Improvements in Access and Care Through the Affordable Care Act

Julie A. Schmittdiel, PhD; Jennifer C. Barrow, MSPH; Deanne Wiley, BA; Lin Ma, MS; Danny Sam, MD; Christopher V. Chau, MPH; Susan M. Shetterly, MS

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.1 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.2 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.3 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 state4-6 or examined care trends at the population level.6 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 χ2 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%; P <.01) and significant decreases in the percentage of people who reported delaying needed medical care due to costs (37% vs 25%; P <.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%; P <.01) (Figure 1). Among the individuals who reported having fewer than 4 months of healthcare coverage in 2013, these improvements were even more pronounced (Figure 2). 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%; P <.01) and who reported receiving advice to quit smoking or using tobacco (46% vs 72%; P <.05) (Figure 2).
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 trends6; 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 plans7 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.3,8 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 system9 in people obtaining insurance coverage through the healthcare exchanges.
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