a sociology essay
cesare07
French_et_al-2016-Health_Services_Research.pdf
Key Provisions of the Patient Protection and Affordable Care Act (ACA): A Systematic Review and Presentation of Early Research Findings Michael T. French, Jenny Homer, Gulcin Gumus, and Lucas Hickling
Objectives. To conduct a systematic literature review of selected major provisions of the Affordable Care Act (ACA) pertaining to expanded health insurance coverage. We present and synthesize research findings from the last 5 years regarding both the imme- diate and long-term effects of the ACA. We conclude with a summary and offer a research agenda for future studies. Study Design. We identified relevant articles from peer-reviewed scholarly journals by performing a comprehensive search of major electronic databases. We also identi- fied reports in the “gray literature” disseminated by government agencies and other organizations. Principal Findings. Overall, research shows that the ACA has substantially decreased the number of uninsured individuals through the dependent coverage provi- sion, Medicaid expansion, health insurance exchanges, availability of subsidies, and other policy changes. Affordability of health insurance continues to be a concern for many people and disparities persist by geography, race/ethnicity, and income. Early evidence also indicates improvements in access to and affordability of health care. All of these changes are certain to ultimately impact state and federal budgets. Conclusions. The ACA will either directly or indirectly affect almost all Americans. As new and comprehensive data become available, more rigorous evaluations will pro- vide further insights as to whether the ACA has been successful in achieving its goals. Key Words. Affordable Care Act (ACA), health insurance, health care, systematic review
On March 23, 2010, following a long and controversial political and legislative process, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law, ushering in the most significant changes to the U.S. health care system since the passage of Medicare and Medicaid in 1965. The ACA
© Health Research and Educational Trust DOI: 10.1111/1475-6773.12511 POLICY-MANAGERIAL IMPACTARTICLE
1735
Health Services Research
includes a series of ambitious reforms that build upon the existing system of employer-sponsored insurance (ESI) and creates new requirements for indi- viduals, employers, health care providers, and insurance companies. It is intended to address three main areas: access to health insurance, health care costs, and the delivery of care (Blumenthal, Abrams, and Nuzum 2015). Cer- tain elements of the law became active soon after its passage in 2010, but most provisions took effect in 2014 (see Table 1 for the ACA timeline).1
The ACA includes multiple strategies to target different groups and increase overall insurance coverage. Young adults are now able to remain on their parents’ insurance plans as dependents until age 26 (dependent coverage provision). Larger employers are required to offer affordable, comprehensive health insurance to full-time employees (employer mandate). Individuals who do not have ESI must purchase insurance on their own or pay a penalty (indi- vidual mandate), and premium tax credits are available to some. These indi- viduals and small businesses can purchase plans through state-level exchanges or the federal marketplace. To assist low-income individuals, the ACA expands Medicaid eligibility to all individuals under age 65 (nonelderly) with annual incomes up to 133 percent of the federal poverty level, but not all states have agreed to participate. These provisions aim not only to expand insurance coverage but also to improve the affordability of insurance plans.
The ACA also imposes new regulations on insurance companies and their policies. For example, insurance companies can no longer charge higher premiums or deny coverage due to preexisting conditions, and insurance poli- cies have to provide a minimum amount of preventive services without any cost-sharing. The ACA calls for changes in various taxes pertaining to insur- ance policies and overall financing. Other provisions focus on improving the delivery of care by streamlining services, incorporating health information technology, strengthening the health care workforce, reducing fraud and waste, and altering payments in a way that incentivizes providers to contain costs while improving the quality of care.2
Assessing the full and lasting impacts of the ACA is challenging because the provisions are multifaceted and the potential outcomes extend to
Address correspondence to Michael T. French, Ph.D., Departments of Sociology, Health Sector Management and Policy, Economics, and Public Health Sciences, University of Miami, 5202 University Drive, Merrick Building, Room 121F, P.O. Box 248162, Coral Gables, FL 33124- 2030; e-mail: [email protected]. Jenny Homer, M.P.A., M.P.H., and Lucas Hickling, B.A., are with the Health Economics Research Group, University of Miami, Coral Gables, FL. Gulcin Gumus, Ph.D., is with the Department of Management Programs, Florida Atlantic University, Boca Raton, FL; IZA, Bonn, Germany.
1736 HSR: Health Services Research 51:5 (October 2016)
Table 1: Timeline for Implementation of Major Provisions of the ACA
2010 Employers are provided funding to cover individuals retiring between the ages of 55 and 65
Federal government offers tax credits to cover a portion of the employer’s contribution for small businesses with less than 25 employees†
Establishes a new Patient’s Bill of Rights‡
Requires all plans to include certain preventive services without cost-sharing‡
Insurance companies cannot deny coverage to children under age 19 with preexisting conditions‡
Creates a new process to monitor premium rate increases and report the minimum medical loss ratio†
*Young adults are covered by their parent’s health insurance until age 26 (dependent coverage provision)‡
Provides financial incentives to PCPs, nurses, and physician assistants, and increases payments to PCPs in rural communities, underserved areas, and community health centers§
2011 Provides a 10% bonus payment from Medicare to PCPs for 5 years 2012 Imposes new annual fees on the pharmaceutical manufacturing sector†
Creates a Medicare Value-Based Purchasing program¶
2013 *Initial open enrollment in the individual health insurance marketplace begins¶
The Bundled Payments for Care Improvement Initiative begins to test models for reimbursement
*Increases Medicaid reimbursement rates for primary care services provided by PCPs to 100% of the Medicare rates for 2013 and 2014
Increases Medicare Part A tax rate from 1.45% to 2.35% on individuals earning over $200,000 and couples earning $250,000, as well as a 3.8% tax on unearned income for high-income tax payers
Imposes 2.3% excise tax on the sale of any taxable medical device Modifies tax treatment of health savings and flexible spending accounts
2014 Insurance companies cannot deny coverage based on preexisting conditions and can only vary rates based on rating area, family size, tobacco use, and age (but not on health status, previous claims history, or gender)
Risk adjustment, reinsurance, and risk corridor programs go into effect to help stabilize premiums and reduce adverse selection
*Increases small business tax credits for those participating in the state insurance exchanges†
*Provides tax credits to individuals or families earning between 100% and 400% of the federal poverty level who purchase their health insurance through the exchanges
All health insurance plans must provide an “essential health benefits package” *Expands federally funded Medicaid coverage to cover individuals earning up to 133% of the federal poverty level in certain states
Initial enrollment in the Small Business Health Options Program (SHOP) begins on November 15
Imposes annual fees on the health insurance sector†
*U.S. citizens without health insurance pay a tax penalty (individual mandate)†
2015 *Employers with 100 or more full-time employees pay a penalty if they fail to offer health insurance coverage (employer mandate)
Continued
The ACA’s Key Provisions: A Systematic Review 1737
taxpayers, patients, health care providers, insurance companies, and govern- ments. Preimplementation projections of the ACA’s effects were largely based on simulation models of earlier Medicaid enrollment or the Massachusetts health insurance expansion (e.g., Gruber 2011a). In 2010, the Congressional Budget Office (CBO 2010) projected that by 2019, 32 million people would gain health insurance coverage, ESI coverage would decline slightly, and signif- icant increases in federal spending due to the ACAwould be offset by increased revenue. Making precise predictions is daunting, however, as many factors affect successful implementation of the ACA, such as enrollment levels, insurer participation, and providers’ willingness to accept Medicaid patients.
While the ACA is comprised of 10 titles and hundreds of sections, this review focuses on key provisions related to expansion of health insurance cov- erage through dependent coverage provisions and ESI, health insurance exchanges, employer and individual mandates, and Medicaid expansion. Unlike other summaries of the existing literature (e.g., Hall and Lord 2014; Blumenthal, Abrams, and Nuzum 2015), we conduct a structured and system- atic review of research findings regarding the effects of the ACA since 2010 and focus on the key provisions listed above. Besides a summary and synthesis of current findings, we also offer suggestions for future research.
METHODS
Literature Search
We used three methods to identify relevant studies for our analysis. First, we performed structured and systematic searches using the Thomson Reuters’
Table 1. Continued
2016 *Employers with 50 or more full-time employees pay a penalty if they fail to offer health insurance coverage (employer mandate)
2018 Excise tax of 40% imposed on employer-sponsored private health insurance plans above a certain value (“Cadillac tax”)
Notes. Provisions went into effect on January 1, unless noted otherwise. The provisions discussed in this review are marked with an asterisk (*). PCP stands for primary care physician. †Assessed annually. ‡Effective for plans beginning on or after September 23, 2010. §Effective dates vary. ¶Effective October 1. Source: Compiled by the authors using information from the US Department of Health and Human Services (http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html) and Kaiser Family Foundation (http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/) websites.
1738 HSR: Health Services Research 51:5 (October 2016)
Web of Science, the National Library of Medicine’s Medline (PubMed), and the American Economic Association’s EconLit. We searched for the phrase “Affordable Care Act” in titles, abstracts, or topics without any additional key- words to avoid inadvertently excluding relevant studies. These searches yielded a total of 1,375 studies from Web of Science, 1,656 studies from Med- line, and 97 studies from EconLit. We focused on published articles in the Eng- lish language that appeared in peer-reviewed scholarly journals as well as reports that appeared in the “gray literature.” Second, we augmented our sys- tematic searches to include relevant reports from various research organiza- tions and government agencies. Third, we browsed the reference sections of the retrieved articles. The entire search process was conducted from July to September 2015, and it was limited to studies appearing since 2010.
Inclusion Criteria and Screening
Our inclusion criteria are essentially based on whether the study provides a systematic evaluation of one or more elements of the ACA’s implementation. Given the vast number of studies on this topic, we focus on those provisions related to the expansion of health insurance coverage. Both quantitative and qualitative studies were included, but we excluded studies that merely describe the legislation or examine data from prior to the implementation (i.e., to establish a baseline). We also eliminated any studies that simply use projections or extrapolations based on data prior to implementation of the ACA. Finally, we excluded studies pertaining to ethical, legal, or political aspects of the ACA.
During the first round of screening, two coauthors independently screened the title and abstract of each study to identify those that poten- tially met the inclusion criteria. After a comparison of the two sets of rat- ings, any inconsistencies were resolved through discussions. When necessary, a third coauthor was asked to render a judgment. As a result, we obtained 162 full-text articles for a final examination pertaining to rele- vance and to eliminate any inappropriate items such as opinion pieces. Ultimately, we selected a total of 72 studies through our elaborate screening process. These were augmented by 24 reports and articles found in the gray literature. While Table 2 lists the final set of 96 studies together with brief descriptions, given space limitations, we do not cover all in the results sec- tion. The discussion below includes only those studies that were deemed most relevant or provide more recent evidence, and they are organized by groupings of key ACA provisions.
The ACA’s Key Provisions: A Systematic Review 1739
T ab
le 2:
S u m m ar y o fS
el ec te d R es ea rc h S tu d ie s
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
A b ra h am
, Fe ld m an
,a n d
S im
o n (2 01 4) *
N at io n al A ss o ci at io n o fI n su ra n ce
C o m m is si o n er s; C P S ;
K F F ;D
es cr ip ti ve
st at is ti cs
to d es cr ib e ea ch
st at e’ s in su ra n ce
m ar ke ta n d to
te st th e d if fe re n ce s in
at tr ib u te s b et w ee n
ex ch an
ge p ar ti ci p an
ts an
d n o n p ar ti ci p an
ts ;M
u lt iv ar ia te
re gr es si o n an
al ys is w it h an
in cu m b en
ti n su re r’ s d ec is io n to
p ar ti ci p at e in
th e ex
ch an
ge s as
th e o u tc o m e m ea su re
In su re r p ar ti ci p at io n in
ex ch an
ge s is re la te d to
p re se n ce
in th e re gi o n an
d si ze
o ft h e in su re r.
