ACA Progress Report: What has changed so far?

The first open enrollment period for the Affordable Care Act closed on March 31, with 8 million Americans enrolled by the deadline. The marketplace re-opens in November, though individuals can register at any time if they lose insurance because of a life event such as marriage or a new job. An estimated 4 million more Americans are expected to enroll in this way before the next enrollment period. With so many people now on board, researchers are examining how the ACA is doing so far.

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Young Adults: In 2010, the ACA expanded coverage to allow young adults under 26 years old to remain under their parents’ health insurance policy, allowing 7.8 million adults aged 19-25 to stay under a parent’s plan last year. Additionally, the number of uninsured young adults has dropped 25% from 4 to 3 million since the provision has been in place.

Private Insurance: The Congressional Budget Office estimates that 5 million Americans will gain insurance coverage directly through private insurers this year. New standards were put into place for private insurance sold to individuals and small groups. These plans cannot set prices on the basis of health or exclude coverage for those with pre-existing conditions, are limited in charges for older vs. younger adults, and must meet minimum benefit standards. Additionally, four different levels of cost sharing were set: Bronze plans must cover on average at least 60% of medical costs, silver 70%, gold 80% and platinum 90%.

Individuals who purchased plans after the ACA went into effect in March 2010, and whose plans did not meet the new minimum benefit standards, received notices that these policies would be cancelled—creating a political firestorm because of the Obama administration’s assurances that individuals would not be forced to change from plans they liked. In fact, 1 in 5 people with private insurance received such a notice. As a response, the Obama administration granted states the ability to allow insurance companies to renew non-compliant health plans. Thirty-six states have chosen to do so, allowing an estimated 500,000 individuals to renew noncompliant plans.

The Marketplace: A new private marketplace was created in each state to sell subsidized insurance to individuals and small groups. Fourteen states and the District of Columbia opted to run their own marketplace, with the other states opting to leave control with the federal government. As mentioned before, 8 million people enrolled in the marketplace plans (5.4 million in the federal marketplace and 2.6 million in the state-based marketplaces), 85% of which qualified for subsidies, which dramatically lowered their premiums. Of the 8 million, 80-90% have paid their first month’s premiums. However, time will tell if enrollees continue to pay each month, with premium levels, cost-sharing obligations, and restrictions on provider choice influencing the success of continued payment and increased enrollment.

Medicaid: Medicaid eligibility has been expanded in 28 states and the District of Colombia to include those with incomes up to 138% of the federal poverty level. The federal government will cover 100% of costs through 2016, and will then gradually reduce its contribution to 90% by 2020. In the 6 months after these provisions went into effect, 6 million Americans enrolled in Medicaid or CHIP, many of whom were informed of their eligibility after attempting to enroll in the marketplace. The CBO projects new enrollment will reach 7 million this year and 13 million eventually, indicating 17% of the non-elderly population could be enrolled in Medicaid or CHIP by 2018.

In total, 20 million Americans gained coverage by May 1 under the ACA. Polling data seems to show that only 13.4% of US adults lacked health insurance by May 2014, falling from 18% in the third quarter of 2013. All in all, it seems that the ACA is proving it can reach enrollment targets, but it remains to be seen if the money to sustain these provisions will follow.

Blumenthal, D. and Collins, S.R. NEJM. 2014; 371: 275-281.

This Policy Prescriptions^® review is written by Vidya Eswaran. Ms. Eswaran is currently a medical student at Baylor College of Medicine in Houston, TX. She completed her undergraduate education in Biology at the Massachusetts Institute of Technology.