First Year Participation in the Affordable Care Act: Costs and Accessibility to Gynecologic Oncology

Abstract

With the ending of the operational first year of the American Affordable Care Act, health insurance premiums were accessed online. For a US$50,000 income, the lowest premiums ranged from US$805 annually (age 20 years) to US$3802 (age 64 years), while the highest ranged from US$2186 (age 20 years) to US$10,326 (age 64 years). The lowest premiums at age 50 years were higher in rural areas in contrast to the highest premiums that were less expensive rurally. At age 64 years, the lowest premiums were 9–12.6% of a US$50,000 income, while the most expensive varied between 16.5 and 39%. Access to gynecologic oncologists was variable in different networks. Medicaid enrollment nationally was ∼6x higher than paid enrollment. Eligible participation in Affordable Care Act coverage exceeded expectations by >190%. Performance of four healthcare exchange traded funds indicated that investor confidence is high in the American healthcare sector.

Keywords

Affordable Care Act cost gynecologic oncology network participation penalties premiums

On 31 December 2014 the first operational year of the American Affordable Care Act (ACA) ended while second year enrollments were underway for new and existing participants [1 –4], so that it became possible to tabulate first year enrollment and premium prices of ACA health insurance for the second year of operation. The healthcare insurance system in the USA prior to the ACA was cumbersome and complicated stretching the comprehension of individuals and their caregivers, and while the ACA has introduced significant changes designed to extend coverage to many more Americans, it too seems cumbersome and complicated with its own vexations [5 –7].

Legislation for the ACA (Patient Protection And ACA) was created at the onset of the Great American Recession in 2008, which involved government bailouts of American banks and the American auto industry. The legislation for ACA service provisions received amendments and was coupled to budgetary reconciliation in separate legislation [8 –10]. Year 1 enrollments in various ACA health insurance plans began in November of 2013 with availability of coverage beginning 1 January 2014. This availability of coverage coincided with a major economic recovery in the USA. ACA health insurance coverage was designed to have a closing date for enrollment and annual re-enrollments so that insurance exchanges would not be open to enrollments for most of each year, except for certain special circumstances. The 31 December 2014 closing enrollment date received 4–6 week extensions by the President. For year 2, the ACA health insurance exchanges re-opened for additional new and changed enrollments on 15 November 2014 and closed on 15 February 2015. Certain extenuating circumstances allowed for enrollment in ACA coverage beyond this point. To begin to understand the access to health insurance in the USA, one must realize that most individuals in the USA consider healthcare to be local, thinking in terms of nearby doctors and healthcare facilities. Consequently, arranging healthcare insurance coverage by long distance using telephone, fax or internet can seem discordant with local access. This report focuses on the local aspect of access to health insurance, especially premium costs and participation. This presentation is not comprehensive, but tailored to bring to world readers a cross-sectional street-view of the initial year of operation of this new American healthcare program.

Methods

The authors explored the range of premiums on exchange-based qualifying health plans (QHPs) for Kentucky [11], California [12], Minnesota [13], Alabama [14], Nebraska [14], South Carolina [14] and Utah [14]. The costs of insurance in four cities of each state were obtained. The two largest cities were included, as well as two rural cities with the widest geographical separation, chosen at random.

Information on overall enrollments in exchange QHPs and Medicaid was obtained as cited from state, federal and foundation sources.

Because Kentucky has been highly successful in ACA initiation, leading the nation in enrollments [15], it has been featured in this report.

Visited sites were abstracted by four of the authors and checked for concurrence. Nonconcurrent summaries were re-examined and adjusted for accuracy. In making observations to evaluate the usable quality related different exchange web sites, the following criteria were employed:

The site used all parameters on which premium price would be based (applicant age, dependent age and income);

The site used a locating zip code to determine premium cost for different locations;

The site determined tax credits and premium cost to distinguish the actual cost;

The site returned multiple premium results that could be compared.

Exchange web sites that met all of these criteria were designated as excellent and straightforward for the purposes of this report.

Results

Entry point for the purchase of health insurance coverage

Individuals in the state of Kentucky purchase health insurance through the Kentucky Health Insurance Exchange. Accessibility to the exchange is through multiple means, including internet, telephone and in person at enrollment centers with the aid of certified financial assistors called ‘kynectors’.