A ko
sa A n tw
i, M or iy a, an
d S im
o n (2 01 3) *
S IP
P ;D
D w it h in su ra n ce
co ve ra ge
an d la b o r m ar ke t
o u tc o m es
as o u tc o m e m ea su re s
D ep
en d en
tc ov
er ag e p ro vi si on
is as so ci at ed
w it h in cr ea se s in
co ve ra ge
an d p ar en ta lc ov
er ag e am
on g yo
u n g ad
ul ts re la ti ve
to co m p ar is o n
gr o up
. A ko
sa A n tw
ie t al .
(2 01 5) *
N at io n al E m er ge n cy
D ep
ar tm
en tS
am p le ;D
D w it h E D vi si ts
as th e o u tc o m e m ea su re
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h m o d es td
ec li n e in
E D
vi si ts fo r yo
u n g ad
u lt s re la ti ve
to co m p ar is o n gr o u p .
A ko
sa A n tw
i, M or iy a, an
d S im
o n (2 01 5) *
N at io n w id e In p at ie n tS
am p le ,H
ea lt h ca re
C os ta n d
U ti li za ti o n P ro je ct ;D
D w it h n u m b er
an d so u rc es
o f
in p at ie n ta d m is si o n s, fr ac ti o n o fa d m is si o n s in su re d ,a n d th e
in te n si ty
o ft re at m en
ta s o u tc o m e m ea su re s
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h in cr ea se s in
m en
ta l
h ea lt h vi si ts an
d in p at ie n tv
is it s b y yo
u n g ad
u lt s re la ti ve
to co m p ar is o n
gr o u p .
A n gi er
et al .
(2 01 5) *
L o n gi tu d in al st u d y o fc o ve ra ge
st at u s fo r ad
u lt en
co u n te rs in
co m m u n it y h ea lt h ce n te rs (C
H C s) ;m
u lt iv ar ia te re gr es si o n
an al ys is o fC
H C vi si ts b y in su ra n ce
an d M ed
ic ai d
ex p an
si o n st at u s
T h e p ro p o rt io n o fu
n in su re d vi si ts d ec re as ed
an d M ed
ic ai d -c o ve re d
vi si ts in cr ea se d in
M ed
ic ai d ex
p an
si o n st at es
in 2 01 4 co m p ar ed
to 2 01 3.
A rt ig a, R ud
o w it z,
an d R an
ji (2 01 5) *
Fo cu s gr o u p s w it h ei th er
p re vi o u sl y u n in su re d ad
u lt s w h o
en ro ll ed
in th e A C A M ed
ic ai d ex
p an
si o n (O
h io
an d
A rk an
sa s) o r th o se
w h o w o u ld
b e el ig ib le if th ei r st at e h ad
ex p an
d ed
M ed
ic ai d (M
is so u ri )
S ta te s’ d ec is io n w h et h er
to ex
p an
d M ed
ic ai d o r h o w th ey
w en
ta b o u tt h e
ex p an
si o n im
p le m en
ta ti o n af fe ct ed
ex p er ie n ce s o fl o w -i n co m e ad
u lt s,
in cl u d in g th ei r ac ce ss to
ca re
as w el la s th ei r ab
il it y to
w o rk .
A rt ig a, S te p h en
s, an
d D am
ic o
(2 01 5) *
C P S ;D
es cr ip ti ve
st at is ti cs
o n th e u n in su re d an
d th o se
w h o
fa ll w it h in
th e “c o ve ra ge
ga p ” af te r im
p u ti n g el ig ib il it y fo r
A C A su b si d ie s, u n au
th o ri ze d im
m ig ra n ts ta tu s, an
d E S I
o ff er
st at u s
E st im
at e th er e ar e 3. 7 m il li o n ad
u lt s in
th e co ve ra ge
ga p in
2 2 st at es
th at
h av e n o te x p an
d ed
M ed
ic ai d as
o fM
ar ch
2 01 5.
B ac h ra ch ,
B o o za n g, an
d G la n z (2 01 5) *
In te rv ie w s w it h st at e o ffi ci al s; es ti m at es
o ft h e b u d ge ta ry
im p ac to
fM ed
ic ai d ex
p an
si o n in
a sa m p le o fe ig h ts ta te s
M ed
ic ai d ex
p an
si o n al lo w s st at es
to re al iz e sa vi n gs
(t h ro u gh
re d u ct io n s
in sp en
d in g o n p ro gr am
s fo r th e u n in su re d )a n d re ve n u e ga in s (t h ro u gh
ex is ti n g in su re r o r p ro vi d er
ta x es ).
C on ti nu ed
1740 HSR: Health Services Research 51:5 (October 2016)
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
B ar b ar es co ,
C ou
rt em
an ch e,
an d Q i( 2 01 5) *
B R F S S ;D
D w it h o u tc o m es
re la te d to
h ea lt h ca re
ac ce ss ,
p re ve n ti ve
ca re
u ti li za ti o n ,r is ky
b eh
av io rs ,a n d se lf -
as se ss ed
h ea lt h
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h so m e im
p ro ve m en
ts in
h ea lt h ca re
ac ce ss an
d h ea lt h -r el at ed
o u tc o m es
am o n g yo
u n g ad
u lt s
re la ti ve
to co m p ar is o n gr o u p .R
ep o rt la rg e ga in s fo r m en
an d co ll eg e
gr ad
u at es .
B ar ce ll o s
et al .( 20
14 )*
A m er ic an
L if e P an
el ;m
u lt iv ar ia te re gr es si o n an
al ys is w it h
kn o w le d ge
ab o u tA
C A ,h ea lt h in su ra n ce
li te ra cy ,a n d
ex p ec ta ti o n s fo r ch an
ge s in
h ea lt h ca re
as o u tc o m es
K n o w le d ge
o ft h e A C A an
d h ea lt h li te ra cy
is lo w o ve ra ll ,e sp ec ia ll y
am o n g lo w -i n co m e in d iv id u al s.
B ar ke r
et al .( 20
14 a) *
A re a H ea lt h R es o u rc e F il e; d es cr ip ti ve
st at is ti cs
o n
ge o gr ap
h ic va ri at io n in
m ar ke tp la ce
p re m iu m s
P re m iu m s fo r ex
ch an
ge p la n s ar e h ig h er
in le ss d en
se ly p o p u la te d ar ea s.
B ar ke r
et al .( 20
14 b )*
H ea lt h ca re .g o v an
d st at e ag en
ci es ;o
ve rv ie w o fi m p o rt an
t fa ct o rs th at in fl u en
ce th e d if fe re n ce s in
m ar ke tp la ce
p la n s
ac ro ss ge o gr ap
h ic ar ea s (u rb an
vs .r u ra l)
U rb an
co u n ti es ,o
n av er ag e, h av e m o re
p la n s an
d p la n s w it h h ig h er
ac tu ar ia lv
al u es
av ai la b le o n th ei r ex
ch an
ge s.
B la vi n
et al .( 20
15 )*
H ea lt h R ef o rm
M o n it o ri n g S u rv ey ;m
u lt iv ar ia te re gr es si o n
an al ys is w it h em
p lo ye r o ff er
ra te s, em
p lo ye e ta ke -u p ra te s,
an d E S I co ve ra ge
as o u tc o m es
O ff er ,t ak e- u p ,a n d co ve ra ge
ra te s fo r E S I h av e re m ai n ed
th e sa m e u n d er
th e A C A .
B lu m b er g an
d R if ki n (2 01 4) *
C as e st u d y u si n g st ak eh
o ld er
in te rv ie w s in
ei gh
ts ta te s
Id en
ti fy
re as o n s fo r S H O P ’s sl o w st ar ta n d ar ea s fo r im
p ro ve m en
t.
B lu m en
th al an
d C ol li n s (2 01 4) *
O ve rv ie w an
d as se ss m en
to fe x is ti n g fi n d in gs
P ro vi d e a p ro gr es s re p o rt o n A C A as
o fm
id -2 01 4.
B lu m en
th al ,
A b ra m s, an
d N u zu m
(2 01 5) *
O ve rv ie w an
d as se ss m en
to fe x is ti n g fi n d in gs
R ev ie w va ri o u s ef fe ct s o ft h e A C A at th e 5- ye ar
m ar k.
B ra n d o n an
d C ar n es
(2 01 4) *
C as e st u d ie s o fm
ar ke tp la ce
la u n ch es
in K en
tu ck y an
d N o rt h
C ar o li n a
D es cr ib e el em
en ts o fs u cc es sf u le x ch an
ge s.
B ro o ks
(2 01 4) *
D es cr ip ti o n an
d d is cu ss io n o ft h e “f am
il y gl it ch ”
M an
y d ep
en d en
ts fa ce
ch al le n ge s w it h “a ff or d ab
le ” ca re
an d w ill re m ai n
u n in su re d if th e fa m ily
gl it ch
is n ot
fi x ed
.L o w -i n co m e fa m ili es
an d th os e
w h o liv
e in
M ed
ic ai d n on
ex p an
si on
st at es
h av e b ee n d is p ro p or ti on
at el y
af fe ct ed
. B u sc h ,
G o lb er st ei n ,a n d
M ea ra
(2 01 4) *
M E P S ;D
D w it h in su ra n ce
co ve ra ge
an d o u t- o f- p o ck et
m ed
ic al ex
p en
d it u re s as
o u tc o m e m ea su re s
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h a d ec re as e in
th e
p ro p o rt io n o fy
o u n g ad
u lt s w it h h ig h o u t- o f- p o ck et m ed
ic al ex
p en
se s
re la ti ve
to co m p ar is o n gr o u p .
C on ti nu
ed
The ACA’s Key Provisions: A Systematic Review 1741
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
C an
to r
et al .( 2 01 2) *
C P S ;D
D w it h in su ra n ce
co ve ra ge
b y so u rc e as
o u tc o m e
m ea su re
E st im
at e ra p id
an d su b st an
ti al in cr ea se
in th e n u m b er
o fy
o u n g ad
u lt s
w h o ga in ed
p ar en
ta lc o ve ra ge
b y 2 01 1.
C ar ls o n
et al .( 2 01 4) *
C P S ;D
D w it h se lf -r at ed
h ea lt h as
o u tc o m e m ea su re
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h im
p ro ve m en
ts in
se lf -
re p o rt ed
h ea lt h am
o n g yo
u n g ad
u lt s re la ti ve
to co m p ar is o n gr o u p .
C M S (2 01 4) *
C M S p re ss re le as e o fd
at a o n m ar ke tp la ce s
R ep
o rt s th at m o re
is su er s an
d h ea lt h p la n s ar e av ai la b le th ro u gh
ex ch an
ge s in
2 01 5 th an
in 2 01 4.
