A new study from Ben Sommers and researchers at the Harvard T. H. Chan School of Public Health suggests that at least some of the daily lived experience of people has not changed, even as fewer and fewer of them have become uninsured. That study finds that churn in three states in 2015 after the major coverage expansions of Obamacare was not significantly different from churn in 2013 before those expansions came into effect. For both years, roughly about one-fifth of the population of low-income adults in Texas, Arkansas, and Kentucky changed their insurance. Among those, Texas did not opt to expand Medicaid to all low-income adults, which suggests that reforms have so far done little to change the latent instability of coverage for the most vulnerable people.
From a policy perspective, these results are actually promising, because such a sweeping law with so many policy changes, new requirements, and insurers dropping in and out of markets should be expected to increase churn by a great deal. That it hasn’t means President Obama’s unrealistic promise about keeping health-insurance plans has actually been less damaging than it could be. But for millions of Americans—even those who switch between coverage types and don’t enter the ranks of the long-term uninsured—churn is inconvenient, if not dangerous. The Harvard study finds that 56 percent of all low-income people who changed coverage or status in 2015 faced some temporary or long-term gap in coverage where they were essentially uninsured. Almost 20 percent of all these churners had to change physicians, and 40 percent reported that the quality of their health care declined.
The results from this study may not be generalizable across the country and only speak to the experience of low-income people who are generally at the highest risk for instability, but those are also the people most likely to be uninsured and affected by coverage expansions. For most other people, the coverage gains of Obamacare are even less apparent as immediate benefits. For employer-based private coverage, under which most Americans receive their insurance, costs have increased at about the same rate over inflation and wages as they always have. For people who enroll for coverage in the private insurance exchanges, premiums jumped by between 13 percent and 21 percent over the last year. While most people who receive coverage this way are protected from insurance cost increases by government subsidies, those who have to pay full price have to shoulder the entire burden of that increase. Among people with exchange coverage, dissatisfaction with costs has risen for each of the years since the exchanges were created.
The expansion of health-insurance coverage has had real, positive effects on the ability of families to pay for medical bills, but those effects might not move the enthusiasm needle much. Results for the end of 2015 and first quarter of 2016 are forthcoming, but the National Health Interview Survey indicates that the proportion of non-elderly people in households that had trouble paying for medical bills dropped from 18 percent in 2014 to 16.5 percent in early 2015. That’s a significant decrease in the number of people hampered by medical bills, but the decrease is part of a gradual, neatly sloped decrease predating Obamacare’s passage, which might indicate that the rising tide of economic recovery simply makes families more economically resilient. The Affordable Care Act played a role in that recovery and in macroeconomic effects leading to those families’ improving fortunes, but that point is likely obscure where public opinion is concerned.