A snapshot view of the Kentucky Health Insurance Exchange (KY-Nect) [11], the web-based access and purchase point is as follows: the online user progresses through several screens that collect information to determine the scope of an individual's eligibility for various health insurance plans. The spectrum of available plans includes different premium costs and different potential levels of payment reduction through a government tax credit. A summary screen informs the applicants of what plans they are eligible for. The coverage to be considered is fine-tuned for certain options (i.e., medical alone or medical and dental), and then further fine-tuned for personal cost, deductibles and out-of-pocket limits with slider filters. Finally, the user is advanced to an array of health insurance purchase choices that include premium costs.

When the health insurance suitable to the user is found and selected, a process of user vetting is begun that involves submission of documents to qualify for subsidized discounted rates, the issuing of an application ID, insurance plan selection with the insurance company, receipt of the bill from the company and processing of payment for the initial coverage period. In the first year of operation, delays in this enrollment process extended 2–4 weeks [16]. Time to start of coverage was shorter in Kentucky, but the kynect exchange currently states that applications would take two weeks to begin coverage [17]. All coverage began as of 1 January 2015, and applications submitted later in the year were the most likely to have delayed coverage. No coverage was issued without completion of the payment process. Some individuals did not submit their first monthly payment and consequently did not complete the enrollment process. In contrast to the online purchase of automobile insurance [18], a delay to coverage was routine to both the online and telephone enrollment process when qualification for a subsidy was an issue. Individuals with incomes above subsidy levels could obtain next day coverage using a bankcard both online and by telephone.

Consumer cost issues of health insurance for fiscal year 2015

We have structured this report to deal with the lowest bronze premiums and the highest platinum premiums. We have not dealt with every plan, nor every family size, nor every income and consequently have not dealt with silver plans (lying between lowest bronze and highest platinum). The mother–daughter family illustration that we present allows them to take advantage of the lowest premiums available with the subsidized bronze plan and also explores what a top-tier platinum plan would cost in the event that they would anticipate heavy use of the healthcare system. Any consideration, for example, of the silver plan cost sharing neither conserves income with low premiums nor presents any advantage for heavy use of the healthcare system in the mother-daughter family illustrated in this report. Table 1 describes premium costs for three different scenarios including costs for a single woman (case A), the same woman with a 20 years old dependent child with modified adjusted gross income (MAGI) of US$50,000 (case B), and the woman with a MAGI of US$65,000 (case C). All data are for a plan purchased in the largest city in the state (Louisville, Kentucky). These figures were obtained during the open enrollment period for 2015 (Table 1). Cost increases nationally averaged ∼5% for 2015 over costs in the 2014 inaugural year, and varied by state with decreases occurring in several states [19 –21].

Table 1.

Financial factors for a woman purchasing health insurance in Louisville, Kentucky.

Factors determining cost	Single woman A	Single woman + 20-years-old child B	Single woman + 20-years-old child C
Kentucky	Louisville	Louisville	Louisville
Zip	40204	40204	40204
Income (MAGI)	$50,000	$50,000	$65,000
Premium subsidy threshold (400% of FPL)	$46,680	$62,920	$62,920
Lowest bronze (monthly premium)
Age (years):
−20	$67
−30	$120			Tax credit (B)
−40	$135	$202	$202	$0
−50	$189	$253	$256	$3
−60	$287	$197	$354	$157
−64	$317	$180	$384	$204
Total deductable	$6,500	$13,000	$13,000
Max out of pocket	$6,600	$13,200	$13,200
Penalty for no insurance 2014†	$399	$399	$549
Penalty for no insurance 2015†	$797	$797	$1097
Child income or second job		$15,000
parent
Adjusted MAGI		$65,000
Income tax increase for 2014 due to tax credit loss
Age (years):
−50		$37
−60		$1883
−64		$2452

Note that premiums are highest at age 64 years with eligibility ending at age 65 years.

All $ currency is in US$.

†

Must sign up before February 15 to avoid penalty, extended to 30 April 2015. Filling single not as head of household.

FPL: Federal poverty level; MAGI: Modified adjusted gross income.