C h an
d ra ,H
o lm
es ,
an d S ki n n er
(2 01 3) *
V ar io u s so u rc es ;o
ve rv ie w o ft re n d s in
h ea lt h ca re
sp en
d in g
an d th e co n tr ib u ti n g fa ct o rs
A s o f2
01 3, co st -s av in g fe at u re s o ft h e A C A w er e n o ty
et fu ll y
im p le m en
te d ,s o th ey
co u ld
n o te x p la in
th e sl o w d o w n in
h ea lt h ca re
ex p en
d it u re s th at b eg an
in 2 00
6. C h u a an
d So
m m er s (2 01 4) *
M E P S ;D
D w it h in su ra n ce
co ve ra ge ,s el ec te d m ea su re s o f
h ea lt h ca re
u ti li za ti o n ,a n d se lf -r ep
o rt ed
h ea lt h as
o u tc o m e
m ea su re s
T h e d ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h im
p ro ve m en
ts in
se lf -r ep
o rt ed
h ea lt h st at u s an
d p ro te ct io n ag ai n st m ed
ic al ex
p en
d it u re s
am o n g yo
u n g ad
u lt s ag ed
19 – 2 5 ye ar s.
C la x to n et
al .
(2 01 2)
K F F /H
R E T S u rv ey
o fE
m p lo ye r H ea lt h B en
efi ts ;
D es cr ip ti ve
st at is ti cs
o n E S I co ve ra ge ,p
re m iu m s, an
d p ar en
ta lc o ve ra ge
fo r yo
u n g ad
u lt s
E x am
in e tr en
d s in
E S I co ve ra ge ,p
re m iu m s, an
d p ar en
ta lc o ve ra ge
fo r
yo u n g ad
u lt s.
C la x to n
et al .( 2 01 4a )*
K F F /H
R E T E m p lo ye r H ea lt h B en
efi tS
u rv ey ;d
es cr ip ti ve
st at is ti cs
o n E S I o ff er s, en
ro ll m en
t, p re m iu m s, co st -s h ar in g,
an d w o rk er
co n tr ib u ti o n s
T h e E S I m ar ke th
as ex
p er ie n ce d li tt le ch an
ge si n ce
th e p as sa ge
o ft h e
A C A .
C oh
en an
d M ar ti n ez
(2 01 5) *
E ar ly re le as e o fN
H IS
es ti m at es
fo r h ea lt h in su ra n ce
co ve ra ge
an d th e o ve rt im
e tr en
d s
P ro vi d e es ti m at es
o fh
ea lt h in su ra n ce
co ve ra ge
fo r 2 01 4 b y ag e, ra ce /
et h n ic it y, ge o gr ap
h y, ty p e o fi n su ra n ce ,a n d p o ve rt y le ve l.
C ol li n s
et al .( 2 01 2)
C F H ea lt h In su ra n ce
T ra ck in g S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n in su ra n ce
co ve ra ge
an d b u rd en
o fm
ed ic al b il ls an
d d eb
t T h e h ea lt h an
d m o n et ar y co n se q u en
ce s o fu
n in su ra n ce
ar e si gn
ifi ca n tf o r
yo u n g ad
u lt s, p ar ti cu la rl y th o se
w h o ar e p o o r.
C ol li n s
et al .( 2 01 3a )*
C F H ea lt h In su ra n ce
T ra ck in g S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n u n in su ra n ce
an d en
ro ll m en
tu n d er
p ar en
ts ’ p o li cy
am o n g th e yo
u n g ad
u lt s
R ep
o rt in cr ea se
in th e n u m b er
o fy
o u n g ad
u lt s o n a p ar en
ts ’ p o li cy
b et w ee n 2 01 1 an
d 2 01 3, in
p ar ti cu la r am
o n g th o se
w it h lo w in co m es .
C ol li n s
et al .( 2 01 3b
) C F A C A T ra ck in g S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n
co n su m er s’ ex
p er ie n ce s in
m ar ke tp la ce
at th e en
d o ft h e fi rs t
m o n th
M aj o ri ty
o fp
o te n ti al ly
el ig ib le ad
u lt s ar e aw
ar e o ft h e m ar ke tp la ce
as a
so u rc e o fc o ve ra ge
b u tf ew
re p o rt ed
vi si ti n g it at th is p o in ti n ti m e.
So m e in d iv id u al s w h o vi si te d b u td
id n o te n ro ll ye tr ep
o rt ed
te ch n ic al
p ro b le m s w it h m ar ke tp la ce
w eb
si te s.
C on ti nu ed
1742 HSR: Health Services Research 51:5 (October 2016)
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
C o ll in s et
al .
(2 01 4a )*
M E P S ;d
es cr ip ti ve
st at is ti cs
o n th e n at io n al tr en
d s in
E S I
co ve ra ge ,p
re m iu m s, co st -s h ar in g, an
d w o rk er
co n tr ib u ti o n s
E S I p re m iu m s, d ed
u ct ib le s, an
d em
p lo ye e co n tr ib u ti o n s in cr ea se d
b et w ee n 2 00
3 an
d 2 01 3 b u ta ta
sl o w er
ra te af te r 2 01 0.
C o ll in s et
al .
(2 01 4b
) C F A C A T ra ck in g S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n
co n su m er s’ ex
p er ie n ce s in
m ar ke tp la ce
at th e en
d o ft h e fi rs t
3 m o n th s
C o n su m er s’ ab
il it y to
co m p ar e b en
efi ts an
d p re m iu m s in
th e
m ar ke tp la ce
h as
im p ro ve d si n ce
th e ro ll o u t, b u tm
an y re p o rt ed
d if fi cu lt ie s w it h p la n se le ct io n .
C o ll in s et
al .
(2 01 5a )*
C F B ie n n ia lH
ea lt h In su ra n ce
S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n h ea lt h in su ra n ce
co ve ra ge ,a ff o rd ab
il it y, b u rd en
o f
m ed
ic al b il ls an
d d eb
t, ac ce ss to
ro u ti n e h ea lt h ca re
R ep
o rt re su lt s o fs u rv ey
sh o w in g im
p ro ve m en
ts in
co ve ra ge
an d
af fo rd ab
il it y.
C o ll in s et
al .
(2 01 5b
)* C F A C A T ra ck in g S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n
co n su m er s’ ex
p er ie n ce s w it h m ar ke tp la ce
an d M ed
ic ai d
co ve ra ge
R ep
o rt re su lt s o fs u rv ey
sh o w in g sa ti sf ac ti o n w it h h ea lt h p la n s an
d im
p ro ve m en
ts in
co ve ra ge
an d ac ce ss .
C B O
(2 01 4) *
V ar io u s so u rc es ;e st im
at es
o ft h e n u m b er
o fu
n in su re d
su b je ct to
A C A -r el at ed
p en
al ti es
E st im
at es
4 m il li o n o u to
f3 0 m il li o n u n in su re d w il lb
e su b je ct to
p en
al ti es
in 2 01 6.
C B O
(2 01 5a )*
V ar io u s so u rc es ;e st im
at es
th e b u d ge ta ry
an d ec o n o m ic
co n se q u en
ce s th at w o u ld
ar is e fr o m
re p ea li n g th e A C A
P ro vi d es
es ti m at ed
ef fe ct s o fr ep
ea lo
n h ea lt h in su ra n ce
co ve ra ge
an d th e
fe d er al b u d ge tb
o th
in th e sh o rt an
d lo n g te rm
,w it h a w ar n in g th at th ey
ar e su b je ct to
su b st an
ti al u n ce rt ai n ty .
C B O
(2 01 5b
)* V ar io u s so u rc es ;f ed
er al b u d ge tp
ro je ct io n s fo r 2 01 5–
2 0 2 5
T h e ap
p en
d ix
p ro vi d es
es ti m at ed
b u d ge ta ry
ef fe ct s o ft h e in su ra n ce
co ve ra ge
p ro vi si o n s o ft h e A C A .
C o x et
al .( 2 01 4) *
M ar ke tp la ce
en ro ll m en
td at a fr o m
se ve n st at es ;c al cu la te
st at e- sp ec ifi c m ea su re s o fm
ar ke tc o m p et it io n fo r in d iv id u al
p la n m ar ke ts an
d th e ex
ch an
ge s
T h er e ar e so m e in st an
ce s in
w h ic h in su re rs ’ m ar ke ts h ar es
h av e ch an
ge d
si gn
ifi ca n tl y u n d er
th e A C A ,w
it h so m e n o ta b le ex
am p le s d u e to
n ew
en tr an
ts .
C o x et
al .( 2 01 5) *
H ea lt h in su re r ra te fi li n gs
in 10
st at e d ep
ar tm
en ts an
d W as h in gt o n ,D
C ;d
es cr ip ti ve
st at is ti cs
o n m ar ke tp la ce
p re m iu m s an
d in su re r p ar ti ci p at io n
In su re r p ar ti ci p at io n in
2 01 6 is si m il ar
to 2 01 5. A ve ra ge
in cr ea se
in p re m iu m s fo r si lv er
p la n s b et w ee n 2 01 5 an
d 2 01 6 is 4. 4%
.
C u n n in gh
am ,
G ar fi el d ,a n d
R u d o w it z (2 01 5) *
A sc en
si o n H ea lt h d at a o n d is ch ar ge s an
d h o sp it al fi n an
ce s;
p re -p o st d es cr ip ti ve
st at is ti cs
o n d is ch ar ge
vo lu m es ,
u n co m p en
sa te d ca re ,a n d h o sp it al fi n an
ce s
E va lu at e ch an
ge s in
h o sp it al d is ch ar ge s an
d fi n an
ci al o u tc o m es
fo r
A sc en
si o n H ea lt h sy st em
in M ed
ic ai d ex
p an
si o n an
d n o n ex
p an
si o n
st at es
im m ed
ia te ly
b ef o re
an d af te r th e A C A im
p le m en
ta ti o n .
D ep
ew an
d B ai le y
(2 01 5) *
M E P S ;D
D w it h to ta lp
re m iu m s an
d em
p lo ye e co n tr ib u ti o n s
fo r fa m il y o r si n gl e p la n s as
o u tc o m es
P re m iu m s fo r fa m il y h ea lt h p la n s in cr ea se d b y 2. 5–
2. 8%
d u e to
th e
d ep
en d en
tc o ve ra ge
p ro vi si o n .
C on ti nu ed
The ACA’s Key Provisions: A Systematic Review 1743
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
D ic ks te in
et al .
(2 01 5) *
H ea lt h ca re .g o v;
U .S .C
en su s; M u lt iv ar ia te re gr es si o n
an al ys is w it h n u m b er
o fi n su re rs an
d h ea lt h in su ra n ce
p re m iu m s as
o u tc o m es
E x am
in e w h et h er
th e d efi
n it io n o ft h e co ve ra ge
re gi o n af fe ct s m ar ke t
o u tc o m es
in th e A C A in su ra n ce
ex ch an
ge s.
D o ty ,R
as m u ss en
, an
d C ol li n s
(2 01 4) *
C F A C A T ra ck in g S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n in su ra n ce
co ve ra ge
an d m ar ke tp la ce
ex p er ie n ce s am
o n g L at in o s
U n in su re d ra te am
o n g L at in o s d ec re as ed
in st at es
ex p an
d in g M ed
ic ai d .
O ve ra ll ra te o fu
n in su re d ad
u lt s d ec re as ed
fr o m
2 0%
in 2 01 3 to
15 %
in 2 01 4.
G ab
el et
al .
(2 01 3) *
S u rv ey
o fp
ri va te fi rm
s w it h 3–
5 0 em
p lo ye es ;d
es cr ip ti ve
st at is ti cs
o n in su ra n ce
p la n s in
th e sm
al l- gr o u p m ar ke ta n d
sm al le m p lo ye rs ’ ex
p er ie n ce s w it h S H O P ex
ch an
ge s
B o th
sm al lfi
rm s th at d ec id ed
to o ff er
h ea lt h in su ra n ce
b en
efi ts an
d th o se
th at d id
n o tr at ed
m o st fe at u re s o fS
H O P ex
ch an
ge s h ig h ly .T
h es e
d ec is io n s w er e ve ry
p ri ce
se n si ti ve .
