I have long argued that the Affordable Care Act (and health care reform in general) has been about improving access. More specifically, it's been about the uninsured. The ACA's main raison d' etre was to reduce the number of uninsured in the United States.

By that metric, the ACA appears to be working. As Sarah Kliff wrote yesterday on Vox, citing new work from Gallup:

The evidence is pretty overwhelming at this point that Obamacare has driven down the uninsured rate. Data from Gallup, the Commonwealth Fund, Robert Wood Johnson Foundation/Urban Institute, RAND Corporation and the Kaiser Family Foundation all have similar findings. Namely, that millions more people have insurance than before Obamacare's insurance expansion.

It's early, yes, and there's still some ways to go, but it's a start. Let's look more closely at the latest from RWJF and the Urban Institute, "The ACA and America’s Cities: Fewer Uninsured and More Federal Dollars":

This report estimated the effect of the Affordable Care Act (ACA) on 14 large and diverse cities: Los Angeles, Chicago, Houston, Philadelphia, Phoenix, Indianapolis, Columbus, Charlotte, Detroit, Memphis, Seattle, Denver, Atlanta, and Miami.

Among the seven cities in states that have expanded Medicaid, the ACA will likely decrease the number of uninsured by an average of 57 percent. City by city, the reduction is projected to vary between 49 percent in Denver and 66 percent in Detroit by 2016. New federal spending on health care from 2014 to 2023 would range from $4.1 billion in Seattle to $27 billion in Los Angeles.

Among the seven cities in states not expanding Medicaid, the ACA will likely decrease the number of uninsured by an average of 30 percent. The decrease would range from 25 percent in Atlanta to 36 percent in Charlotte by 2016. New federal spending due to the ACA from 2014 to 2023 would increase by between $1.9 billion in Atlanta and $9.9 billion in Houston

I've spent a significant amount of time talking about how the Medicaid expansion, or lack thereof in certain places, will leave many in the coverge gap. This report confirms that. But it's important to note that even in cities where the Medicaid expansion is not taking place, the levels of uninsurance are expected to drop an average of 30%.

That's not an insignificant amount. Remember that about 50 million Americans were considered uninsured before the ACA went into play. A 30% drop would constitute 15 million Americans achieving coverage.

Of course, in cities where the expansion is occurring, gains are even more dramatic. It's expected that in those areas, the number of uninsured will drop by 57%.

The report estimates that if the remaining seven cities expanded Medicaid, then the levels of uninsured will drop by more than 50% in every city except Houston. In my own city of Indianapolis, which looks more likely to expand the program in the last month or so, it appears that the number of uninsured could drop by more than 55%, instead of the less than 30% expected without an expansion.

This sill isn't universal coverage, though. Upwards of 25 million people in the United States will still be uninsured. Many of them will be undocumented immigrants. Some will be people who are still too poor to afford insurance. And some will be people who choose not to buy insurance and pay the mandate "tax" instead.

Things won't be perfect. But with respect to the numbers of uninsured in the United States, things will certainly be improved. We won't be done with health care reform, but for those who have been struggling to improve access for decades, it's a big start.



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