The premium subsidy threshold is based on 400% of the federal poverty level that changes with family size. MAGI is determined from US Federal Income Tax Forms and other information [22]. In Table 1 costs were obtained for the lowest priced plan in the lowest priced tier of coverage (bronze). It is clear that ACA health insurance premiums increase with age. Case A premiums apply to all MAGI >US$46,680, while case B & C apply to MAGI >US$62,920. The deductible in the tables is the amount that is paid on a medical expense before health insurance pays for anything, while the total out-of-pocket expense is a protection limit on the individual's responsibility to settle annual healthcare costs for covered services, and represents the maximum an individual would pay before the health insurance starts to pay for covered essential services (i.e., emergency services, hospitalizations, laboratory services, maternity care, mental health and substance abuse treatment, outpatient or ambulatory care, pediatric care, prescription drugs, preventive care and rehabilitative [helping, maintain daily functioning] services, and vision and dental care for children). Once the out-of-pocket limit has been reached, the health insurance completely covers all costs (100%) of essential services with the deductible counting toward the out of pocket limit.

The penalty for failing to enroll in health insurance before February 15 was estimated at 1% of income above the income filing limit of US$10,150 for 2014 and at 2% for 2015. A woman with a dependent child receives a tax credit discount to her monthly premium because together they are below the family-size dependent premium subsidy threshold and the premiums shown have had the discount applied (case B, Table 1 ); however, if during the year income increases due to a second job, a raise or the dependent gaining part-time employment, then a reduction in the tax credit must occur, and this adjustment will be paid as an increase on the subsequent Federal tax filing to the Internal Revenue Service. For an unanticipated US$15,000 increase in income for case B, the mother and daughter will be above the US$62,920 premium subsidy threshold and therefore will have age-related increases in tax owed to the Internal Revenue Service as shown at the bottom of Table 1. In summary, the costs to the individual introduced by the ACA are related to age, participation plans and accurate estimation of income during the coverage year.

Table 2 expands the insurance premium consideration to Kentucky's two largest cities (Louisville and Lexington) as well as to cities in two rural areas (Whitesburg and Benton) for a single woman with an adjusted income of US$50,000. For the lowest premium plans, there was a difference in the deductible limit between the metropolitan and rural areas that favored the rural areas and there was no differences in the maximum out-of-pocket limit. Premiums varied with location. Premiums in a bronze plan were lowest in the largest city (Louisville: US$67–317/month) and most expensive in the two rural cities of Whitesburg (US$90–424/month) and Benton (US$90–424/month). At age 20 years the lowest premiums ranged from 1.6 to 2.2% of MAGI, while at age 64 years they ranged from 7.6 to 10.2% of MAGI. The most expensive premium in the platinum tier was in Louisville and ranged in price in the other cities from 4–4. 4% of MAGI at age 20 years to 18.9–20.7% at age 64 years. Note that federally sponsored Medicare eligibility begins at age 65 years as universal coverage that does not involve means testing.

Table 2.

Cost of health insurance in Kentucky for a single woman.

Factors determining cost	Single woman
	Louisville (KY, USA)	Lexington (KY, USA)	Whitesburg (KY, USA)	Benton (KY, USA)
Zip	40204	40513	41858	42025
Income (MAGI)	$50,000	$50,000	$50,000	$50,000
Premium subsidy threshold (400% of FPL)	$46,680	$46,680	$46,680	$46,680
Lowest (bronze)
Age (years):
−20	$67	$79	$90	$90
−30	$120	$141	$160	$160
−40	$135	$159	$181	$181
−50	$189	$222	$252	$252
−60	$287	$337	$383	$383
−64	$317	$372	$424	$424
$Total deductable	$6500	$6500	$4750	$4750
$Max out of pocket	$6600	$6600	$6600	$6600
Annual premium, age 60 years	$3439	$4042	$4600	$4600
% MAGI, age 64 years	7.60%	8.90%	10.20%	10.20%
Highest (platinum)
Age (years):
−20	$182	$170	$167	$167
−30	$326	$304	$299	$299
−40	$367	$342	$336	$336
−50	$512	$478	$470	$470
−60	$778	$727	$714	$714
−64	$860	$803	$789	$789
Total deductable	$1000	$1000	$1000	$1000
Max out of pocket	$1500	$1500	$1500	$1500
Annual premium, age 60 years	$9341	$8719	$8566	$8566
MAGI, age 64 years	20.70%	19.30%	18.90%	18.90%

Louisville and Lexington have Kentucky's two largest metropolitan areas. Whitesburg is located in Appalachian eastern Kentucky and Benton is 375 miles away in a low population region of western Kentucky.

Note that premiums are highest at age 64 years with eligibility ending at age 65 years.

All $ currency is in US$.

FPL: Federal poverty level; MAGI: Modified adjusted gross income.