G ey m an
(2 01 5)
O ve rv ie w an
d as se ss m en
to fe x is ti n g fi n d in gs
A ss es se s th e A C A ’s fi rs t5
ye ar s an
d p re se n ts ar gu
m en
ts fo r re p la ci n g it
w it h si n gl e- p ay er
n at io n al h ea lt h in su ra n ce .
G A O
(2 01 4a )*
C M S an
d st at e d at a; d es cr ip ti ve
st at is ti cs
o n th e n u m b er
an d
ty p es
o fi ss u er s p ar ti ci p at in g in
ex ch an
ge s an
d p ri o r to
th e
ex ch an
ge s
M os ts ta te ex
ch an
ge s h ad
m u lt ip le is su er s in
2 01 4, w it h va ri at io n ac ro ss
st at es .
G A O
(2 01 4b
)* C M S ,s ta te d at a, an
d in te rv ie w s w it h st ak eh
o ld er s;
d es cr ip ti ve
st at is ti cs
an d st ak eh
o ld er s’ vi ew
s re ga rd in g
S H O P ch ar ac te ri st ic s
D is cu ss es
fa ct o rs co n tr ib u ti n g to
lo w er
th an
ex p ec te d en
ro ll m en
ti n th e
S H O P.
G A O
(2 01 5) *
V ar io u s so u rc es ;s tr u ct u re d li te ra tu re
se ar ch ;s ta ke h o ld er
in te rv ie w s; d es cr ip ti ve
st at is ti cs
o n p re m iu m s
E x am
in es
th e ef fe ct s o ft ax
cr ed
it s an
d th e av ai la b il it y o fa ff o rd ab
le h ea lt h p la n s. R ev ie w s th e va ri at io n s in
p re m iu m
co st s b y in co m e, ag e,
an d ge o gr ap
h y.
G io va n n el li ,
L u ci a, an
d C or le tt e (2 01 5) *
R ev ie w o fs ta te -s p ec ifi c p ro vi d er
n et w o rk
ad eq
u ac y
st an
d ar d s fo r m ar ke tp la ce
p la n s in
th e 5 0 st at es
an d
W as h in gt o n ,D
C
S ta te re gu
la to rs se ek
to en
h an
ce n et w o rk
tr an
sp ar en
cy fo r co n su m er s
an d to
m o n it o r co m p li an
ce .
G o lb er st ei n
et al .( 2 01 5) *
N at io n al in p at ie n ts am
p le s; C al if o rn ia st at e d at a; D D w it h
in p at ie n ta d m is si o n s an
d E D vi si ts fo r p sy ch ia tr ic d ia gn
o se s
as o u tc o m es
A C A ’s d ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h in cr ea se d
in p at ie n ta d m is si o n s an
d d ec re as ed
E D vi si ts fo r 19 -t o 2 5- ye ar
o ld s,
re la ti ve
to co m p ar is o n gr o u p .
G ra et z et
al .
(2 01 4) *
P re m iu m
d at a fr o m
al lm
ar ke tp la ce s; d es cr ip ti ve
st at is ti cs
o n
af fo rd ab
il it y o fp
re m iu m s (b y ag e, in co m e, ge o gr ap
h ic ar ea )
M an
y p eo
p le w it h in co m es
ju st ab
o ve
th re sh o ld
fo r su b si d ie s w il ln
o t
h av e af fo rd ab
le co ve ra ge ,a n d h en
ce w il lb
e ex
em p tf ro m
th e in d iv id u al
m an
d at e.
C on ti nu ed
1744 HSR: Health Services Research 51:5 (October 2016)
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
H ae d er
an d
W ei m er
(2 01 3) *
V ar io u s so u rc es ;q
u al it at iv e an
al ys es
to id en
ti fy
th e co m m o n
th em
es in
in su ra n ce
ea rl y ex
ch an
ge im
p le m en
ta ti o n ;
m u lt iv ar ia te re gr es si o n an
al ys is o ft im
el y ex
ch an
ge es ta b li sh m en
t
M an
y st at e co m m is si o n er s o fi n su ra n ce
h av e p la ye d co n st ru ct iv e ro le s in
ex ch an
ge p la n n in g d es p it e st ro n g p o li ti ca lo
p p o si ti o n to
th e A C A fr o m
st at e go
ve rn o rs an
d le gi sl at u re s.
H al la n d M o o re
(2 01 2)
S ta te d at a; d es cr ip ti ve
st at is ti cs
o n th e P re ex
is ti n g C on
d it io n
In su ra n ce
P la n en
ro ll m en
ta n d co st s
E x am
in e th e ex
p er ie n ce
w it h th e te m p o ra ry
P re ex
is ti n g C o n d it io n
In su ra n ce
P la n .
H al la n d Sw
ar tz
(2 01 2)
C as e st u d ie s o fM
ar yl an
d ,C
al if o rn ia ,a n d C o lo ra d o
D o cu m en
tt h e d if fe re n ce s ac ro ss st at es
in te rm
s o ft h ei r in it ia la p p ro ac h es
an d ex
p er ie n ce s w it h es ta b li sh in g an
d d es ig n in g ex
ch an
ge s.
H al la n d L o rd
(2 01 4) *
O ve rv ie w an
d as se ss m en
to fe x is ti n g fi n d in gs
In su ra n ce
in d u st ry ’s p ro fi ta b il it y d o es
n o ts ee m
to b e h u rt ,i n d iv id u al
in su ra n ce
p re m iu m s h av e b ee n lo w er
th an
ex p ec te d ,a n d go
ve rn m en
t co st s h av e b ee n le ss th an
in it ia ll y p ro je ct ed
. H am
el et
al .
(2 01 4) *
K F F S u rv ey
o fN
o n gr o u p H ea lt h In su ra n ce
E n ro ll ee s;
d es cr ip ti ve
st at is ti cs
o n th e vi ew
s an
d ex
p er ie n ce
o f
n o n gr o u p en
ro ll ee s
M aj o ri ty
w it h ex
ch an
ge co ve ra ge
is p re vi o u sl y u n in su re d an
d sa ti sfi ed
w it h co ve ra ge .
H er n an
d ez -
B o u ss ar d
et al .( 2 01 4) *
S ta te In p at ie n ta n d E m er ge n cy
D ep
ar tm
en tD
at ab
as es
fr o m
C al if o rn ia ,F
lo ri d a, N ew
Y o rk ;D
D w it h E D vi si ts (b y
va ri o u s in d iv id u al ch ar ac te ri st ic s) as
th e o u tc o m e m ea su re
R at e o fE
D vi si ts in cr ea se d af te r A C A ’s d ep
en d en
tc o ve ra ge
p ro vi si o n
im p le m en
ta ti o n b u ta ta
sl o w er
ra te fo r yo
u n g ad
u lt s re la ti ve
to co m p ar is o n gr o u p .
H o la h an
, B u et tg en
s, an
d D o rn
(2 01 3) *
U rb an
In st it u te ’s H ea lt h In su ra n ce
P o li cy
S im
u la ti o n M od
el ;
n at io n al an
d st at e- le ve lp
ro je ct io n s o fc o st an
d co ve ra ge
u n d er
th e A C A M ed
ic ai d ex
p an
si o n fo r th e p er io d 2 01 3–
2 0 2 2
T h e st at es
th at h ad
n o te x p an
d ed
M ed
ic ai d as
o fJ u ly 2 01 3 ge n er al ly ar e
th e o n es
th at w o u ld
p o te n ti al ly
b en
efi tt h e m o st fr o m
th is p ro vi si o n .
H o w ar d an
d S h ea re r (2 01 3)
D es cr ip ti o n an
d d is cu ss io n o fv
ar io u s st at e p o li ci es
an d
p ro gr am
s to
re d u ce
ch u rn in g an
d p ro m o te co n ti n u it y o f
co ve ra ge /c ar e
T h er e ar e va ri o u s ap
p ro ac h es
b y st at es
to li m it th e p ro gr am
el ig ib il it y
ch an
ge s an
d /o r th e im
p ac tt h o se
ch an
ge s h av e o n in d iv id u al
co n su m er s.
Ja co b s an
d C al la gh
an (2 01 3) *
Q u al it at iv e an
d q u an
ti ta ti ve
an al ys is to
ex p la in
th e va ri at io n s
in re la ti ve
st at e p ro gr es s in
im p le m en
ti n g M ed
ic ai d
ex p an
si o n
E x am
in e h o w ec o n o m ic co n d it io n s, p as tp
o li ci es ,p
o li ti cs ,a n d
ad m in is tr at iv e ca p ac it y in fl u en
ce st at es ’ M ed
ic ai d ex
p an
si o n d ec is io n .
C on ti nu ed
The ACA’s Key Provisions: A Systematic Review 1745
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
K F F an
d C F (2 01 5)
* K F F /C
F 2 01 5 N at io n al S u rv ey
o fP
ri m ar y C ar e P ro vi d er s;
d es cr ip ti ve
st at is ti cs
o n th e im
p ac to
ft h e A C A o n p at ie n t
p o p u la ti o n ,p
ro vi d er s’ p ra ct ic e ca p ac it y, an
d th ei r o p in io n s
ab o u tt h e A C A ’s im
p ac to
n m ed
ic al p ra ct ic e
M aj o ri ty
o fp
ri m ar y ca re
p ro vi d er s su rv ey ed
sa w in cr ea se
in u n in su re d
o r M ed
ic ai d p at ie n ts (i n ex p an si on
st at es )w
it h ou
tr ed
uc in g qu
al it y o f
ca re .
K ar p m an
,W ei ss ,
an d L o n g (2 01 5) *
U rb an
In st it u te H ea lt h R ef o rm
M o n it o ri n g S u rv ey ;
d es cr ip ti ve
st at is ti cs
T h e p ro p o rt io n o fm
id d le -a n d h ig h -i n co m e ad
u lt s re p o rt in g ac ce ss
p ro b le m s d ec re as ed
in 2 01 4 co m p ar ed
to 2 01 3. D is p ar it ie s p er si st fo r
ce rt ai n ag e, in co m e, an
d et h n ic gr o u p s, an
d 4 0%
o fa d ul ts re po
rt ed
va ri ou
s p ro vi d er
ac ce ss p ro b le m s.
K au
fm an
et al .( 2 01 5) *
E n co u n te r d at a fr o m
Q u es tD
ia gn
o st ic s; d es cr ip ti ve
st at is ti cs
o n th e n u m b er
o fn
ew ly id en
ti fi ed
d ia b et es
p at ie n ts in
2 01 3
ve rs u s 2 01 4
N u m b er
o fM
ed ic ai d p at ie n ts w it h n ew
d ia b et es
d ia gn
o se s in cr ea se d ,
p ar ti cu la rl y in
M ed
ic ai d ex
p an
si o n st at es .
K ee h an
et al .
(2 01 5) *
D at a fr o m
va ri o u s so u rc es
in cl u d in g C M S ,B
u re au
o f
E co n o m ic A n al ys is ,U
.S .C
en su s; p ro je ct io n s b as ed
o n
ac tu ar ia la n d ec o n o m et ri c m o d el in g m et h o d s
P ro vi d e va ri o u s p ro je ct io n s fo r n at io n al h ea lt h ex
p en
d it u re s (b y
sp en
d in g ca te go
ri es ,p
er en
ro ll ee ,b
y sp o n so r ty p e, et c. )f o r 2 01 4–
2 0 2 4.
