Key Provisions of the Patient Protection and Affordable Care Act ( ACA ): A Systematic Review and Presentation of Early Research Findings

* Address correspondence to Michael T. French, Ph.D., Departments of Sociology, Health Sector Management and Policy, Economics, and Public Health Sciences, University of Miami, 5202 University Drive, Merrick Building, Room 121F, P.O. Box 248162, Coral Gables, FL 33124‐2030; e‐mail: ude.imaim@hcnerfm.

Associated Data

Abstract

Objectives

To conduct a systematic literature review of selected major provisions of the Affordable Care Act ( ACA ) pertaining to expanded health insurance coverage. We present and synthesize research findings from the last 5 years regarding both the immediate and long‐term effects of the ACA . We conclude with a summary and offer a research agenda for future studies.

Study Design

We identified relevant articles from peer‐reviewed scholarly journals by performing a comprehensive search of major electronic databases. We also identified reports in the “gray literature” disseminated by government agencies and other organizations.

Principal Findings

Overall, research shows that the ACA has substantially decreased the number of uninsured individuals through the dependent coverage provision, Medicaid expansion, health insurance exchanges, availability of subsidies, and other policy changes. Affordability of health insurance continues to be a concern for many people and disparities persist by geography, race/ethnicity, and income. Early evidence also indicates improvements in access to and affordability of health care. All of these changes are certain to ultimately impact state and federal budgets.

Conclusions

The ACA will either directly or indirectly affect almost all Americans. As new and comprehensive data become available, more rigorous evaluations will provide further insights as to whether the ACA has been successful in achieving its goals.

On March 23, 2010, following a long and controversial political and legislative process, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law, ushering in the most significant changes to the U.S. health care system since the passage of Medicare and Medicaid in 1965. The ACA includes a series of ambitious reforms that build upon the existing system of employer‐sponsored insurance (ESI) and creates new requirements for individuals, employers, health care providers, and insurance companies. It is intended to address three main areas: access to health insurance, health care costs, and the delivery of care (Blumenthal, Abrams, and Nuzum 2015). Certain elements of the law became active soon after its passage in 2010, but most provisions took effect in 2014 (see Table 1 for the ACA timeline). 1

Table 1

Timeline for Implementation of Major Provisions of the ACA

Provisions went into effect on January 1, unless noted otherwise. The provisions discussed in this review are marked with an asterisk (*). PCP stands for primary care physician.

The ACA includes multiple strategies to target different groups and increase overall insurance coverage. Young adults are now able to remain on their parents’ insurance plans as dependents until age 26 (dependent coverage provision). Larger employers are required to offer affordable, comprehensive health insurance to full‐time employees (employer mandate). Individuals who do not have ESI must purchase insurance on their own or pay a penalty (individual mandate), and premium tax credits are available to some. These individuals and small businesses can purchase plans through state‐level exchanges or the federal marketplace. To assist low‐income individuals, the ACA expands Medicaid eligibility to all individuals under age 65 (nonelderly) with annual incomes up to 133 percent of the federal poverty level, but not all states have agreed to participate. These provisions aim not only to expand insurance coverage but also to improve the affordability of insurance plans.

The ACA also imposes new regulations on insurance companies and their policies. For example, insurance companies can no longer charge higher premiums or deny coverage due to preexisting conditions, and insurance policies have to provide a minimum amount of preventive services without any cost‐sharing. The ACA calls for changes in various taxes pertaining to insurance policies and overall financing. Other provisions focus on improving the delivery of care by streamlining services, incorporating health information technology, strengthening the health care workforce, reducing fraud and waste, and altering payments in a way that incentivizes providers to contain costs while improving the quality of care. 2

Assessing the full and lasting impacts of the ACA is challenging because the provisions are multifaceted and the potential outcomes extend to taxpayers, patients, health care providers, insurance companies, and governments. Preimplementation projections of the ACA's effects were largely based on simulation models of earlier Medicaid enrollment or the Massachusetts health insurance expansion (e.g., Gruber 2011a). In 2010, the Congressional Budget Office (CBO 2010) projected that by 2019, 32 million people would gain health insurance coverage, ESI coverage would decline slightly, and significant increases in federal spending due to the ACA would be offset by increased revenue. Making precise predictions is daunting, however, as many factors affect successful implementation of the ACA, such as enrollment levels, insurer participation, and providers’ willingness to accept Medicaid patients.

