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The American Journal of Accountable Care September 2014
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Update on the Impact of the Affordable Care Act on Consumers
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Update on the Impact of the Affordable Care Act on Consumers

Patricia Salber, MD, MBA , and Christobel E. Selecky, MA
Five years after the implementation of the first provisions of the Affordable Care Act and 5 months after the close of the first open enrollment period for the Health Insurance Marketplaces, we are starting to be able to measure the impact of the law.

The Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA), or more informally Obamacare, was signed into law by President Obama on March 3, 2010.

The Act was designed to be phased in over a number of years, and its goals are to expand coverage and add consumer protections, control healthcare costs, and improve the healthcare delivery system.

The first provisions of the Affordable Care Act were implemented in 2010 and focused primarily on coverage expansion and consumer protections. These included provisions that allow young adults to stay on their parents’ policies until they turn 26; implementation of temporary insurance programs for people with preexisting conditions and for early retirees; provision of federal matching funds to states to cover some additional low-income individuals and families under Medicaid; and institution of new insurance rules, such as banning plans from rescinding coverage when a beneficiary gets sick and banning lifetime caps on coverage.

In 2011, limits on nonmedical or administrative spending by health plans kicked in. Under this provision, known as the Medical Loss Ratio or MLR, health plans in the large-group market must spend 85% or more of their premiums on medical care; for the small-group market, the figure is 80%. Plans that fail to meet this MLR requirement must offer rebates to their enrollees. Other 2011 provisions include “donut hole” discounts, a pharmaceutical manufacturer fee, and restrictions of over-the-counter drug reimbursement to those drugs prescribed by a doctor.

In 2012, several programs focused on quality and cost containment were initiated, including the Medicare Shared Savings Program, establishing accountable care organizations (ACOs), a Medicare hospital preventable readmission program, and a hospital value-based purchasing program. 2013 provisions included flexible spending limits and some new Medicare taxes.

The state-based and federally facilitated health insurance Marketplaces went live on October 1, 2013, allowing people to compare participating plans online and to sign up for insurance with coverage starting on January 1, 2014. As of August 28, 2014, there were 17 state-based Marketplaces (SBMs), 17 federally facilitated Marketplaces, and 7 partnership Marketplaces. In this paper we refer to both federally facilitated and partnership Marketplaces as FFMs. The difference between them is that the latter may administer plan management functions, in-person consumer assistance functions, or both, and HHS will perform the remaining Marketplace functions.1

Although the roll-out of the FFM website,, was seriously flawed and deterred some people from signing up initially, by the end of open enrollment (including the Special Election Period) on April 14, 2014, there had been almost 100 million website visits and 33 million calls to the call centers.2

A full listing of the ACA provisions through 2018 can be found in Table 1.

The remainder of this article will summarize the current status of the coverage expansion and consumer protection provisions.


The total number of people insured under the various provisions of the ACA is about 14 million.3 This includes approximately 8 million who signed up via the SBMs and the FFMs, 3 million young adults who were able to stay on their parents’ plans until age 26, and 3 million people newly covered because of Medicaid/Children’s Health Insurance Program (CHIP) expansion.

According to a detailed enrollment report published by HHS in May 2014,2 more than 8 million Americans enrolled via an SBM or FFM during the open enrollment period (October 1, 2013, to March 31, 2014); people who qualified for the Special Enrollment Period (SEP) enrolled through April 19, 2014. It is important to note that the report included people who had signed up, but might not have yet paid their first premium.

The demographic breakdown is as follows:
• 54% female, 46% male
• 2.2 million (28%) are between the ages 18 of 34 years
• 2.7 million (34%) are between the ages of 0 and 34 years

Impact on the Uninsured

The results of formal federal surveys measuring the impact of 2013 open enrollment (for 2014 coverage), such as those of the US Census Bureau and the National Center for Health Statistics, won’t be available until later this year, with the estimated date of release being fall 2015. Researchers have therefore turned to “rapid-turnaround” data sources such as the Gallup-Healthways Well-Being Index (WBI) and the Kaiser Family Foundation surveys.

A Kaiser Family Foundation survey published in June 2014 found that 57% of the 8 million people who enrolled in a Marketplace plan were previously uninsured.4 Seven in 10 of those who were uninsured prior to purchasing a Marketplace plan said they decided to purchase insurance because of the law; most had been uninsured for 2 years or more.