K ir zi n ge r,
C o h en
,a n d
G in d i( 20
13 )*
N H IS ;d
es cr ip ti ve
st at is ti cs
o n th e tr en
d s in
in su ra n ce
co ve ra ge
an d so u rc e o fc o ve ra ge
am o n g yo
u n g ad
u lt s
A ft er
th e d ep
en d en
tc o ve ra ge
p ro vi si o n o ft h e A C A to o k ef fe ct ,p
ri va te
h ea lt h in su ra n ce
co ve ra ge
am o n g yo
u n g ad
u lt s ag ed
19 – 2 5 in cr ea se d
re la ti ve
to a co m p ar is o n gr o u p ,w
h il e co ve ra ge
in th ei r o w n n am
e h as
d ec re as ed
. K o ta ga le t al .
(2 01 4) *
B R F S S ,N
H IS ;D
D w it h h ea lt h st at u s, p re se n ce
o fa
u su al
so u rc e o fc ar e an
d ab
il it y to
af fo rd
m ed
ic at io n s, d en
ta lc ar e,
o r p h ys ic ia n vi si ts as
o u tc o m e m ea su re s
F in d in cr ea se
in co ve ra ge
fo r yo
u n g ad
u lt s o f1 9–
2 5 ye ar s o ld
re la ti ve
to a co m p ar is o n gr o u p ,b
u tm
o re
li m it ed
ch an
ge s in
ac ce ss to
ca re
an d
h ea lt h st at u s.
K o w al sk i( 2 01 4) *
N at io n al A ss o ci at io n o fI n su ra n ce
C o m m is si o n er s d at a; st at e-
sp ec ifi c se as o n al ly ad
ju st ed
tr en
d re gr es si o n s o fh
ea lt h
in su ra n ce
co ve ra ge ,p
re m iu m s, an
d co st s
S u gg es ts th at st at e p o li ci es
to w ar d th e A C A h av e d if fe re n ti al ef fe ct s o n
w el fa re
o fm
ar ke tp
ar ti ci p an
ts .
L au
et al .( 2 01 4) *
M E P S ;p
re -p o st d es ig n u si n g m u lt iv ar ia te re gr es si o n an
al ys is
o fh
ea lt h ca re
u se
in cl u d in g ro u ti n e ex
am in at io n in
th e p as t
ye ar ,b
lo o d p re ss u re /c h o le st er o ls cr ee n in gs ,i n fl u en
za va cc in at io n ,a n d an
n u al d en
ta lv is it
A C A ’s d ep
en d en
tc o ve ra ge
p ro vi si o n h as
in cr ea se d in su ra n ce
co ve ra ge
an d th e u se
o fs o m e p re ve n ti ve
se rv ic es
am o n g yo
u n g ad
u lt s.
L ev it t, C o x ,a n d
C la x to n (2 01 5) *
H ea lt h C o ve ra ge
P o rt al d at a o n in su ra n ce
co m p an
y fi li n gs ;
d es cr ip ti ve
st at is ti cs
o n m ar ke tp la ce
en ro ll m en
ts (b y st at e)
D is cu ss in d iv id u al m ar ke tc o ve ra ge
in 2 01 4. A b o u t8
5% o ft h o se
w it h
m ar ke tp la ce
p la n s w er e el ig ib le fo r su b si d ie s.
C on ti nu ed
1746 HSR: Health Services Research 51:5 (October 2016)
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
L ip to n an
d D ec ke r (2 01 5) *
N H IS ;D
D w it h li ke li h o o d o fH
P V va cc in e in it ia ti o n ,
co m p le ti o n an
d aw
ar en
es s as
o u tc o m e m ea su re s
A C A ’s d ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h an
in cr ea se
in H P V va cc in at io n ra te s fo r yo
u n g ad
u lt s re la ti ve
to co m p ar is o n gr o u p .
M ar ti n ez ,W
ar d ,
an d A d am
s (2 01 5) *
N H IS ;d
es cr ip ti ve
st at is ti cs
o n ch an
ge s in
h ea lt h in su ra n ce
co ve ra ge
an d se le ct ed
m ea su re s o fh
ea lt h ca re
ac ce ss an
d u ti li za ti o n
D o cu m en
td is p ar it ie s in
ac ce ss to
ca re ,c o ve ra ge ,a n d h ea lt h ca re
u ti li za ti o n .
M cC
u e an
d H al l( 2 01 3)
In su re r d at a fr o m
th e D ep
ar tm
en to
fH ea lt h an
d H u m an
Se rv ic es ;d
es cr ip ti ve
st at is ti cs
o n p re m iu m
in cr ea se s fo r
in d iv id u al an
d sm
al l- gr o u p p la n s as
w el la s th e co n tr ib u ti n g
fa ct o rs in cl u d in g th e A C A
In su re rs at tr ib u te d th re e- q u ar te rs o r m o re
o ft h e la rg er
ra te in cr ea se s to
fa ct o rs su ch
as tr en
d s in
m ed
ic al ex
p en
se s. T h ey
at tr ib u te d o n ly a ve ry
sm al lp
o rt io n o ft h es e ch an
ge s to
th e A C A .
M cC
u e an
d H al l( 2 01 5) *
In su re r d at a fr o m
th e D ep
ar tm
en to
fH ea lt h an
d H u m an
Se rv ic es ;d
es cr ip ti ve
st at is ti cs
o n p re m iu m
in cr ea se s fo r
in d iv id u al an
d sm
al l- gr o u p p la n s as
w el la s th e co n tr ib u ti n g
fa ct o rs in cl u d in g th e A C A
In su re rs at tr ib u te d th e gr ea tp
o rt io n o fl ar ge r ra te in cr ea se s to
fa ct o rs
su ch
as tr en
d s in
m ed
ic al ex
p en
se s, an
d m o st o ft h em
d id
n o ta tt ri b u te
th es e ch an
ge s to
th e A C A .
M cM
o rr o w
et al .( 2 01 5) *
N H IS ;d
es cr ip ti ve
st at is ti cs
o n th e tr en
d s in
in su ra n ce
co ve ra ge
an d so u rc e o fc o ve ra ge
am o n g yo
u n g ad
u lt s
T h e d ep
en d en
tc o ve ra ge
p ro vi si o n re d u ce d u n in su ra n ce
m ai n ly
am o n g
h ig h -i n co m e yo
u n g ad
u lt s, w h il e th e la te r A C A p ro vi si o n s re d u ce d
u n in su ra n ce
m ai n ly
am o n g lo w -a n d m o d er at e- in co m e yo
u n g ad
u lt s,
p ar ti cu la rl y in
M ed
ic ai d ex
p an
si o n st at es .
M u lc ah
y et
al .( 2 01 3) *
IM S H ea lt h C h ar ge
D at a M as te r d at ab
as e; D D w it h
n o n d is cr et io n ar y E D vi si ts (b y ty p e o fi n su ra n ce
co ve ra ge
an d re as o n fo r vi si t) as
th e o u tc o m e m ea su re
A C A ’s d ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h an
in cr ea se
in th e
p ri va te ly
co ve re d p ro p o rt io n o fy
o u n g ad
u lt E D vi si ts (a n d a d ec re as e
in u n in su re d yo
u n g ad
u lt E D vi si ts )r el at iv e to
co m p ar is o n gr o u p .
O ’H
ar a an
d B ra u lt (2 01 3) *
A C S ;D
D w it h u n in su ra n ce
an d p ri va te h ea lt h in su ra n ce
co ve ra ge
ra te s as
th e o u tc o m e m ea su re s
E st im
at e in su ra n ce
ra te s b y st at e, ge n d er ,r ac e, et h n ic it y, E n gl is h
sp ea ki n g, an
d ci ti ze n sh ip
st at u s. D is p ar it ie s b y ge n d er
n ar ro w ed
,b u t
th o se
b y ra ce
an d et h n ic it y p er si st .
O ls o n (2 01 5)
C as e st u d y o fP
en n sy lv an
ia in
te rm
s o fi ts ex
is ti n g M ed
ic ai d
p ro gr am
an d h o w it h as
b ee n af fe ct ed
b y th e A C A
E x am
in e fi n an
ci al an
d o th er
co n si d er at io n s in
p o li cy
m ak er s’ M ed
ic ai d
ex p an
si o n d ec is io n .
P o ls ky
et al .
(2 01 4) *
D at a o n al lp
la n s o ff er ed
in th e m ar ke tp la ce s fr o m
th e H ea lt h
In su ra n ce
E x ch an
ge s (H
IX )2
.0 d at as et ;d
es cr ip ti ve
st at is ti cs
o n si lv er
p la n s
C om
p ar e in su re r co m p et it io n ,p
la n ch ar ac te ri st ic s, an
d p re m iu m s in
h ea lt h in su ra n ce
ex ch an
ge s fo r ru ra la n d u rb an
ar ea s.
P o ls ky
et al .
(2 01 5) *
S im
u la te d p at ie n ts tu d y o fp
ri m ar y ca re
p ra ct ic es
in 10
st at es ;
d es cr ip ti ve
st at is ti cs
o n th e av ai la b il it y o fa p p o in tm
en ts an
d w ai ti n g ti m es
fo r ap
p o in tm
en ts fo r n ew
p at ie n ts b y st at e an
d in su ra n ce
ty p e
A va il ab
il it y o fp
ri m ar y ca re
ap p o in tm
en ts fo r M ed
ic ai d p at ie n ts
in cr ea se d fo ll o w in g an
in cr ea se
in M ed
ic ai d re im
b u rs em
en ts w h il e n o
ch an
ge s w er e o b se rv ed
fo r th e p ri va te in su ra n ce
gr o u p .
C on ti nu ed
The ACA’s Key Provisions: A Systematic Review 1747
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
R as m u ss en
et al .( 2 01 4) *
C F A C A T ra ck in g S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n p re m iu m s,
o u t- o f- p o ck et co st s, p eo
p le ’s ab
il it y to
co m p ar e p la n s an
d th ei r ex
p er ie n ce s in
te rm
s o ffi
n d in g o u ta b o u tt h ei r
el ig ib il it y fo r fi n an
ci al as si st an
ce o r M ed
ic ai d
M os ta d u lt s w it h m ar ke tp la ce
co ve ra ge
ar e sa ti sfi ed
w it h th ei r p la n s.
T h o se
w it h lo w o r m o d er at e in co m es
re p o rt h av in g p re m iu m s an
d d ed
u ct ib le s si m il ar
to th o se
w it h E S I.
R as m u ss en
et al .( 2 01 5)
C F B ie n n ia lH
ea lt h In su ra n ce
S u rv ey ;d
es cr ip ti ve
st at is ti cs
o n h ea lt h in su ra n ce
co ve ra ge ,c o st -r el at ed
p ro b le m s ge tt in g
n ee d ed
ca re ,a n d m ed
ic al d eb
ti n C al if o rn ia ,F
lo ri d a, N ew
Y o rk ,a n d Te x as
C al if o rn ia an
d N ew
Y o rk
h av e th ei r o w n ex
ch an
ge s an
d ex
p an
d ed
M ed
ic ai d .U
n in su re d ra te s in
th es e st at es
ar e lo w er
an d af fo rd ab
il it y is
b et te r th an
in F lo ri d a an
d T ex
as ,w
h ic h re ly o n th e fe d er al ex
ch an
ge an
d d id
n o te x p an
d M ed
ic ai d .
R os en
b au
m et
al .( 2 01 4) *
R ev ie w p la n -t o -p la n tr an
si ti o n p o li ci es
im p le m en
te d in
16 st at es
an d W as h in gt o n ,D
C ,t o m it ig at e th e ef fe ct s o f
ch u rn in g an
d to
en su re
co n ti n u it y o fc ar e.
