The Affordable Care Act (ACA) set out to expand affordable coverage options in the United States. Four years since the law was in full effect, researchers are beginning to assess its impact on access to services and health outcomes. At the same time, the current administration and Congress are working to unwind some of the law’s key provisions.

In CHIRblog’s February installment of What We’re Reading, I dig into new research that highlights the consequences of the recent short-term limited-duration health plan rule, the effects of expanded private insurance on access to primary and specialty care, the impact of the ACA’s dependent coverage provision on birth and prenatal outcomes, and an assessment of state-level efforts to expand access, affordability, and quality of coverage.

Blumberg, L. et al. The Potential Impact of Short-Term Limited-Duration Policies on Insurance Coverage, Premiums, and Federal Spending. Urban Institute; Feb. 26, 2018. This brief assesses the consequences of the Trump Administration’s recent proposed rule to relax limits on short-term limited-duration (STLD) health policies. It examines the proposed rule’s impact in combination with the repeal of the ACA’s individual mandate penalty, slated to take effect in 2019. Urban projects enrollment and premium changes nationally as well as in each state.

What it Finds

• The uninsurance rate will rise to 12.5 percent from the current 10.2 percent, adding 6.4 million people to the country’s uninsured population.
• Loosening the rules for STLD plans coupled with no individual mandate penalty will reduce enrollment in ACA-compliant plans by 2.1 million people, employer coverage by 230,000 people, and Medicaid and CHIP by 150,000 people.
• The expected STLD plan population is 4.2 million in 2019, more than half of whom will have moved from the ACA-compliant market.
• In states that do not prohibit STLD plans, premiums for ACA-compliant plans are expected to rise by 18.2%.
• Higher premiums for ACA-compliant plans will increase federal spending on premium tax credits by 9.3 percent, or $33.3 billion.

Why it Matters

The Administration’s proposed short-term plan rule is just that – proposed. Its authors admit that they don’t have sufficient data to fully gauge the impact of the policy change. The Urban Institute study should give them pause, given the serious adverse consequences they project. Additionally, states have broad authority to regulate short-term plans, but most currently have very limited standards and oversight. The Urban study, which includes impact analyses at the state level, can arm state policymakers with data to better inform future regulation of these policies.

Daw, J. et al. Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes. JAMA; Feb. 13, 2018. This study looks at the effects of the ACA’s provision requiring plans to cover young adults up to age 26 on access to labor and delivery services and prenatal care, as well as birth outcomes.

What it Finds

• Private insurance coverage and payments for births increased in women aged 24 to 25 by 1.9 percentage point while Medicaid and self-payments for this population decreased by 1.4 and 0.3 percentage points, respectively.
• Preterm births decreased and early, comprehensive prenatal care increased for unmarried women.

Why it Matters

Four years in, researchers are beginning to quantify the effects of the ACA’s coverage expansions on access to services and health outcomes. This study suggests that due to the requirement that plans cover young adults up to age 26, women who previously would have to self-pay for maternity services or go without prenatal care are better able to obtain such care. Further, the study provides early signs that improving access also can improve health outcomes.

Alcala, H. et al. Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act. Medical Care; Feb. 2018. This brief analyzes the variations in access to primary and specialty care providers among those with employer-sponsored insurance (ESI) and those in individual and Medicaid policies in California.

What it Finds

• Those in Medicaid and individual market plans have poorer access to primary care providers than those with ESI.
• Covered California exchange plans have narrower networks than individual market plans sold off-exchange. For example, those enrolled in Covered California plans have access to 35% fewer hospitals than those in other commercial insurance.
• These trends were more apparent in primary care than specialty care when comparing on- and off-exchange plans to ESI. 

Why it Matters

Individual market plans in the post-ACA era have been under fire for offering overly narrow provider networks. This study adds fuel to those concerns. However, the ACA includes a requirement that all exchange plans maintain adequate provider networks, a standard that is largely enforced at the state level. As a state that operates its own exchange, California can use this data to inform its future oversight of plans sold via the exchange.

Weiner, J. et al. State Efforts to Close the Health Coverage Gap. University of Pennsylvania Leonard Davis Institute of Health Economics; Feb. 6, 2018. This review compares efforts in Massachusetts, Vermont, Colorado, California, and Nevada to expand health coverage to the uninsured between 2006 and 2017, and identifies best practices and opportunities for future reform efforts.

What it Finds

• Unified support or bipartisan effort is key to health reform efforts.
• The benefits of universal coverage accrue primarily a relatively small uninsured population within the state. As a result, states pursing expansion efforts faced opposition among many insured individuals, who feared that they would pay more or get fewer benefits in order to benefit a much smaller group of people.
• Public education about the health program, health care costs, and financing mechanisms are essential to a successful reform. For example, the authors note that employees might not realize the full cost of their health coverage due to their employer’s contribution, but they will notice an increase on their tax bill to finance health coverage for someone else.
• Stakeholder involvement and buy-in, including from the federal government, is key to gaining political and public support.

Why it Matters

As the Trump Administration and Congress continue to roll back provisions of the ACA, states have had to step up to protect and expand on the coverage gains achieved after the ACA was implemented. Past state-level experiences attempting to enact coverage reforms can offer important lessons for future efforts.