Table 3 extends these comparisons to a single mother with a 20-years-old-dependent daughter. For this family, the lowest bronze premiums decreased after age 50 years, but did not for the highest premiums in the platinum health insurance plan. For the lowest premium plans, deductible limits were higher in the rural areas than metropolitan areas. There was no difference between metropolitan and rural areas in the maximum out of pocket limit. Premiums varied with location with bronze premiums being least expensive in the largest Kentucky city (Louisville: US$180–202) and most expensive in the two rural cities of Whitesburg (US$185–270) and Benton (US$185–270). At age 40 years the lowest premiums in a bronze plan ranged from 4.8 to 6.5% of MAGI, and at age 64 years from 4.3 to 4.4% of MAGI. Platinum premiums were highest in Louisville (US$11527 at age 60 years) and ranged from 9.3–10.1% of MAGI at age 40 years to 17.7–19.2% at age 64 years. Note that premiums are presented at age 64 years because they are greatest at this age (eligibility ends for ACA health insurance at age 64 years).

Table 3.

Cost of health insurance in Kentucky for a single mother with a 20-year-old child.

Factors determining cost	Woman + 20-year-old child
	Louisville (KY, USA)	Lexington (KY, USA)	Whitesburg (KY, USA)	Benton (KY, USA)
Zip	40204	40513	41858	42025
Income (MAGI)	$50,000	$50,000	$50,000	$50,000
Premium subsidy threshold (400% of FPL)	$62,920	$62,920	$62,920	$62,920
Lowest (bronze)
Age (years):
−40	$202	$237	$270	$270
−50	$253	$286	$256	$256
−60	$197	$242	$202	$202
−64	$180	$229	$185	$185
Total deductable	$13,000	$13,000	$13,200	$13,200
Max out of pocket	$13,200	$13,200	$13,200	$13,200
Annual premium, age 60 years	$2361	$2907	$2425	$2425
MAGI, age 64 years	4.30%	5.50%	4.40%	4.40%
Highest (platinum)
Age (years):
−40	$549	$512	$503	$503
−50	$694	$648	$637	$637
−60	$961	$897	$881	$881
−64	$1043	$973	$956	$956
Total deductable	$3000	$3000	$3000	$3000
Max out of pocket	$4500	$4500	$4500	$4500
Annual premium, age 60 years	$11,527	$10,759	$10,570	$10,570
MAGI, age 64 years	19.20%	18.00%	17.70%	17.70%

Estimates assumed that 20 and 30 years old women would not have a 20-year-old child. Note that premiums are highest at age 64 years with eligibility ending at age 65 years.

All $ currency is in US$.

FPL: Federal poverty level; MAGI: Modified adjusted gross income.

Penalties at tax time

For a single mother with a 20-year-old child, their family MAGI is under the US$62,920 premiums subsidy threshold, so that they are entitled to an immediate subsidy discount applied each month to their health insurance premiums (Table 4). This discount is administratively considered as a tax credit so that if the actual MAGI at the end of the tax year is higher than the MAGI reported to obtain the health insurance discount, then this credit must be repaid when taxes are due. This situation could occur due to an unanticipated raise in pay, because of part-time work that increased the MAGI or due to an underestimation of the MAGI at the start of the year. When income increases above the $62,920 subsidy threshold, repayments at tax time are different in four Kentucky cities because of higher subsidy discounts received in each region (Table 4) [23].

Table 4.

Fiscal year tax increase for health insurance tax credits forfeited by increased income from US$50,000 to US$65,000 for a single mother with a 20-year-old child in different regions of Kentucky.

Age (years)	Louisville	Lexington	Whitesburg	Benton
Monthly discount for 2014 due to tax credit
50	$3	$15	$86	$86
60	$157	$173	$271	$271
64	$204	$222	$328	$328
Income tax increase for 2014 due to tax credit loss †
50	$37	$180	$1026	$1026
60	$1883	$2081	$3251	$3251
64	$2452	$2667	$3937	$3937

All $ currency is in US$.

†

Estimation is based on filing single not as head of household. Note that premiums are highest at age 64 years with eligibility ending at age 65 years.