T h er e ar e va ri o u s st ra te gi es
to m it ig at e th e ef fe ct s o fc h u rn in g ac ro ss
M ed
ic ai d ,C
H IP ,a n d p u b li cl y su b si d iz ed
p ri va te co ve ra ge ,b
u tt h ey
ar e
ra th er
co m p le x an
d m ay
ta ke
ti m e to
im p le m en
ta n d to
yi el d th e
d es ir ed
re su lt s.
S al o n er
an d L e
C o o k (2 01 4) *
N at io n al S u rv ey
o fD
ru g U se
an d H ea lt h ;D
D w it h se le ct ed
m ea su re s o fm
en ta lh
ea lt h an
d su b st an
ce ab
u se
tr ea tm
en ta s
o u tc o m es
A C A ’s d ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h in cr ea se d u se
o f
m en
ta lh
ea lt h tr ea tm
en ta m o n g yo
u n g ad
u lt s re la ti ve
to co m p ar is o n
gr o u p .N
o si gn
ifi ca n tc h an
ge s w er e o b se rv ed
in su b st an
ce u se
tr ea tm
en t.
Sc h o en
,R ad
le y,
an d C o ll in s
(2 01 5) *
M E P S ,C
P S ;d
es cr ip ti ve
st at is ti cs
o n E S I p la n tr en
d s
re ga rd in g th ei r p re m iu m s, af fo rd ab
il it y, w o rk er
co n tr ib u ti o n s, an
d o u t- o f- p o ck et co st s
R ep
o rt th at th e co st o fE
S I p re m iu m s ro se
fa st er
th an
m ed
ia n in co m es
d u ri n g 2 00
3– 2 01 3. A sl o w d o w n in
th e gr o w th
ra te o fp
re m iu m s w as
o b se rv ed
o ve r th e la st 3 ye ar s fo ll o w in g th e A C A im
p le m en
ta ti o n .
Sc o tt et
al .( 2 01 5) *
N at io n al T ra u m a D at a B an
k; D D w it h u n in su ra n ce
st at u s an
d cl in ic al o u tc o m es
fo r tr au
m a p at ie n ts as
o u tc o m e m ea su re s
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h a si gn
ifi ca n td
ec re as e in
th e ra te o fu
n in su re d tr au
m a p at ie n ts ag es
19 – 2 5, b u tt h er e ar e n o
si gn
ifi ca n tc h an
ge s in
cl in ic al tr au
m a o u tc o m es .
S h an
e an
d A yy
ag ar i( 2 01 4) *
M E P S ;D
D w it h in su ra n ce
co ve ra ge
b y ra ce ,i n co m e, m ar it al
st at u s, an
d p o li cy
h o ld er
st at u s as
th e o u tc o m e m ea su re s
W h il e th e d ep
en d en
tc o ve ra ge
p ro vi si o n in cr ea se d in su ra n ce
co ve ra ge
am o n g al lr ac ia la n d et h n ic gr o u p s, it d id
n o tr ed
u ce
o ve ra ll d is p ar it ie s.
D is p ar it ie s m ay
h av e w id en
ed am
o n g lo w -i n co m e in d iv id u al s.
S ko
p ec
an d
K ro n ic k (2 01 3) *
V ar io u s so u rc es
in cl u d in g M E P S an
d m ar ke tp la ce
in su ra n ce
p re m iu m s fr o m
se le ct ed
st at es ;d
es cr ip ti ve
co m p ar is o n s o f
th e p re m iu m s in
th e in d iv id u al an
d sm
al l- gr o u p m ar ke ts to
ea rl ie r C B O
es ti m at es
P re m iu m s fo r si lv er
p la n s in
2 01 4 ar e lo w er
th an
C B O
es ti m at es
an d
ap p ea r to
b e af fo rd ab
le fo r th e m o st p ar t.
So m m er s an
d K ro n ic k (2 01 2) *
C P S ;D
D w it h in su ra n ce
co ve ra ge
an d ty p e as
w el la s p o li cy
h o ld er
st at u s as
o u tc o m es
D ep
en d en
tc o ve ra ge
p ro vi si o n le d to
in cr ea se s in
in su ra n ce
co ve ra ge
fo r
yo u n g ad
u lt s, es p ec ia ll y am
o n g m in o ri ti es .
C on ti nu
ed
1748 HSR: Health Services Research 51:5 (October 2016)
T ab
le 2.
C on ti nu ed
R es ea rc h St ud y
D at a/ M et ho ds
B ri ef D es cr ip ti on
So m m er s
et al .( 2 01 3) *
N H IS ,C
P S ;D
D w it h in su ra n ce
co ve ra ge
an d ac ce ss to
ca re
as o u tc o m e m ea su re s
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h si gn
ifi ca n ti n cr ea se s in
p ri va te h ea lt h in su ra n ce
an d ac ce ss to
ca re
fo r yo
u n g ad
u lt s re la ti ve
to co m p ar is o n gr o u p .
So m m er s,
K en
n ey ,a n d
E p st ei n (2 01 4) *
A d m in is tr at iv e re co rd s o n M ed
ic ai d en
ro ll m en
ti n fo u r
st at es ,A
C S ;D
D w it h co ve ra ge
th ro u gh
M ed
ic ai d ,p
ri va te
h ea lt h in su ra n ce
co ve ra ge ,a n d u n in su ra n ce
as o u tc o m e
m ea su re s
F in d st ea d y in cr ea se
in M ed
ic ai d en
ro ll m en
ti n fo u r M ed
ic ai d ex
p an
si o n
st at es ,e sp ec ia ll y am
o n g th o se
w it h h ea lt h -r el at ed
li m it at io n s.
So m m er s et
al .
(2 01 4a )*
G al lu p -H
ea lt h w ay s, W el l- B ei n g In d ex
,a n d C M S d at a;
m u lt iv ar ia te re gr es si o n an
al ys is w it h in su ra n ce
co ve ra ge
an d ac ce ss to
ca re
as o u tc o m e m ea su re s
R ep
o rt th at 7. 3 to
17 .2
m il li o n ad
u lt s ga in ed
co ve ra ge
b y m id -2 01 4.
So m m er s et
al .
(2 01 5) *
G al lu p -H
ea lt h w ay s W el l- B ei n g In d ex
;m u lt iv ar ia te
re gr es si o n an
al ys is an
d D D w it h se lf -r ep
o rt ed
co ve ra ge ,
ac ce ss to
ca re ,a n d h ea lt h as
o u tc o m e m ea su re s
Se lf -r ep
o rt ed
in su ra n ce
co ve ra ge ,a cc es s to
p ri m ar y ca re
an d
m ed
ic at io n s, af fo rd ab
il it y, an
d h ea lt h im
p ro ve d si gn
ifi ca n tl y af te r th e
fi rs t2
ye ar s u n d er
th e A C A .
Sw ar tz ,H
al l, an
d Jo st (2 01 5) *
V ar io u s so u rc es
in cl u d in g in te rv ie w s; ca se
st u d y o fA
rk an
sa s,
C al if o rn ia ,C
on n ec ti cu t, M ar yl an
d ,M
on ta n a, an
d Te x as
D es cr ib e va ri o u s co m p et it iv e st ra te gi es
ad o p te d b y in su ra n ce
ca rr ie rs
d u ri n g th e fi rs ty
ea r o ft h e A C A m ar ke tp la ce s. T h es e co m p et it iv e
st ra te gi es
va ry
b y st at e.
V u jic ic ,
Y ar b ro u gh
,a n d
N as se h (2 01 4) *
N H IS ,2 00
8– 2 01 2;
D D w it h p ri va te d en
ta lb
en efi
ts co ve ra ge ,
d en
ta lc ar e u ti li za ti o n ,a n d fi n an
ci al b ar ri er s to
o b ta in in g
n ee d ed
d en
ta lc ar e as
o u tc o m e m ea su re s
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h “s p il lo ve r”
in cr ea se s in
d en
ta lc o ve ra ge ,d
en ta lc ar e u ti li za ti o n ,a n d af fo rd ab
il it y fo r yo
u n g
ad u lt s re la ti ve
to co m p ar is o n gr o u p .
W al la ce
an d
So m m er s (2 01 5) *
B R F S S ;D
D w it h in su ra n ce
co ve ra ge ,s el f- re p o rt ed
h ea lt h ,
an d ac ce ss to
h ea lt h ca re
as o u tc o m e m ea su re s
D ep
en d en
tc o ve ra ge
p ro vi si o n is as so ci at ed
w it h b et te r se lf -r ep
o rt ed
h ea lt h an
d ac ce ss to
h ea lt h ca re
am o n g yo
u n g ad
u lt s re la ti ve
to co m p ar is o n gr o u p .
W il en
sk y an
d G ra y (2 01 3)
R ev ie w o fM
ed ic ai d p o li ci es
in al l5
0 st at es
an d W as h in gt o n ,
D C
E va lu at e co ve ra ge
o fA
C A -r eq
u ir ed
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The ACA’s Key Provisions: A Systematic Review 1749
RESULTS
Dependent Coverage Provision
Under the so-called young adult mandate, individuals between the ages of 19– 25 years are allowed to remain on their parents’ health insurance plans. Since this mandate took effect in 2010, many researchers have already examined the impact of the law on this population. Most of this literature uses a quasi-experi- mental difference-in-differences approach to compare young adults aged 19–25 to slightly older individuals before and after 2010. Although magni- tudes vary, all studies show a rapid increase in insurance coverage among young adults after this provision took effect (Cantor et al. 2012; Sommers and Kronick 2012; Akosa Antwi, Moriya, and Simon 2013; Kirzinger, Cohen, and Gindi 2013; O’Hara and Brault 2013; Chua and Sommers 2014; Kotagal et al. 2014). Collins et al. (2013a) reported that in 2013 an estimated 15 million young adults were on a parent’s policy in the past 12 months, an increase of 1.3 million since 2011. Approximately half of these were full-time students (Collins et al. 2013a). These estimates are in line with other studies suggesting that 1–3 million uninsured young adults gained coverage under the ACA (Akosa Antwi, Moriya, and Simon 2013; O’Hara and Brault 2013; Blumen- thal, Abrams, and Nuzum 2015; McMorrow et al. 2015).
The gains in coverage are especially pronounced for men, unmarried individuals, and nonstudents (Sommers et al. 2013). Consistent with adverse selection, young adults in worse health acquired coverage sooner and with greater frequency than others (Sommers et al. 2013). This man- date primarily benefitted those with relatively high incomes, while Medi- caid expansion and marketplace reforms implemented in 2014 targeted lower income young adults (McMorrow et al. 2015). Overall, the rate of uninsured young adults decreased from 30 percent in 2009 to 19 percent in 2014, which translates to about 6 million of them remaining uninsured in 2014 (McMorrow et al. 2015). Disparities persist by race, ethnicity, and income (O’Hara and Brault 2013; Shane and Ayyagari 2014). Most studies report that gains in insurance coverage are associated with better access to health care for young adults (Sommers et al. 2013; Wallace and Sommers 2015), especially among men and college graduates (Barbaresco, Courte- manche, and Qi 2015). Others find that the ACA is associated with improvements in self-reported health status among young adults (Carlson et al. 2014; Chua and Sommers 2014; Barbaresco, Courtemanche, and Qi 2015; Wallace and Sommers 2015).
