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Posted: February 19th, 2019

The Passage and Impact of the Affordable Care Act on Healthcare Access in the USA

The Passage and Impact of the Affordable Care Act on Healthcare Access in the USA
The enactment of the Affordable Care Act (ACA) in 2010 marked a watershed moment in American healthcare. Signed into law by President Barack Obama, the ACA aimed to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of healthcare for individuals and the government (Blumenthal et al., 2015). A key goal of the law was to improve access to healthcare for millions of Americans through these reforms. In the decade since its passage, numerous studies have evaluated the real-world impact of the ACA on various dimensions of access to care. This article examines the literature on the effects of the ACA on healthcare access in the United States to date.
Access to Insurance Coverage
One of the primary ways the ACA sought to improve access was by substantially reducing the number of uninsured Americans through two main channels. First, the law expanded eligibility for Medicaid to non-elderly adults with incomes up to 138% of the federal poverty level in states that elected to participate in the Medicaid expansion (Sommers et al., 2013). Second, the ACA established health insurance marketplaces, also known as exchanges, where individuals could purchase subsidized private plans (Sommers et al., 2015).
Research shows that these reforms were successful in lowering the uninsured rate nationally. According to one study, 20.0 million fewer nonelderly adults were uninsured in 2015 compared to prior to the ACA’s main coverage provisions taking effect (Sommers et al., 2017). State Medicaid expansions led to significant declines in the uninsured rate, reducing it by 5.2 percentage points in expansion states versus 3.2 percentage points in non-expansion states (Sommers et al., 2015). Marketplace plan enrollment also contributed, with 11.7 million obtaining private coverage through exchanges in 2014 alone (Blumenthal & Collins, 2014). By 2016, the uninsured rate among nonelderly adults had fallen to a record low of 10.9% (Sommers et al., 2017).
Access to Care
Increased insurance coverage under the ACA translated to notable improvements in access to healthcare services. Individuals gaining Medicaid were more likely to report having a usual source of care, such as a primary care doctor, compared to similar uninsured low-income adults (Sommers et al., 2013). Those obtaining marketplace plans also saw access gains, with one study finding they were 25% more likely than the uninsured to have had a medical visit in the past year (Sommers et al., 2015).
The ACA provisions were further associated with reduced financial barriers to care. After implementation, low-income adults had lower out-of-pocket medical expenditures and were less likely to report problems paying medical bills or foregoing care due to costs compared to higher-income individuals (Miller & Wherry, 2017). Gains were again larger in Medicaid expansion states versus non-expansion states (Sommers et al., 2017). The ACA also improved the affordability of prescription drugs by closing the Medicare Part D donut hole and capping out-of-pocket drug costs for marketplace enrollees (Doshi et al., 2016).
In terms of service utilization, Medicaid expansion was linked to increased use of preventive care services, including cancer screenings and diabetes and cholesterol checks (Sommers et al., 2015). However, the ACA did not significantly impact overall healthcare spending or utilization patterns according to one study analyzing national medical expenditure data (Miller & Wherry, 2017). This suggests coverage gains did not correspond to substantial increases in unnecessary care.
Quality of Care
While the ACA primarily aimed to expand access through insurance reforms rather than directly target quality, some research has examined its relationship to ambulatory care quality. One study found adults below 400% of the federal poverty level who gained coverage had larger relative increases in receiving recommended preventive testing like mammograms and colonoscopies compared to higher-income individuals (Miller & Wherry, 2019). However, the law did not significantly change performance on other quality measures like diabetes and hypertension control.
Patient Experience
Beyond access and quality indicators, studies have also evaluated the ACA’s impact on patients’ experience of care. Individuals below 400% of poverty who became insured reported greater improvements in their overall health ratings, communication with doctors, and ability to access needed care services relative to higher-income groups (Miller & Wherry, 2019). Medicaid expansion was similarly associated with better patient experience and primary care ratings (Sommers et al., 2017). This indicates coverage gains under the ACA enhanced how patients interact with and perceive the healthcare system.
Discussion and Conclusion
In summary, the literature demonstrates the ACA has meaningfully increased access to healthcare in the U.S. through substantially reducing the uninsured population and improving financial protection and utilization of important services. Medicaid expansion and marketplace subsidies were successful at connecting millions to needed insurance coverage who previously lacked options. This new coverage translated to gains across multiple dimensions of access, including having a usual source of care, affordability of care, preventive service use, and patient experience.
However, the law did not appear to significantly impact overall healthcare spending, utilization patterns more broadly, or performance on all quality measures according to available research. Additionally, not all states opted into the Medicaid expansion portion of the ACA, contributing to geographic variability in access impacts. Some access barriers also remain, such as underinsurance. Looking ahead, policymakers and health system leaders seeking to further strengthen value of care under the ACA could explore additional reforms targeting total cost and broader quality improvement beyond coverage alone (Miller & Wherry, 2019). But overall, the preponderance of evidence demonstrates the ACA has meaningfully fulfilled its goal of expanding access to healthcare for millions of Americans since taking effect.

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