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Affordable Care Act Improves Access but Disparities Persist

Faculty at 91���� and the University of Miami reviewed nearly 100 studies of the ACA, dating back to 2010, compiling key findings about the ACA’s impact on the U.S. health care system.

In the first five years of the ACA, 11.7 million individuals purchased new plans from the marketplace, 10.8 million more now have Medicaid coverage and 3 million young adults are on their parents’ policies. Expanded coverage has led to better access to a physician among all income groups.

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The Affordable Care Act (ACA) has substantially decreased the number of uninsured Americans and improved access to health care, though insurance affordability and disparities by geography, race/ethnicity, and income persist, according to a new review study by faculty at 91���� and the University of Miami.

The authors reviewed nearly 100 studies of the ACA, dating back to 2010. Their article, soon to be published in the journal , is based on a structured and systematic review of these studies, compiling dozens of key findings about the ACA’s impact on the U.S. health care system.

“The scientific research so far suggests that ACA's progress is encouraging, especially in terms of expanding coverage,” said co-author , Ph.D., associate professor of Management Programs, Health Administration at the .  “However, disparities are reported for some groups in terms of insurance coverage as well as access to care,” she added.

In the first five years of the ACA, 11.7 million individuals purchased new plans from the marketplace, 10.8 million more now have Medicaid coverage and 3 million young adults are on their parents’ policies. Expanded coverage has led to better access to a physician among all income groups. 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 individuals still reported at least one access problem.

Between 1 and 3 million uninsured young adults gained coverage under the ACA. Most studies report that gains in insurance coverage are associated with better access to health care for young adults, especially among men and college graduates. The uninsured are more likely to be young, low-income and Hispanic. The review found that the amount of uncompensated care for young adults decreased as a greater proportion of health care utilization is being covered by private insurance.

Plans purchased in the marketplace accounted for 43 percent of all individually purchased plans in 2014, and 85 percent of those enrolling in marketplace plans qualified for tax credits. The review also found that in 2014, tax credits reduced marketplace premiums by an average of 76 percent.

As incomes rise and subsidies decline, however, premiums may increase sharply, making it increasingly difficult for those at the subsidy threshold to afford health insurance. Due to the ACA’s “family glitch,” whereby a low-income employee can’t afford family coverage through his/her employer and doesn’t qualify for subsidies through the exchanges, a significant number of low- to moderate-income individuals – 2-4 million according to various estimates – may be denied financial assistance.

The participation of insurers has been another major often discussed aspect in the implementation of the ACA. As the ACA matures, participation may increase further—25 percent more insurance companies joined the marketplace in 2015 than in 2014.

One of the most important provisions of the ACA is the expansion of health coverage to low-income families through the Medicaid program. While 31 states and the District of Columbia have expanded Medicaid, 19 states have not, meaning an estimated 3.7 million adults in non-expansion states are in the “coverage gap,” with low-income blacks disproportionately affected. This means they earn too much to qualify for Medicaid, but not enough to be eligible for premium tax credits in the marketplace.

Changes brought on by the ACA will no doubt impact state and federal budgets. Overall, studies present evidence that expanding Medicaid is financially prudent for most states. Federal contributions cover all expansion costs during the first three years, which will benefit providers and generate economic activity. However, 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. Due to its major role in Medicaid expansion and the establishment of health insurance exchanges, the federal government will likely end up financing a larger proportion of health care than before the ACA. Overall, the Congressional Budget Office (CBO) estimates that federal deficits will grow by $137 billion from 2016 to 2025 if the ACA were repealed.

“Our paper provides the public with a non-partisan, scientific perspective on the initial impact of the Affordable Care Act,” said , Ph.D., professor of  at the , a co-author of the paper. “With new research studies on the ACA being published every month, another comprehensive status report will be necessary in the near future." 

To read an online version of the article, .

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