1750 HSR: Health Services Research 51:5 (October 2016)
Studies have examined the effect of expanded dependent coverage on the utilization of emergency department (ED) care (Mulcahy et al. 2013; Hernandez-Boussard et al. 2014; Akosa Antwi et al. 2015), preventive ser- vices (Lau et al. 2014; Barbaresco, Courtemanche, and Qi 2015; Lipton and Decker 2015), dental care (Vujicic, Yarbrough, and Nasseh 2014), and mental health treatment (Saloner and Le Cook 2014; Golberstein et al. 2015). Akosa Antwi, Moriya, and Simon (2015) found that inpatient hospital visits increased 3.5 percent and mental health visits increased 9 percent among young adults, without significant differences in hospital length of stay or charges. ED visits actually decreased among young adults (Hernandez-Boussard et al. 2014; Akosa Antwi et al. 2015).
Besides the changes in insurance coverage and health care utilization among this group, the proportion of young adults reporting high out-of-pocket spending for health care decreased significantly following passage of the ACA (Busch, Golberstein, and Meara 2014; Chua and Sommers 2014). Compared to individual plans, premiums for plans covering children have increased 2.5–2.8 percent more due to the dependent coverage provision, but employ- ers absorbed much of this increase (Depew and Bailey 2015). The amount of uncompensated care for young adults decreased as a greater proportion of ED, trauma center, and psychiatric inpatient utilization being covered by pri- vate insurance (Mulcahy et al. 2013; Akosa Antwi, Moriya, and Simon 2015; Golberstein et al. 2015; Scott et al. 2015).
Overall Health Insurance Coverage, Access, and Affordability
Preliminary data suggest that the law has substantially decreased the number of uninsured Americans (Sommers et al. 2014a, 2015; Cohen and Martinez 2015; Collins et al. 2015a,b). Figure 1 shows recent trends and projections for various sources of health insurance coverage and uninsurance rates (Kee- han et al. 2015). The rate of uninsured adults decreased from 20 percent in 2013 to 15 percent in 2014 (Doty, Rasmussen, and Collins 2014), with further declines expected in coming years (Keehan et al. 2015). According to Blu- menthal, Abrams, and Nuzum (2015), an estimated 7–16 million uninsured people acquired coverage since 2010, with young adults, low-income indi- viduals, and minorities experiencing large gains. Similarly, the CBO (2015a) estimates that 17 million more people would have been uninsured in 2015 without the ACA. In the first 5 years of the ACA, 11.7 million purchased new plans from the marketplace, 10.8 million more have Medicaid coverage, and 3 million young adults are on their parents’ policies (Blumenthal, Abrams, and Nuzum 2015).
The ACA’s Key Provisions: A Systematic Review 1751
The majority of new enrollees are satisfied with their plans and feel more financially secure, although paying the premiums is still a challenge for some (Hamel et al. 2014; Collins et al. 2015b). The 2014 Commonwealth Fund Biennial Health Insurance Survey was the first since 2003 to show a decline in the number of adults reporting problems affording needed medical care (Collins et al. 2015b). Sommers et al. (2015) found significant improvements in access to primary care services and medications, affordability of care, and self-reported health after the first 2 years of the ACA. Analyses indicate that expanded coverage has led to better access to a physician (Sommers et al. 2014a; Collins et al. 2015b) among all income groups (Karpman, Weiss, and Long 2015). Although the proportion without a regular source of care decreased from 29.8 percent in 2013 to 26 percent in 2014, almost 40 percent of respondents still had at least one access problem (Karpman, Weiss, and Long 2015). Disparities in access measures persist for different racial/ethnic
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Notes. *Indicates projections. Estimated percentages in a given year do not sum to 100% due to rounding and because individuals can have multiple sources of health insurance coverage. Source: Keehan et al. (2015).
1752 HSR: Health Services Research 51:5 (October 2016)
and income groups (Cohen and Martinez 2015; Karpman, Weiss, and Long 2015; Martinez, Ward, and Adams 2015).
Over the 2016–2025 period, the CBO (2015b) projects that the ACAwill reduce the number of uninsured by 24–25 million people relative to what would have occurred otherwise. However, about 26–29 million nonelderly are still expected to lack coverage, including unauthorized immigrants, those who live in non-Medicaid expansion states, individuals affected by the “family glitch” (discussed below), and those who choose not to enroll in Medicaid or purchase insurance (CBO 2015b). The uninsured are more likely to be young, low-income, and Hispanic (Collins et al. 2015b).
Health Insurance Exchanges, Tax Credits, and the Individual Mandate
Impact of Marketplace Design and Implementation. Political factors along with administrative capabilities influenced whether a state established its own exchange or relied on the federal marketplace (Haeder and Weimer 2013; Brandon and Carnes 2014). The type of exchange established and malfunctions in implementation can have significant implications for market participants (Kowalski 2014). According to Brandon and Carnes (2014), commodification of insurance plans (i.e., making them transparent and accessible to consumers), competition, and communication are three elements of successful exchanges.
Blumenthal, Abrams, and Nuzum (2015) discussed several problems that occurred during ACA implementation including cancelation notices for non- compliant plans (which were later allowed to be renewed), narrow provider networks, and plans with very high deductibles. Furthermore, the public had a limited understanding and awareness of the ACA provisions (Collins et al. 2013a; Barcellos et al. 2014; KFF and CF 2015). Some survey results show that premiums and deductibles for plans purchased through the marketplace are comparable to ESI for those with similar incomes (Rasmussen et al. 2014). Premiums for marketplace plans are generally lower in areas that are more den- sely populated and in states with state-based exchanges (Barker et al. 2014a).
Use of Marketplace Subsidies. Levitt, Cox, and Claxton (2015) estimate that plans purchased in the marketplace accounted for 43 percent of all individu- ally purchased plans in 2014, and 85 percent of those enrolling in marketplace plans qualified for tax credits. A Government Accountability Office (GAO 2015) analysis suggests that the premium tax credit has contributed to higher rates of insurance coverage—in contrast to the employer tax credit, which had
The ACA’s Key Provisions: A Systematic Review 1753
a more limited impact. In 2014, tax credits reduced marketplace premiums by an average of 76 percent (GAO 2015). As incomes rise and subsidies decline, however, premiums may increase sharply, making it increasingly difficult for those at the subsidy threshold (300–400 percent of the FPL) to afford health insurance (Graetz et al. 2014).
Although almost anyone can purchase insurance through the market- place (undocumented immigrants is a key exception), those who have access to ESI may not be eligible for tax credits, even if they meet the income requirements (HHS, 2014).3 Employees are not eligible if they and/or their spouses are offered “affordable” ESI coverage. When assessing affordability, however, the provision is unclear whether to consider the cost of individual coverage for the employee alone or the cost of family coverage. The Internal Revenue Service interprets the statute on the basis of individual coverage, which is much cheaper than family coverage. Due to this so-called fam- ily glitch, a significant number of low- to moderate-income individuals—2– 4 million according to various estimates—may be denied financial assistance (Brooks 2014).
Effect of the Individual Mandate. The individual mandate is intended to attract new enrollees, increase the number of insured, diversify risk pools, and lower premiums (Gruber 2011b). The CBO (2014) estimates that 4 million people will be penalized for violating the individual mandate in 2016 and about $4 billion will be collected in penalties. Sheils and Haught (2011) predict that nongroup premiums would increase by 12.6 percent and 7.8 million people would not have coverage without this mandate.
Participation and Competition in the Exchanges. Several studies focus on partici- pation of (Abraham, Feldman, and Simon 2014; CMS 2014; GAO 2014a) and competition among (Cox et al. 2014; Swartz, Hall, and Jost 2015) insurers in the exchanges. Among the incumbent insurers in 2012, 10 percent partici- pated in the marketplace in 2014—depending on presence in the region, size, and whether the insurer had prior experience in the group market (Abraham, Feldman, and Simon 2014). As the ACA matures, participation may increase further—25 percent more insurance companies joined the marketplace in 2015 than in 2014 (CMS 2014).
Competition in state-sponsored exchanges varies considerably both within and across states (Cox et al. 2014; GAO 2014a; Kowalski 2014; Polsky
1754 HSR: Health Services Research 51:5 (October 2016)
et al. 2014; Dickstein et al. 2015; Swartz, Hall, and Jost 2015). Dickstein et al. (2015) reported that states can alter competition and market outcomes by how they define their coverage regions. In 2014, almost all state exchanges had multiple issuers, most included a mix of large and small companies, and more populous states usually had a wider selection of plans (GAO 2014a). An aver- age of 37.3 plans were available through exchanges in urban counties com- pared to 25.7 plans in rural counties (Barker et al. 2014b). As the ACA restricts the ability of insurance companies to alter their risk pool, they com- pete instead by offering different cost-sharing arrangements, benefits, and pro- vider networks (Swartz, Hall, and Jost 2015). Furthermore, incentives may remain to restrict or ration care for some higher cost patients (McGuire et al. 2014). To protect consumers from the risks associated with “narrow network plans,” 27 states established quantitative standards for network adequacy and governmental oversight is expected to increase over time (Giovannelli, Lucia, and Corlette 2015).
Employer Mandate and the ESI System
One of the overarching questions about the ACA is how it will impact ESI, and whether the vast majority of workers will continue to obtain health insur- ance via their workplace. Recent studies indicate an absence of major changes in ESI since the ACA has gone into effect (Claxton et al. 2014a; Blavin et al. 2015). In 2014, the proportion of employers offering ESI (55 percent) and the average annual premium for individual coverage therein ($6,025) were simi- lar to those in 2013 (Claxton et al. 2014a). Since 2003, premiums, deductibles, and employee contributions for ESI have gradually increased, but at a slower rate starting in 2010 (Collins et al. 2014a; Schoen, Radley, and Collins 2015). Note that these preliminary findings are based on partial implementation of the employer mandate. Thus, additional research is needed to evaluate whether these trends persist as the employer mandate and associated penalties go into full effect in 2016.
The Small Business Health Options Program (SHOP). As of June 2014, 18 state- based SHOP marketplaces enrolled 76,000 individuals from 12,000 small employers, and premiums for SHOP plans were similar to those for other small-group plans (GAO 2014b). Gabel et al. (2013) surveyed small firms and found the majority favored several SHOP features. However, participation in SHOP is lower than expected due to a number of challenges (GAO 2014b).
The ACA’s Key Provisions: A Systematic Review 1755
Some employers believe the small business tax credit, intended as an incentive to use SHOP, is too limited in its scope and requires a complex application process (Blumberg and Rifkin 2014; GAO 2014b). Initial participation in SHOP was also hampered by technical problems with the website, lack of awareness about the program, and limited involvement by brokers (Blumberg and Rifkin 2014; GAO 2014b). Moving forward, it is unclear whether small businesses will embrace this feature of the ACA, especially as some employers consider other options to provide coverage, such as private insurance exchanges or continued reliance on grandfathered, noncompliant plans (Blumberg and Rifkin 2014).
Medicaid Expansion
Although provisions for full Medicaid expansion did not take effect until 2014, California, Connecticut, Minnesota, and Washington, DC began early enrollment in 2010. Sommers, Kenney, and Epstein (2014) found a steady increase in Medicaid enrollment in these states, with the highest take-up among those with health limitations. Potential Medicaid beneficiaries are gen- erally healthier than those who are already enrolled, but those with chronic conditions are less likely than existing enrollees to have the disease(s) under control (Decker et al. 2013). As of September 2015, 30 states and Washington, DC had implemented Medicaid expansion and 20 chose not to participate (KFF 2015). Expansion decision is heavily influenced by political factors as well as state economic conditions, administrative capabilities, and prior poli- cies toward low-income residents and the uninsured (Jacobs and Callaghan 2013). An estimated 3.7 million adults in nonexpansion states are in the “cov- erage gap,” with low-income blacks disproportionately affected (Artiga, Ste- phens, and Damico 2015). This means they earn too much to qualify for Medicaid, but not enough to be eligible for premium tax credits in the market- place.