While the ACA is comprised of 10 titles and hundreds of sections, this review focuses on key provisions related to expansion of health insurance coverage through dependent coverage provisions and ESI, health insurance exchanges, employer and individual mandates, and Medicaid expansion. Unlike other summaries of the existing literature (e.g., Hall and Lord 2014; Blumenthal, Abrams, and Nuzum 2015), we conduct a structured and systematic review of research findings regarding the effects of the ACA since 2010 and focus on the key provisions listed above. Besides a summary and synthesis of current findings, we also offer suggestions for future research.

Methods

Literature Search

We used three methods to identify relevant studies for our analysis. First, we performed structured and systematic searches using the Thomson Reuters’ Web of Science, the National Library of Medicine's Medline (PubMed), and the American Economic Association's EconLit. We searched for the phrase “Affordable Care Act” in titles, abstracts, or topics without any additional keywords to avoid inadvertently excluding relevant studies. These searches yielded a total of 1,375 studies from Web of Science, 1,656 studies from Medline, and 97 studies from EconLit. We focused on published articles in the English language that appeared in peer‐reviewed scholarly journals as well as reports that appeared in the “gray literature.” Second, we augmented our systematic searches to include relevant reports from various research organizations and government agencies. Third, we browsed the reference sections of the retrieved articles. The entire search process was conducted from July to September 2015, and it was limited to studies appearing since 2010.

Inclusion Criteria and Screening

Our inclusion criteria are essentially based on whether the study provides a systematic evaluation of one or more elements of the ACA's implementation. Given the vast number of studies on this topic, we focus on those provisions related to the expansion of health insurance coverage. Both quantitative and qualitative studies were included, but we excluded studies that merely describe the legislation or examine data from prior to the implementation (i.e., to establish a baseline). We also eliminated any studies that simply use projections or extrapolations based on data prior to implementation of the ACA. Finally, we excluded studies pertaining to ethical, legal, or political aspects of the ACA.

During the first round of screening, two coauthors independently screened the title and abstract of each study to identify those that potentially met the inclusion criteria. After a comparison of the two sets of ratings, any inconsistencies were resolved through discussions. When necessary, a third coauthor was asked to render a judgment. As a result, we obtained 162 full‐text articles for a final examination pertaining to relevance and to eliminate any inappropriate items such as opinion pieces. Ultimately, we selected a total of 72 studies through our elaborate screening process. These were augmented by 24 reports and articles found in the gray literature. While Table 2 lists the final set of 96 studies together with brief descriptions, given space limitations, we do not cover all in the results section. The discussion below includes only those studies that were deemed most relevant or provide more recent evidence, and they are organized by groupings of key ACA provisions.

Table 2

Summary of Selected Research Studies

Studies that are marked with an asterisk (*) were deemed most relevant or provide more recent evidence and are discussed in this review.

ACA, Affordable Care Act; ACS, American Community Survey; BRFSS, Behavioral Risk Factor Surveillance System; CBO, Congressional Budget Office; CF, Commonwealth Fund; CMS, Centers for Medicare & Medicaid Services; CPS, Current Population Survey; DD, difference‐in‐differences analysis; ED, emergency department; ESI, employer‐sponsored insurance; HRET, Health Research and Educational Trust; KFF, Kaiser Family Foundation; MEPS, Medical Expenditure Panel Survey; NHIS, National Health Interview Survey; SIPP, Survey of Income and Program Participation.

Results

Dependent Coverage Provision

Under the so‐called young adult mandate, individuals between the ages of 19–25 years are allowed to remain on their parents’ health insurance plans. Since this mandate took effect in 2010, many researchers have already examined the impact of the law on this population. Most of this literature uses a quasi‐experimental difference‐in‐differences approach to compare young adults aged 19–25 to slightly older individuals before and after 2010. Although magnitudes vary, all studies show a rapid increase in insurance coverage among young adults after this provision took effect (Cantor et al. 2012; Sommers and Kronick 2012; Akosa Antwi, Moriya, and Simon 2013; Kirzinger, Cohen, and Gindi 2013; O'Hara and Brault 2013; Chua and Sommers 2014; Kotagal et al. 2014). Collins et al. (2013a) reported that in 2013 an estimated 15 million young adults were on a parent's policy in the past 12 months, an increase of 1.3 million since 2011. Approximately half of these were full‐time students (Collins et al. 2013a). These estimates are in line with other studies suggesting that 1–3 million uninsured young adults gained coverage under the ACA (Akosa Antwi, Moriya, and Simon 2013; O'Hara and Brault 2013; Blumenthal, Abrams, and Nuzum 2015; McMorrow et al. 2015).