Researchers led by Benjamin Sommers, MD, PhD, assistant professor of health policy and economics at the Harvard School of Public Health in Boston, Massachusetts, reported the results of their analysis of the Gallup-Healthways WBI surveys in a Special Report in the August 28, 2014, issue of the New England Journal of Medicine.5 They used survey data for January 1, 2012, to June 30, 2014. This means that the increases in the number of insured people related to extending coverage for young adults on their parents’ policies to age 26 years, implemented in 2010, had largely already been incorporated into the baseline. Also, the survey sample included only people aged between 18 and 64 years, so increases related to newly insured children were also not counted, nor were individuals who enrolled in Medicaid due to some early Medicaid expansions in 2010 and 2011. Because open enrollment  via the Marketplaces began in October 2013, the study compares increases in the percentage of insured individuals pre- and post open enrollment.

Here is what they found:
• Compared with the baseline of about 20% to 21%, the uninsured rate declined by 5.2 percentage points (P = .001) between September 2013 and April 2014—a 26% decline.
• For individuals with incomes ≤138% of the federal poverty level, there was a statistically significant decline in the uninsured rate of 6 percentage points (P = .006) in the states that expanded Medicaid compared with a non-significant decline of 3.1 percentage points (P = .13) in states that did not.
• When directly comparing low-income adults in states with expansion versus those without, Medicaid expansion was associated with a reduction in uninsured of 5.1 percentage points (P = .01).
• People with incomes between 139% and 400% of the federal poverty level were eligible for subsidies even in states that didn’t expand Medicaid. In the Medicaid expansion states, uninsured rates among these individuals dropped by 9 percentage points and in the non-expansion states by 5.5 points (P = .01 for both comparisons).

Having insurance, of course, is only part of the story. The 2 access to care measures included in the survey both showed the changes you might expect with an expansion of insurance coverage:
• A 2.2% increase in the number of people stating they have a personal doctor (P = .001).
• A 2.7% decrease in those stating they couldn’t afford medical care (P = .001).


As noted above, results of federal surveys are not yet available, but a survey conducted by the Commonwealth Fund and published in July 20146 reported that:
• 81% of people with new Marketplace or Medicaid coverage are optimistic that it will improve their ability to get the care they need.
• More than half (58%) said they are better off now than they were before enrolling in their new insurance plan.
• By June 2014, 6 of 10 adults with new Marketplace or Medicaid coverage said they had already used their insurance to go to a doctor or hospital or to fill a prescription.
• A majority (62%) said they would not have been able to access or afford this care before enrolling.
• 54% of adults with new coverage said their plan included all or some of the doctors they wanted.
• 68% said they were able to get an appointment with a PCP within 1 to 2 weeks; 58% were able to get a specialist appointment within that time frame.
• One of 5 adults with new coverage tried to find a new primary care physician; three-fourths found it very or somewhat easy to do so.


The Essential Health Benefits

Individual and small-group plans, offered both inside and outside of the Marketplaces, must now offer a set of defined Essential Health Benefits (EHBs). These benefits must be offered for the plan to be certified as a qualified health plan and offered in the Marketplaces. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid. There can be no annual or lifetime coverage caps on these benefits. The EHBs include:
• Ambulatory patient services

• Emergency services

• Hospitalization

• Maternity and newborn care

• Mental health and substance use disorder services including behavioral health treatment

• Prescription drugs

• Rehabilitative and habilitative services and devices

• Laboratory services

• Preventive and wellness services and chronic disease management

• Pediatric services, including oral and vision care.

Plans must offer EHBs, but may add additional benefits and services.

Preventive Services

Preventive services, provided by a network provider, cannot be subject to co-payments, co-insurance, or deductibles. Examples of such services for adults include screenings for blood pressure, cholesterol, colorectal cancer, and depression; alcohol misuse screening and counseling; and a variety of age-appropriate vaccinations.

Services for women include cervical cancer screening, domestic violence screening and counseling, and breast cancer-screening mammograms for women over 40 years of age. It also includes FDA-approved contraception with no cost sharing, a benefit that is estimated to have reduced out-of-pocket costs by $483.3 million, comparing 2013 with 2012.*

Preventive services for children include hearing screening for newborns, age-appropriate vaccinations, autism screening at ages 18 and 24 months, and depression screening for adolescents.

A complete listing of preventive services can be found at

Approximately 76 million Americans became newly eligible for expanded preventive services because of the ACA.7

The “Metal Levels”

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