The availability of coverage affects access and health outcomes of Medi- caid beneficiaries (Artiga, Rudowitz, and Ranji 2015; Kaufman et al. 2015; Sommers et al. 2015). According to the 2014 Commonwealth Fund Biennial Health Insurance Survey (Collins et al. 2015b), 78 percent of adults who have used their newly gained Medicaid coverage to obtain care said “they would not have been able to access or afford this care before.” Another study found that new coverage led to increases in the number of diabetes diagnoses for Medicaid patients (Kaufman et al. 2015). Sommers et al. (2015) found the pro- portion of low-income adults with difficulties accessing a physician and
1756 HSR: Health Services Research 51:5 (October 2016)
medication decreased more in Medicaid expansion states than in nonexpan- sion states.
Frequent eligibility changes or “churning” is an ongoing concern in all states as individuals’ incomes vary and they transition to and from Medicaid, the marketplace, possibly ESI, and no coverage (Rosenbaum et al. 2014; Sommers et al. 2014b). Low-income adults in nonexpansion states are particu- larly vulnerable to being uninsured (Collins et al. 2015b) or incurring high out-of-pocket costs in the marketplace (Hill 2015). Eventually, states will need to address churning, which has implications for tax credits, continuity of care, and health outcomes (Rosenbaum et al. 2014).
A group of studies have focused on providers’ experiences with expand- ing Medicaid (Angier et al. 2015; Cunningham, Garfield, and Rudowitz 2015; KFF and CF 2015). Ascension Health, the largest nonprofit health system in the United States, had more Medicaid discharges and revenues, and lower cost of care for the poor in expansion states. In other states, however, they experi- enced only a small increase in Medicaid discharges, a decrease in Medicaid revenue, and higher cost of care for the poor (Cunningham, Garfield, and Rudowitz 2015). Provider participation in public insurance programs has been an ongoing concern as some physicians are reluctant to accept Medicaid bene- ficiaries due to low reimbursement rates (Polsky et al. 2015). Following a tem- porary increase in Medicaid payments to providers during 2013–2014, the availability of primary care appointments increased for Medicaid enrollees, while wait times for new appointments remained the same (Polsky et al. 2015). A survey of primary care providers shows that the proportion accepting new Medicaid patients in 2015 is similar to that in 2011–2012 (KFF and CF 2015). A majority of providers surveyed, however, saw an increase in unin- sured or Medicaid patients in expansion states without negatively affecting the quality of care (KFF and CF 2015).
Insurance Premiums, Health Care Expenditures, and Government Budgets
Health Insurance Premiums. Premiums continue to increase faster than median family income, leading more individuals to opt for high–deductible plans (Collins et al. 2014a; Schoen, Radley, and Collins 2015). While certain provi- sions of the ACA are likely to increase premiums (e.g., expansion of depen- dent coverage, extended benefits, ban on charging more for preexisting conditions), other features (e.g., restrictions on administrative costs and profits for insurance companies, risk-sharing programs, individual mandate, compe- tition in the marketplace) are expected to have the opposite effect (Blumenthal
The ACA’s Key Provisions: A Systematic Review 1757
and Collins 2014; Collins et al. 2014a; Cox et al. 2015; Schoen, Radley, and Collins 2015). Overall, average premiums and spending by private health insurers in 2014 were lower than projected (Skopec and Kronick 2013). Aver- age annual growth in premiums per enrollee for all private health insurance was 2.1 percent in 2013 and is projected to be 5.4 percent in 2014 and 2.8 per- cent in 2015 (Keehan et al. 2015). Insurers requesting large rate increases pri- marily attributed the change to higher prices for services and certain ACA requirements such as new taxes (McCue and Hall 2015). Even if premiums continue to gradually increase, most individuals are expected to receive expanded insurance benefits, and out-of-pocket costs may actually decline for those who are eligible for tax credits (Hill 2012; Keehan et al. 2015).
Health Care Expenditures. In recent years, national health care spending slo- wed from the relatively high growth rates experienced during the 1990s and early 2000s, averaging 4.0 percent annually over the 2008–2013 period (Chandra, Holmes, and Skinner 2013; Dranove, Garthwaite, and Ody 2014; Keehan et al. 2015). Nevertheless, the portion of GDP spent on health care is expected to increase from 17.4 percent in 2013 to 19.6 percent in 2024 (Keehan et al. 2015). Health care spending is projected to grow at an average annual rate of 5.8 percent over the period of 2014–2024, and much of this increase may be driven by the ACA’s coverage expansions as well as higher prescrip- tion drug spending, a stronger economy, and an aging population (Keehan et al. 2015).
The expansion of insurance coverage under the ACA is expected to increase utilization of primary care and other services (Dall et al. 2013). The ACA includes a number of different approaches that have the potential to con- trol rising health care expenditures, such as reducing medical errors, creating exchanges, taxing high cost insurance plans, and adjusting provider reim- bursements (Gruber 2011a). It is too soon, however, to fully evaluate whether or to what extent these cost control measures will impact prices and utilization (Chandra, Holmes, and Skinner 2013; Blumenthal, Abrams, and Nuzum 2015). Blumenthal, Abrams, and Nuzum (2015) asserted that the ACA may be contributing to slower health care spending growth and, at a minimum, has not led to a rapid increase in spending.
Budgetary Effects of the ACA. As individuals with chronic diseases enroll in Medicaid and gain access to health services, overall health care utilization and
1758 HSR: Health Services Research 51:5 (October 2016)
spending will likely increase, creating challenges for state budgets. The latest estimates indicate that Medicaid spending increased 12 percent and enroll- ment increased 12.9 percent in 2014 (Keehan et al. 2015). Federal contribu- tions cover all expansion costs during the first 3 years, which will benefit providers and generate economic activity (Holahan, Buettgens, and Dorn 2013). State budgets may be more strained later on, when they are required to fund more of the expansion. Even so, decreases in uncompensated care are expected to offset some of spending increases associated with Medicaid expansion. Overall, studies present evidence that expanding Medicaid is financially prudent for most states (Holahan, Buettgens, and Dorn 2013; Bachrach, Boozang, and Glanz 2015).
Due to its major role in Medicaid expansion and the establishment of health insurance exchanges, the federal government will end up financing a larger proportion of health care than before the ACA (Keehan et al. 2015). The actual estimate depends on the number of states participating in Medicaid expansion and a number of other factors. Changes in ESI also need to be taken into account as reductions in ESI coverage could increase federal tax receipts. However, this revenue increase could be offset by higher wages, which generate tax revenues but also lead to higher social security spending. Overall, the CBO (2015a) estimates that federal deficits will grow to $137 bil- lion from 2016 to 2025 if the ACAwere repealed.
DISCUSSION AND OPPORTUNITIES FOR FUTURE RESEARCH
Opportunities abound for researchers to study the most sweeping health care legislation in recent U.S. history. Results from this current systematic review highlight gaps in the existing literature and can serve as a resource for researchers considering where additional work is needed. Studies so far clearly show that the ACA has led to expansions in insurance coverage and improved access to care, especially among young adults, the relatively poor, less healthy populations, and minorities. With the exception of the dependent coverage provision, most investigations of the ACA so far are descriptive in nature, and rigorous study designs are needed to provide more convincing empirical evidence. In addition, further research is required to demonstrate the full impact of the ACA on health care prices, utilization, and perhaps most important, health outcomes.
The ACA’s Key Provisions: A Systematic Review 1759
The findings so far clearly establish areas for future investigation. For example, given that young adults have different health behaviors and health care needs than older adults, it is unknown whether the results for young adults are generalizable to the rest of the nonelderly population. Our review also identified a number of studies related to delivery reforms, workforce issues, and insurance company regulations, but due to the preliminary stage of these inquiries, we chose to exclude them from our analysis.
Augmenting and improving the existing studies will provide a deeper understanding of insurance expansions such as the composition of risk pools, the type of health care (e.g., acute, chronic, preventive, emergency, hospital, diagnostic services) some of the newly insured receive, and the quality of care therein. Going forward, out-of-pocket costs associated with the new plans pur- chased in marketplaces will need to be tracked. How will narrow provider net- works affect consumer satisfaction and outcomes? In the aggregate, health care expenditures have moderated recently, but is this a temporary trend and to what extent it can be attributed to the ACA? More rigorous analyses and study designs, rather than simply reporting descriptive statistics, are needed to control for factors such as economic trends and geographic variation, which will permit further investigation of mechanisms underlying changes and trends in prices, utilization, and cost.
Other questions require better data and longer follow-up periods. What happens to ESI as employer penalties go into full effect? What will the labor market implications be? How do eventual changes in premiums and health care expenditures compare to initial projections? How will federal and state health care expenditures change if more states expand Medicaid? Lastly, the legislative process has largely stalled when it comes to identifying and fixing inefficiencies in the ACA (e.g., family glitch). How will the political process evolve after the 2016 election year?
Studies in the gray literature often present results from surveys of speci- fic populations (e.g., low-income adults, women) or longitudinal surveys that track changes in coverage, costs, and attitudes toward reforms (e.g., Doty, Ras- mussen, and Collins 2014; Hamel et al. 2014; Collins et al. 2015b). Analyses of large and nationally representative datasets will be necessary to substantiate findings from earlier preliminary studies. Both private and federal surveys as well as administrative data sources have limitations, so it is encouraging that several new initiatives are underway to collect better data pertaining to the ACA (Claxton et al. 2014b). An example is the Commonwealth Fund’s joint program with the University of Chicago to track premiums, deductibles, and other features of health insurance plans (Whitmore et al. 2014). Such
1760 HSR: Health Services Research 51:5 (October 2016)
initiatives are critical as many of the compelling research questions related to the long-term effects of the ACA require better data, rigorous research designs, and more time. Although many questions about the ACA remain unanswered, especially regarding costs and outcomes, it is clear that the ACA has accomplished two of its main goals—decreasing the number of uninsured and improving access to care.
ACKNOWLEDGMENTS
Joint Acknowledgment/Disclosure Statement: We gratefully acknowledge two anonymous referees and Theodore Ganiats, M.D., for their constructive com- ments and suggestions on earlier versions of the paper. We also thank Joanna Faley for research assistance and Carmen Martinez for administrative support.
Disclosures: None. Disclaimers: None.
NOTES
1. A more comprehensive and detailed description of the ACA’s provisions is available from the Kaiser Family Foundation (KFF) and the Commonwealth Fund (CF).
2. While not the focus here, the provisions related to improving the delivery of health care are important components of the ACA and have the potential to significantly influence both the cost and quality of care. See Blumenthal, Abrams, and Nuzum (2015) for a progress report on the ACA’s health care delivery reforms.
3. Eligibility for tax credits depends on whether the employer coverage meets two tests: (1) Is it affordable (i.e., the individual employee premium for the least expen- sive plan offered must be less than 9.5 percent of family income)? (2) Does it meet the minimum value (i.e., is it designed to pay 60 percent of total medical costs for a population)? (HHS 2014).
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SUPPORTING INFORMATION
Additional supporting information may be found in the online version of this article:
Appendix SA1: Author Matrix.
The ACA’s Key Provisions: A Systematic Review 1771
