles.

    1. This is a poorly thought out study.
      The particular data used in your study demonstrate a bias towards results that
      fit a political preconceived notion. If this was submitted to a journal I edited, it would be rejected.
      You can do better than that.

  6. Right after ACA was implemented, many hospitals and provider dropped out of ACA insurances.
    Which doctors take Obama Care?
    Solution is not universal coverage of poor quality, but to offer better coverage. Affordable was unaffordable,
    we alll know that, especially those who had 27 years old adults who could not afford the co-payments or high cost of insurance. It was flawed policy that was lumped on the rest of us to support.
    By the way, We still cannot get rid ACA.
    Insurance costs are getting higher, and quality getting poorer!!

  7. I think everyone can agree on universal base coverage for low-cost items with high health yield. No one should die because they can’t afford their amoxicillin, propranolol, or a Coumadin level.
    In a preposterous and true story a twenty-year-old kid I know was in a MVA (not his fault). He had no insurance yet received half-a-million in ER, ICU, and acute rehab care after a car accident to put him back together. But he couldn’t afford his $20 antibiotic once he left the hospital and ended up going back and forth to the ER generating more staggering bills.
    We all have seen this.
    However, we must accept, you will never be able to provide state-of-the-art, comprehensive coverage with no cap allowing pre-existing conditions under any type of an insurance model. Insurance is based on analysis of risk. You cannot assess financial risk for a population when a person can deny insurance, wait till they need a $5 million dollar bone marrow transplant, then apply. And if those costs skyrocket to $20 million…you still have to pay. This is an acctuarialist’s Seven Bridges of Königsberg.

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