Coverage for Adults With Chronic Disease Under the First 5 Years of the Affordable Care Act

BACKGROUND: A key goal of the Patient Protection and Affordable Care Act (ACA) was to increase health insurance coverage for people with chronic disease. Little is known about progress toward this goal over the first 5 years of ACA implementation. OBJECTIVE: The objective of this study was to assess changes in coverage for nonelderly adults with and without chronic disease over the first 5 years of ACA implementation, and the effects of state-level Medicaid eligibility expansions on coverage for these populations. RESEARCH DESIGN: Multivariable and difference-in-differences regression models. PARTICIPANTS: A total of 2,007,271 adults aged 18–64 years in the nationally representative Behavioral Risk Factor Surveillance System 2011–2018 data. MEASURES: Self-reported insurance coverage. RESULTS: Over the first 5 years of ACA implementation, coverage increased among nonelderly adults with versus without chronic disease by 6.9 versus 5.4 percentage points, respectively (95% confidence interval: 6.1–7.6, P<0.001, and 4.4–6.3, P<0.001, respectively). State-level Medicaid eligibility expansions were associated with a coverage increase among people with chronic disease of 2.8 percentage points (95% confidence interval: 1.7–3.8, P<0.001). After ACA implementation diminished in 2017, coverage gains for people with chronic disease declined by 0.9 percentage points (P<0.001). CONCLUSIONS: Coverage significantly improved for people with chronic disease during the first 5 years of ACA implementation, with ACA Medicaid expansions increasing coverage further. After ACA implementation diminished in 2017, coverage gains decreased.