Jennifer C. Barrow, MSPH

To examine the impact of enrolling in a healthcare plan through the Affordable Care Act (ACA) healthcare exchanges on self-reported access to care. 

Cohort study using self-reported data of patients newly enrolled in Kaiser Permanente California and Kaiser Permanente Colorado through the ACA healthcare exchanges for coverage beginning January 1, 2014. 

 Baseline and follow-up surveys conducted via mail and telephone, with response rates of 45% and 51%, respectively. 

 We found significant increases in the percentage of people who reported having a personal healthcare provider (59% vs 73%; 

 <.01) and significant decreases in those who reported delaying needed medical care due to costs (37% vs 25%; 

 <.01) before and after ACA enrollment. There was also a significant increase in the percentage of patients who reported receiving a flu shot during the prior year (41% vs 52%; 

 <.01). Among the people who reported having less than 4 months of healthcare coverage in 2013, these improvements were even more pronounced. This group also showed significant increases in the percentages who felt they had a place to go when they needed medical care (43% vs 56%; 

 <.01) and who reported they received advice to quit smoking or using tobacco (46% vs 72%; 

These findings are an important addition to the evidence base that the ACA is improving the healthcare experience and reducing barriers due to costs for individuals obtaining insurance coverage through the healthcare exchanges.

Among patients newly enrolling in Kaiser Permanente California and Colorado through the Affordable Care Act (ACA) healthcare exchanges, we found: 

		Significant increases in the percentage of people who reported having a personal healthcare provider. 

		Significant decreases in the percentage of people who reported delaying needed medical care due to costs.

		Significant increases in the percentage who felt they had a place to go when they needed medical care and who received advice to quit smoking.

These findings are an important addition to the evidence base that the ACA may be improving access to care for people obtaining insurance coverage through the healthcare exchanges.

A major goal of the Affordable Care Act (ACA) is to increase access to healthcare, particularly for those who are uninsured, underinsured, or without stable healthcare insurance.

 The ACA has reduced the size of the uninsured population, and in 2016, close to 13 million Americans enrolled in a health plan through the federal or state-operated healthcare exchanges.

 However, there has been significant debate as to whether the ACA has achieved its goals of improving access and decreasing costs and whether it should continue in its current form.

 Most empirical studies since implementation of the ACA’s healthcare exchanges in 2014 have focused on the number of uninsured Americans within the United States and by state

 or examined care trends at the population level.

 The impact of insurance obtained through healthcare exchanges on access and costs of care at the individual level is largely unknown. The purpose of our study was to measure changes in self-reported healthcare access and cost-related barriers to healthcare among patients obtaining insurance through the ACA’s healthcare exchanges.

We surveyed 2145 adults aged 18 to 64 years who obtained insurance coverage through Kaiser Permanente (KP) by enrolling via the California or Colorado state healthcare exchanges starting on January 1, 2014. The survey was restricted to individuals who had not had KP healthcare coverage in the 5 years prior to initial exchange enrollment. Survey questions asked about healthcare experiences in the prior year and individuals' perceptions of whether they had a usual source of care and a regular healthcare provider or had delayed healthcare due to cost. Questions also assessed patient self-reported preventive behaviors and health behavior counseling. New KP members eligible for the survey were initially contacted by mail and asked to return a paper version of the survey; nonrespondents were called and offered the survey by phone. Responders to the initial baseline survey were re-contacted in 1 year and asked the same set of questions in order to assess if access, preventive behaviors, or cost barriers had changed since healthcare exchange enrollment. The response rate for the baseline survey was 45%, and the response rate for the follow-up survey was 51%. We compared differences in individual baseline survey responses regarding experiences in the year prior to ACA enrollment (2013) with follow-up survey responses regarding experiences in the year post-ACA enrollment (2014) at the individual level using χ

 tests for significance. Analyses were performed using SAS version 9.2 (SAS Institute, Cary, North Carolina). This study was approved by the KP Northern California and KP Colorado institutional review boards. 

A total of 528 patients completed both the baseline and follow-up surveys; these responders were 55% female and 71% non-Hispanic white, with 62% reporting a household income of less than $50,000 per year (data not shown). We found significant increases in the percentage of people who reported having a personal healthcare provider (59% vs 73%; 

 <.01) and significant decreases in the percentage of people who reported delaying needed medical care due to costs (37% vs 25%; 

 <.01) before and after ACA enrollment. There was a significant increase in the percentage of patients who reported receiving a flu shot as well (41% vs 52%; 

). Among the individuals who reported having fewer than 4 months of healthcare coverage in 2013, these improvements were even more pronounced (

). In addition, healthcare exchange enrollment was associated with significant increases in the percentage who felt they had a place to go when they needed medical care (43% vs 56%; 

