The Affordable Care Act (ACA) has proven successful in meeting one of the law’s primary goals: to extend coverage to more Americans. Nearly 13 million people signed up for marketplace coverage in the 3^rd open enrollment period, contributing to a dramatic reduction in the number of uninsured. But what has that coverage meant for helping more people obtain affordable health care services and attain financial security? To find out, CHIR researchers, with funding from the Robert Wood Johnson Foundation, visited three diverse communities – Tampa, Florida; Columbus, Ohio; and Richmond, Virginia – and met with various community stakeholders who interact directly with consumers, including navigators and assisters, brokers, free clinics and community health center staff, hospital representatives and health insurance regulators. In particular, we wanted to know more about how the ACA is working for consumers who previously were uninsured and now have access to coverage with financial help for premiums and out-of-pocket costs. What we found was a mixed and very fluid picture.

For many, there is no question the ACA has helped make coverage affordable and available. Those with income under 200 percent of poverty ($23,760 for an individual, $48,600 for a family of 4) qualify for substantial financial assistance to lower premiums and out-of-pocket costs for marketplace plans. And the ACA’s first-ever federal prohibition on discrimination based on health status has meant tens of millions of individuals previously shut out of coverage can obtain coverage with comprehensive benefits. But many remain unaware of the financial help they may qualify for, and still others struggle to pay premiums and health care costs even with financial help.  Furthermore, newly insured individuals struggle with understanding how their coverage works, from what rules apply to getting care and choosing a provider, to the myriad ways costs can accrue.

In response, the communities we visited are stepping up to help consumers enroll in coverage, obtain care, and understand how coverage works. The full report can be found here. We found the following in our visits:

• We still need a safety net. Safety net programs in existence before the ACA were expected to become less necessary once the ACA coverage expansions took effect. And to some extent that has indeed been the case. But what was deemed affordable under the ACA for those with income too high for Medicaid eligibility is not necessarily perceived to be affordable to the individuals enrolling in the marketplace plans, particularly when health care spending must compete with other pressing household expenses. As a result, safety net providers report that many patients who start the year with coverage return to them later in the year uninsured.
• People want to maintain provider relationships. Prior to the ACA, uninsured individuals had to cobble together free or low cost care from a variety of safety net providers, including free clinics, hospital-based charity care, emergency departments, and community health clinics. Primary care was often available through these safety net providers; however, access to specialists was usually more challenging. In the wake of the ACA, safety net providers in all three communities report that significant numbers of their newly insured patients continue to obtain health care services at the safety net providers they used prior to 2014, even though their new health plans offer the opportunity to seek care from a broader network of providers.
• The lack of health insurance literacy is a barrier to coverage. The challenges go beyond helping to define terms consumers must know in order to choose the optimal plan. Consumers also need intensive help after they have enrolled, as they obtain care and pay medical bills.
• Data is lacking about consumers’ experiences with marketplace plans. Changes brought about by the ACA are prompting providers in all three communities to collect data in order to better understand how patients are obtaining and paying for care. For example, in one community we visited, the data will inform planned efforts to help marketplace enrollees with cost-sharing assistance under a provider-led coalition.

In the three communities we studied, we found that the need for the safety net is shifting, not shrinking. Safety net providers are adapting to the new coverage and health system landscape ushered in by the ACA. However, there’s not yet enough data to know whether coverage has translated to better, more affordable access to health care services. Many who are eligible for marketplace coverage with financial assistance face a Hobson’s choice. If they enroll in coverage, they lose eligibility for free or low-cost care they were able to get when they were uninsured. Yet the marketplace plans that are most affordable to them often come with high deductibles and other cost-sharing that can make it more difficult to access care than when they were uninsured. Until federal regulators use broad authority they have under the ACA to collect data on a comprehensive range of information from insurers about how consumers are using and paying for health care services under their new coverage options, we may not have a clear picture on how well the ACA is working and where consumers need more help. Unfortunately, to date, those efforts have been limited.