Cross-sectional survey of health insurance cost to American consumers

Three states that had state-run health insurances exchanges (Kentucky, Minnesota and California) and three that did not (South Carolina Nebraska, Utah: health insurance purchase on the Federal exchange) were examined. Central measures were determined over all ages and for four cities. Kentucky had the lowest average bronze premiums across all ages (Table 5) and Utah had the lowest average platinum premiums (Table 6). At age 60 years, the lowest average bronze premiums varied from US$4170 (Kentucky) to US$5715 (Nebraska) and from 9 to 12.4% of MAGI at the oldest eligible age for ACA coverage (64 years years, Table 5). At age 60 years, the lowest average platinum premiums varied from US$8226 (Utah) to US$17655 (South Carolina), and from 16.5 to 39% of MAGI at the oldest eligible age for ACA coverage (64 years, Table 6 ). Thus, bronze premiums as well as platinum premiums differ across states. The maximum average difference for the lowest bronze premiums in the states surveyed was US$1545 for a woman at age 60 years with a maximum average difference as % MAGI at age 64 years of 3.4% (Table 5). In contrast, the maximum average difference for the most expensive platinum premiums in the states surveyed was US$9429 for a woman at age 60 years with a maximum average difference as % MAGI at age 64 years of 22.6% (Table 6). Consequently, not only is the top end of platinum health insurance coverage 3.1x more expensive than the most expensive bronze plan, but platinum coverage could be very much higher than platinum coverage in other states.

Table 5.

Survey of premiums in the lowest priced bronze plans in select states.

Insurance premium cost estimator	Kentucky	Minnesota	California	South Carolina	Nebraska	Utah
Population	4,395,295	5,420,000	38,330,000	4,775,000	1,869,000	2,901,000
Income (MAGI)	$50,000	$50,000	$50,000	$50,000	$50,000	$50,000
Exchange type	State	State	State	Federal	Federal	Federal
Lowest premium (monthly)	$67	$98	$105	$89	$94	$90
Highest premium (monthly)	$424	$580	$586	$653	$569	$399
Average premium (monthly)	$225	$282	$313	$302	$308	$246
Standard deviation (monthly)	$115	$148	$149	$160	$155	$107
SEM (monthly)	$23	$30	$30	$33	$32	$22
Median premium (monthly)	$185	$240	$286	$264	$263	$219
Average Annual Premium, age 60 years	$4170	$5099	$5625	$5592	$5715	$4500
Average MAGI, age 64 years	9.2%	11.3%	12.4%	12.4%	12.6%	9.0%

Cost quotes are for a single woman with a MAGI above the US$46,680 premium subsidy threshold. Health insurance premium quotes were obtained for: Kentucky [11], Minnesota [24]. California [12], South Carolina, Nebraska and Utah [14]. The cities included in the survey were: Kentucky (Louisville, Lexington, Whitesburg, Benton), Minnesota (Minneapolis-St Paul, Duluth, Bemidji, Rochester), California (Los Angeles, Pasadena, Ventura, San Bernadina), South Carolina (Charleston, Columbia, Florence, Greenwood), Nebraska (Omaha, Lincoln, Elsmere, Scottsbluff) and Utah (Salt Lake City, Logan, Price, Delta).

Note that premiums are highest at age 64 years with eligibility ending at age 65 years.

All $ currency is in US$.

MAGI: Modified adjusted gross income; SEM: Standard error of the mean.

Table 6.

Survey of premiums in the most expensive platinum plan in select states.

Insurance premium cost estimator	Kentucky	Minnesota	California	South Carolina	Nebraska	Utah
Population	4,395,295	5,420,000	38,330,000	4,775,000	1,869,000	2,901,000
Income (MAGI)	$50,000	$50,000	$50,000	$50,000	$50,000	$50,000
Exchange type Lowest premium (monthly)	State $167	State $220	State $212	Federal $331	Federal $241	Federal $146
Highest premium (monthly)	$860	$1044	$1156	$1668	$1245	$736
Average premium (monthly)	$475	$548	$636	$953	$688	$449
Standard deviation (monthly)	$235	$264	$317	$472	$341	$201
SEM (monthly)	$48	$54	$65	$96	$70	$41
Median premium (monthly)	$418	$445	$544	$821	$604	$377
Average annual premium, age 60 years	$8798	$9903	$11,790	$17,655	$12,738	$8226
Average % MAGI, age 64 years	19.50%	21.90%	26.10%	39.00%	28.20%	16.50%

Cost quotes are for a single woman with a MAGI above the $46,680 premium subsidy threshold. Health insurance premium quotes were obtained at: Kentucky [11], Minnesota [24]. California [12], South Carolina, Nebraska and Utah [14].

Note that premiums are highest at age 64 years with eligibility ending at age 65 years.

All $ currency is in US$.