 <.01) and who reported receiving advice to quit smoking or using tobacco (46% vs 72%; 

We found that adults obtaining insurance through the healthcare exchanges reported increased access to care, increased use of preventive care, and fewer barriers to medical care due to cost. These positive changes were even greater among patients with fewer than 4 months of healthcare coverage during the year prior to enrollment. One prior study found improved trends in access and affordability after the ACA’s enactment by examining population-level trends

; our analysis adds significant strength to the argument that the ACA has had a positive impact on care access, receipt of preventive services, and costs by examining changes in patient experiences at the individual level. Although our study was conducted among ACA enrollees in systems whose cost-sharing structures might not represent all exchange plans, our finding that delays in receiving needed medical care were reduced after enrolling through the ACA exchanges is particularly important in light of the fact that many exchange insurance products offered are high-deductible health plans

 that involve significant cost sharing for patients until the deductible is met. 

A major goal of the ACA is to help American healthcare achieve the “Triple Aim” of simultaneously optimizing healthcare access and quality while reducing costs.

 These findings are an important addition to the evidence base that the ACA may be improving the healthcare experience, reducing barriers due to costs, and contributing to a greater sense of engagement with the healthcare system

 in people obtaining insurance coverage through the healthcare exchanges.

 Division of Research, Kaiser Permanente Northern California (JAS, DW, LM), Oakland, CA; Institute for Health Research, Kaiser Permanente Colorado (JCB, SMS), Denver, CO; Kaiser Permanente (DS), Santa Clara, CA; School of Public Health, University of California at Berkeley (CVC), Berkeley, CA

 This study was funded by the Kaiser Permanente Center for Effectiveness and Safety Research, Contract no. KR021125. Dr Schmittdiel also received support from the Health Delivery Systems Center for Diabetes Translational Research (CDTR) [NIDDK grant 1P30-DK092924].

 Drs Schmittdiel and Sam, and Ms Barrow and Ms Shetterly are employed by Kaiser Permanente. Ms Barrow and Ms Shetterly received grant funding for this project from the Kaiser Permanente national office. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

 Concept and design (JAS, JCB, DS); acquisition of data (JAS, JCB, CVC, SMS); analysis and interpretation of data (JAS, LM, DS, SMS); drafting of the manuscript (JAS, JCB, DW, LM); critical revision of the manuscript for important intellectual content (JCB, DS, CVC, SMS); statistical analysis (JAS, LM); provision of patients or study materials (DW); obtaining funding (JAS, JCB); administrative, technical, or logistic support (JCB, DW, CVC); and supervision (JAS). 

 Julie A. Schmittdiel, PhD, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612. E-mail: Julie.A.Schmittdiel@kp.org. 

1. Blumenthal D, Abrams M, Nuzum R. The Affordable Care Act at 5 years. 

 2015;372(25):2451-2458. doi: 10.1056/NEJMhpr1503614.

2. Jost T. The 2016 open enrollment tally: 12.7 million selected plans, 1 million more than 2015.  

 Blog website. http://healthaffairs.org/blog/2016/02/04/the-2016-open-enrollment-tally-12-7-million-selected-plans-1-million-more-than-2015/. Published February 4, 2016. Accessed February 11, 2016.

3. Berwick DM, Feeley D, Loehrer S. Change from the inside out: health care leaders taking the helm. 

2015;313(17):1707-1708. doi: 10.1001/jama.2015.2830.

4. Carman KG, Eibner C, Paddock SM. Trends in health insurance enrollment, 2013-15. 

2015;34(6):1044-1048. doi: 10.1377/hlthaff.2015.0266.

5. Sommers BD, Buchmueller T, Decker SL, Carey C, Kronick R. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. 

2013;32(1):165-174. doi: 10.1377/hlthaff.2012.0552.

6. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. 

2015;314(4):366-374. doi: 10.1001/jama.2015.8421.

7. Wharam JF, Ross-Degnan D, Rosenthal MB. The ACA and high-deductible insurance—strategies for sharpening a blunt instrument. 

2013;369(16):1481-1484. doi: 10.1056/NEJMp1309490.

8. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. 

2008;27(3):759-769. doi: 10.1377/hlthaff.27.3.759.

9. Fisher ES, McClellan MB, Bertko J, et al. Fostering accountable health care: moving forward in Medicare. 

2009;28(2):w219-w231. doi: 10.1377/hlthaff.28.2.w219.

Articles

Affordable Care Act exchange enrollees in California and Colorado reported significant improvements in access to care and fewer barriers to receiving care due to costs.

Jennifer C. Barrow, MSPH

Articles

Improvements in Access and Care Through the Affordable Care Act