Post-Obamacare, more adults with schizophrenia have health insurance

The national uninsurance rate for adults under age 65 with schizophrenia decreased by 50% after the implementation of the Affordable Care Act (ACA) in 2014, according to University of Massachusetts Amherst research published this week in JAMA Psychiatry.

Also known as Obamacare, the health care reform law was designed to make health insurance more affordable and accessible to all Americans. Previous research showed that the overall national under-65 uninsurance rate decreased after ACA went into effect, from 16.6% in 2010 to 11.0% in 2021.

"We didn't know if we'd see the same thing with people with schizophrenia and we were interested in looking at this because people with schizophrenia need ongoing care," says Kimberley Geissler, associate professor of health policy and management in the UMass Amherst School of Public Health and Health Sciences. "This is a very serious, chronic condition and having insurance is really important, but people with schizophrenia may have a lot of barriers to maintaining insurance. They are less likely to be employed and have higher social needs, among other things."

Before the Affordable Care Act, 8.4% of people with schizophrenia were uninsured, a lower rate than the general population, Geissler notes, because many people with schizophrenia may qualify for Medicaid and/or Medicare under disability provisions.

Geissler and her team analyzed data from 2008 to 2020 from the Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey (MEPS). The sample totaled 9.173 million individuals with schizophrenia, defined as those who had at least one medical encounter for the mental disorder in a two-year period. The researchers found a "significant reduction" in the percentage of uninsured people with schizophrenia after the ACA. Before Obamacare, 8.4% were uninsured; after the ACA, the rate of uninsured people with schizophrenia dropped to 4%.

"We saw this decrease in uninsurance mostly due to an increase in Medicaid coverage, which makes sense because Medicaid coverage generally has sharply increased with the ACA both because of Medicaid expansion and the mandate for insurance that is no longer in effect," Geissler says. "People who didn't know they were eligible or hadn't applied for Medicaid before were able to get covered after the ACA."

Some 70% of insured people with schizophrenia were covered by Medicaid post-ACA, compared to 61% pre-ACA, the researchers calculated. Medicare coverage increased to 43% post-ACA, up from 38% pre-ACA. Private insurance coverage dropped slightly to 19% post-ACA from 22% pre-ACA.

Geissler says the findings are an encouraging move toward universal coverage for people with schizophrenia. "I was happy to see that the uninsurance rate is as low as it is. There are a lot of people who are now covered who weren't before."

The findings also suggest better care is available for this vulnerable patient population. "We know that having insurance improves a wide variety of outcomes, but we haven't specifically looked at whether this increased insurance rate for people with schizophrenia is associated with increased access," she says. "We suspect it is, but we don't know for sure."