摘要：Objectives. To examine the effects of the Affordable Care Act’s (ACA’s) Marketplace on Texas residents and determine which population subgroups benefited the most and which the least. Methods. We analyzed insurance coverage rates among nonelderly Texas adults using the Health Reform Monitoring Survey-Texas from September 2013, just before the first open enrollment period in the Marketplace, through March 2016. Results. Texas has experienced a roughly 6–percentage-point increase in insurance coverage (from 74.7% to 80.6%; P = .012) after implementation of the major insurance provisions of the ACA. The 4 subgroups with the largest increases in adjusted insurance coverage between 2013 and 2016 were persons aged 50 to 64 years (12.1 percentage points; P = .002), Hispanics (10.9 percentage points; P = .002), persons reporting fair or poor health status (10.2 percentage points; P = .038), and those with a high school diploma as their highest educational attainment (9.2 percentage points; P = .023). Conclusions. Many population subgroups have benefited from the ACA’s Marketplace, but approximately 3 million Texas residents still lack health coverage. Adopting the ACA’s Medicaid expansion is a means to address the lack of coverage. The Affordable Care Act (ACA; Pub L No. 111–148), passed in 2010, was designed to help Americans gain health insurance coverage through a combination of premium subsidies and mandates. Multiple reports indicate that approximately 15.0 to 16.9 million people across the nation have gained health insurance from 2013 to 2015. 1–3 Studies have indicated that substantial differences in health insurance coverage exist among different demographic groups, even though the ACA has narrowed some of these gaps. The 2010 ACA provision enabling young adults to remain on their parents’ insurance plan until age 26 years was estimated to lower uninsurance among those aged 19 to 25 years 3.2 percentage points by 2011 and roughly 6 percentage points by 2013. 4,5 Hispanics have much lower coverage rates than do non-Hispanics, but there is evidence that the gap between these groups is narrowing nationwide. 6,7 Additionally, many employers provide employer-sponsored insurance, whereas part-time workers and unemployed people face a higher financial burden in purchasing coverage. 8 Other studies have shown differences in coverage rates by marital status, parental status, health status, and sexual orientation. 7,9–11 Many of these individual characteristics are correlated, so it is difficult to isolate which factors are most important in determining whether individuals obtain coverage. We measured which factors are most significant in explaining differences in insurance coverage in Texas between September 2013 and March 2016. Texas had the lowest coverage rate in the country before the implementation of the ACA Marketplace in 2014. In 2013 the US Census Bureau reported that 22.1% of all Texas residents lacked coverage (5 748 000 people), whereas the rate nationally was 14.5%. In 2014 after subsidies had been available through the Marketplace for 1 year, the Census found that Texas continued to have the lowest coverage rate, with 19.1% (5 047 000 people) lacking coverage compared with 11.7% nationally. 7 However, recent Marketplace enrollment figures place Texas behind only Florida in Marketplace plan selections, 12 so analysis of insurance coverage with the most recent data may paint a different picture. Texas is the second largest state by population in the country and the largest state that chose not to expand Medicaid under the ACA. As of July 2016, 31 states and Washington, DC, have decided to expand Medicaid. 13 Between September 2013 and January 2016, uninsurance among adults fell 8.5 percentage points in states that expanded Medicaid, compared with 6.5 percentage points for states that had not. 14 Texas’ governor Greg Abbott, a Republican, and other prominent state leaders have refused a Medicaid expansion, because they view the growth in the share of the state budget spent on Medicaid (from 11% in 1987 to 29% in 2015) as unsustainable. 15,16 Abbott has stated, “Medicaid is wrong for Texas,” and he called the ACA a “massive expansion of an already broken and bloated Medicaid program.” 17 Texas voters have elected a Republican governor for the past 20 years, and a Republican legislature for most of these years. A majority of these voters (57%) viewed the federal government unfavorably in 2015. Poll respondents indicated that the state legislature’s top priority should be to limit government, with no new spending or taxes. 18 However, Republican leaders may be misreading voter sentiment, because respondents’ third highest priority for the state legislature was expanding Medicaid under the ACA. The literature has indicated that the states that chose to expand Medicaid have higher coverage rates than do those that did not expand Medicaid. 8,11,19 Texas’s proportion of Hispanics is higher than that of the United States as a whole, 20 so insurance coverage may have increased more in Texas than in other nonexpansion states. We analyzed an oversample of Texas residents using the Health Reform Monitoring Survey (HRMS-TX) from September 2013 to March 2016. Although governmental data provide critical information for longer-term analyses, federal reports are unable to provide quick feedback. The nationwide HRMS sample fielded by the Urban Institute has been shown to be consistent with federal government data and provides timely data on and detailed demographics of the participants. 21,22 We identified which types of individuals have had the largest increases in health insurance coverage since the implementation of the Marketplace. The HRMS provides a rich data set that allows us to estimate a multivariate regression to control for correlation between the determinants of health insurance coverage. Thus, we are able to isolate where the gaps in coverage exist among different subpopulations of Texans. Although many studies on the ACA use multivariate regressions, few have been used to predict rates of health insurance coverage across subgroups.
