Obamacare’s Success So Far
Uninsured rates decline in most states, more so for those “embracing” the legislation, and Wisconsin finds itself in the middle of the pack.
How effective has the Affordable Care Act been in decreasing the ranks of the uninsured around the country and here in Wisconsin? On August 5, Gallup Healthways released its first state-by-state estimates since the provisions setting up health exchanges and encouraging states to expand Medicare took effect at the beginning of this year. These are the first such estimates based on actual polling, rather than economic models.
Gallup divides the states into two groups:
- Those “embracing” the Affordable Care Act by expanding Medicaid and setting up their own exchanges or creating a partnership with the federal government.
- States that have declined Medicare expansion and/or are using the federal exchange.
Gallup found that in states embracing the ACA, the average uninsured rate declined 4.0 percentage points, compared to 2.2 points in the remaining states. This is equivalent to a 25% reduction in the states embracing the ACA and a 12% reduction in the others.
A scatterplot of the state reductions versus last year’s uninsured rates is shown below. States embracing the ACA are shown with solid blue squares. The other states are shown with red circles. The dotted lines represent the trend for each group. Wisconsin is the red triangle.
As Gallup points out, states with the lowest uninsured rates before the ACA kicked in were most likely to embrace it. Ironically, states with the most uninsured were more likely to turn down federal funds for expanding Medicare.
The individual state results should be treated with a healthy dose of skepticism. Gallup estimates the margin of error is as high as +5 points for small states. Particularly for states that started with a low uninsured rate, any apparent changes may simply reflect sampling error.
With that caution in mind, it is useful to look at the results for several states:
- Wisconsin (red triangle) appears to fall between the two groups. Like the states embracing the ACA, it found a way to offer Medicare to people below the poverty line who didn’t have children. But like those opposed to the ACA, it didn’t accept federal money to expand Medicare and did not establish its own exchange.
- The state with a 5.1 point increase in uninsured is Kansas. This may be a sampling error, but Kansas has become a hotbed of ultra-conservative thought and legislation. Is there something about this political environment that also discourages enrollment in health care?
- Outliers in the other direction were Kentucky and Arkansas, the two states with the largest decline in uninsured rates. Both started with high uninsured rates but embraced the ACA. The outgoing Kentucky governor is well regarded for his crusade to provide more residents with health insurance.
Apparently, Gallup used the exchange decision as a proxy for the political establishment’s enthusiasm for the ACA. Was the ACA viewed as an opportunity or a threat? A regression analysis of Gallup’s “embrace” variable paints a more accurate picture than one only the Medicaid expansion decision. Rates of success increase if the people responsible for a project believe in it, so long as they are realistic.
The usefulness of the state exchange decision as a measurement of enthusiasm may not be relevant in the future. Oregon is using the federal exchange because it could not get its own to work. Several other states may switch as well because of web site problems.
Prior to the ACA kicking in, several organizations predicted each state’s rate of decline in the number of uninsured. How accurate were they? The second graph compares the average of predictions from four organizations with Gallup’s polling results. When it comes to the total number of people without insurance, there is overall agreement. Not surprisingly, there is much more variability when it comes to the change in each state. Wisconsin ended up being easy to predict.