The gains in coverage are especially pronounced for men, unmarried individuals, and nonstudents (Sommers et al. 2013). Consistent with adverse selection, young adults in worse health acquired coverage sooner and with greater frequency than others (Sommers et al. 2013). This mandate primarily benefitted those with relatively high incomes, while Medicaid expansion and marketplace reforms implemented in 2014 targeted lower income young adults (McMorrow et al. 2015). Overall, the rate of uninsured young adults decreased from 30 percent in 2009 to 19 percent in 2014, which translates to about 6 million of them remaining uninsured in 2014 (McMorrow et al. 2015). Disparities persist by race, ethnicity, and income (O'Hara and Brault 2013; Shane and Ayyagari 2014). Most studies report that gains in insurance coverage are associated with better access to health care for young adults (Sommers et al. 2013; Wallace and Sommers 2015), especially among men and college graduates (Barbaresco, Courtemanche, and Qi 2015). Others find that the ACA is associated with improvements in self‐reported health status among young adults (Carlson et al. 2014; Chua and Sommers 2014; Barbaresco, Courtemanche, and Qi 2015; Wallace and Sommers 2015).

Studies have examined the effect of expanded dependent coverage on the utilization of emergency department (ED) care (Mulcahy et al. 2013; Hernandez‐Boussard et al. 2014; Akosa Antwi et al. 2015), preventive services (Lau et al. 2014; Barbaresco, Courtemanche, and Qi 2015; Lipton and Decker 2015), dental care (Vujicic, Yarbrough, and Nasseh 2014), and mental health treatment (Saloner and Le Cook 2014; Golberstein et al. 2015). Akosa Antwi, Moriya, and Simon (2015) found that inpatient hospital visits increased 3.5 percent and mental health visits increased 9 percent among young adults, without significant differences in hospital length of stay or charges. ED visits actually decreased among young adults (Hernandez‐Boussard et al. 2014; Akosa Antwi et al. 2015).

Besides the changes in insurance coverage and health care utilization among this group, the proportion of young adults reporting high out‐of‐pocket spending for health care decreased significantly following passage of the ACA (Busch, Golberstein, and Meara 2014; Chua and Sommers 2014). Compared to individual plans, premiums for plans covering children have increased 2.5–2.8 percent more due to the dependent coverage provision, but employers absorbed much of this increase (Depew and Bailey 2015). The amount of uncompensated care for young adults decreased as a greater proportion of ED, trauma center, and psychiatric inpatient utilization being covered by private insurance (Mulcahy et al. 2013; Akosa Antwi, Moriya, and Simon 2015; Golberstein et al. 2015; Scott et al. 2015).

Overall Health Insurance Coverage, Access, and Affordability

Preliminary data suggest that the law has substantially decreased the number of uninsured Americans (Sommers et al. 2014a, 2015; Cohen and Martinez 2015; Collins et al. 2015a,b). Figure 1 shows recent trends and projections for various sources of health insurance coverage and uninsurance rates (Keehan et al. 2015). The rate of uninsured adults decreased from 20 percent in 2013 to 15 percent in 2014 (Doty, Rasmussen, and Collins 2014), with further declines expected in coming years (Keehan et al. 2015). According to Blumenthal, Abrams, and Nuzum (2015), an estimated 7–16 million uninsured people acquired coverage since 2010, with young adults, low‐income individuals, and minorities experiencing large gains. Similarly, the CBO (2015a) estimates that 17 million more people would have been uninsured in 2015 without the ACA. In the first 5 years of the ACA, 11.7 million purchased new plans from the marketplace, 10.8 million more have Medicaid coverage, and 3 million young adults are on their parents’ policies (Blumenthal, Abrams, and Nuzum 2015).

Health Insurance Coverage in the United States before and after the ACA