Potential Impact of ACA Repeal on the Uninsured

By GBS Team

group benefits strategies graham cassidy repeal

There continues to be uncertainty regarding the outcome and impact of legislative efforts to repeal the Affordable Care Act (ACA). Proposed changes could have a significant impact on uninsured populations—affecting the proportion of uncompensated care provided by the healthcare organizations that serve them.

A recent study by Truven Health Analytics®, part of the IBM Watson HealthTM
business, demonstrated that projections of both uninsured inpatient care and
uninsured emergency department (ED) visits reveal substantial differences
across service lines and locality.

As healthcare providers begin to anticipate potential legislative changes to
the ACA, it will be important to gain an accurate picture of the impact of those
changes on the uninsured population in their specific markets.

Projected Increase in Uninsured Inpatient Discharges

Inpatient service lines could see the largest changes in facility charges for the uninsured by 2020 following a repeal of the ACA, as compared with current projections for 2020 under the ACA.

General Surgery


General Medicine






Psych/Drug Abuse




All Others






Thoracic Surgery














Open Heart




Oncology Medicine


Total Projected 


Overall Findings

At the national level, our study found that the potential impact in 2020 of an ACA repeal would include:

  • A projected increase of 735,000 uninsured inpatient discharges (approximately 59%) across the U.S.
  • An additional $23.6 billion charges for these uninsured discharges (of these charges, $11.2 billion in payments could be at risk of non-collection)
  • A projected 67% increase in uninsured ED visits


This research was based on the latest Insurance Coverage Estimates (ICE) from Truven Health Analytics, released in June 2017.

The ICE release contained two scenarios: ACA reform and ACA repeal. Reform estimates reflected continued support of Medicaid expansion and health exchanges. The repeal scenario assumed a rollback of insurance coverage to pre-2014 levels.

Overall, the Truven Health model assumed that the uninsured population will increase by approximately 20 million by 2020. This is a more conservative scenario than other published estimates. The nonpartisan Congressional Budget Office, for example, projected a 24 million-person growth of the uninsured population by 2026 based on one recent legislative proposal. These Truven Health forecasts were distinct in that they estimated impact at a local ZIP code level, using publicly available enrollment figures for health insurance exchanges and expanded Medicaid, combined with U.S. Census Bureau figures of households in poverty. Truven Health then paired the population estimates with utilization models specific to each payer segment to produce utilization scenarios for changes in insurance coverage.

Inpatient Demand Estimates from Truven Health provided local, annual acute care admissions and patient days by diagnosis-related group (DRG) and three-digit ICD-9 diagnosis code. The estimates were reported by age, sex, and principal payer. Inpatient Demand Estimates were derived from all-payer state discharge data from 24 states and Medicare Provider Analysis and Review (MEDPAR) data. Truven Health Outpatient Procedure Estimates, as accessed through the Truven Health Market Expert® solution, provided local, annual procedure group and visit category estimates and forecasts by age, sex, principal payer, and site of service.

The estimates were derived from Truven Health commercial, Medicare, and Medicaid claims.