ACA Gains Most Prevalent Among Adults Living Closest to Poverty Line


The Affordable Care Act reduced financial strain for all low-income adults; however, the most significant reductions were seen in those living closest to the federal poverty line.

The Affordable Care Act (ACA) helped improve health care-related financial strain in low-income groups, particularly among those living closest to the federal poverty line, according to findings from a new study.

In the study, which was published in INQUIRY, researchers from Drexel University sought to analyze changes in poverty-driven disparities in health care financial strain, access, and utilization among working-age adults across the Federal Poverty Level (FPL) spectrum. The study used data from 133,762 adults pulled from the 2011-2016 National Health Interview Surveys. The researchers compared the near-poverty line population with those making an income 4 times greater than the poverty line or more.

Individuals living closest to the federal poverty line experienced the most significant reductions in health-related financial strain and un-insurance rates after the implementation of the ACA compared with before. Relative to those earning more than 400% of the FPL, the largest effects were seen among those earning between 0% to 124% and 125% to 199% of the FPL.

According to the data, un-insurance rates for those below or near the poverty line dropped between 11.2% and 14.2%. Additionally, they were more likely to be able to pay for their prescriptions and pay for care when needed.

“Really, the insurance expansion did more than just provide access to the health care system,” lead author Ryan McKenna, PhD, assistant professor in Drexel’s Dornsife School of Public Health, said in a press release. “Our work shows that the ACA reduced financial strain for all citizens, with the largest gains occurring among the most financially vulnerable individuals.”

According to the researchers, these gains are likely due to a combination of the Medicaid expansion and heavily subsidized private coverage premiums combined with cost-sharing reduction subsidies. Despite the improvements, however, adults in the lower FPL groups continue to have worse outcomes relative to those in the highest FPL group.

To further build on their findings, the researchers hope to analyze the quality of insurance coverage available to those who are on the federal exchanges and Medicaid.

“Specifically, we want to look at the availability of providers within an enrollee’s insurance network,” Dr McKenna said in the press release. “It is unclear how the emergence of narrow provider networks—which might not contain all the necessary specialists and could be far apart—affect the access to and utilization of care for those gaining coverage under the ACA.”

Because the ACA appears to have attenuated health care-related financial strain among those in low- and middle-FPL categories, these groups may be most sensitive to potential repeal efforts, according to the researchers.

“Policy makers should be sensitive to how future changes to the ACA will affect adults in these FPL groups, particularly with respect to increased financial strain that could arise from less generous coverage either through the elimination of cost-sharing reduction payments or cuts to Medicaid benefits as a result of new funding formulas,” they wrote.


McKenna RM, Langellier BA Alcalá HE. The Affordable Care Act attenuates financial strain according to poverty level. INQUIRY. 2018.

Obamacare Relieved Financial Strain of Those Closest to the Federal Poverty Line [news release]. Drexel’s website. Accessed August 6, 2018.

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