MAGI: Modified adjusted gross income; SEM: Standard error of the mean.

Observations on state run exchanges

From the stand-point of usability of state exchange web sites, California, Kentucky and Minnesota were excellent and this defined their prominent use in this report. In addition, Idaho had an excellent, straightforward site. Some issues found at state exchange web sites were as follows.

The site:

Did not accept income to estimate health insurance costs (Colorado);

Did not accept age for calculating estimates (New York, Vermont);

Did not accept the age of a dependent for calculating estimates (Washington);

Did not allow zip code, city or county to be specified (Rhode Island, Vermont);

Did not adjust for or show the tax credit (Colorado, Hawaii);

Made user log in and enroll in order to get all the coverage choices available (Washington, DC);

Had results that could not be sorted by the price of premium and were randomly listed (Washington).

It should be understood that when an individual is participating in an ACA-qualified health insurance plan, they need to receive their care from physicians in that plan's provider network. For individuals with specific needs, determining if certain specialists were in the network and nearby could be important. Our efforts examined physician participation and their proximity by inquiring if the provider network included care from a gynecologic oncologist. The most common problematic issue was finding network information on the exchange web sites. Consequently, our inquiries were performed on the providers Internet sites and involved some persistence to examine provider networks associated with the health insurance plans that we surveyed. The bronze plans with the lowest premiums matched to 15 gynecologic oncologists in Louisville and Lexington that were within 100 miles (closest 1.1–35.9 miles; furthest 11.2–83.7 miles). The platinum plans with the highest premiums matched to three gynecologic oncologists in Louisville and 13 in Lexington that were within 100 miles (closest 3.6–4.2 miles; furthest 3.6–11.8 miles). Distance was a bigger factor in rural Kentucky, so that four matches to gynecologic oncologists for Whitesburg required 25–46 miles of travel, while in Benton 133–210 miles of travel were required and extended out of state. The Whitesburg referral addresses could not confirm practices that included a gynecologic oncologist while the Benton referral addresses did. One provider network serving Lexington listed a referral address that did not include gynecologic oncologists in their practice. While care by a gynecologic oncologist may be achieved through institutional affiliations in these cases, this assumption could not be confirmed by a consumer trying to make an insurance decision based on this availability. Although these inquiries were limited to four Kentucky cities, they demonstrated that there is considerable variability in provider network information about access to care from a gynecologic oncologist.

State-by-state enrollments in ACA healthcare insurance coverage

The basics: The major opportunities provided by the ACA involve enrollments in exchange-based qualified health plans (exchange QHP), Medicaid, and the Children's Health Insurance Program (CHIP). As demonstrated earlier, enrollment in exchange QHPs may or may not be discounted depending on an individual's MAGI and will be either through the federal exchange (Healthcare.gov: 29 states) or through state run exchanges (Table 7: 14 states, including the District of Columbia). The basic difference between state exchanges and the federal exchange is that it is easier for states to ensure a seamless coverage and regulatory approach with consumers especially benefiting from assistance in enrolling. In addition, five states are participating in the ACA as State-Partnership Marketplaces where the states provide consumer assistance, but application and enrollment are through the federally operated Healthcare.gov. Lastly, three states are organized for operation as Federally supported state-based marketplaces where they are responsible for performing all marketplace functions but rely on the federal IT platform for application and coverage through Healthcare.gov (Table 7). Thus, 37 states handle applications and enrollments through the federal Healthcare.gov platform, accounting for the greatest number of paid enrollments (75.3% from Table 7 column G). Americans with the lowest income (US$16,105 individual or US$32,913 family of four) qualify for free or low cost Medicaid and the Children's Health Insurance Program (CHIP) which is paid for with state and federal dollars (100% federal until 31 December 2016, 95% for 2017 with 1% decreases for 2018 & 2019 and 90% for 2020 [25]). The ACA expanded Medicaid coverage up to 138% of the federal poverty level determined annually for families of different sizes with the caveat that states were accorded the decision to participate in expansion. It should be understood that the federal support was only for new Medicaid participants that qualified because they had household incomes above old Medicaid limits established differently in each state. Thus, expanded federal support would not be applied to families that had already been enrolled in pre-ACA Medicaid or to those newly enrolled that would have qualified in their states under pre-ACA limits. Consequently, the federal government is responsible for only 57% of the costs of individuals previously eligible for Medicaid. Medicaid Expansion has occurred in 23 states (Table 7 including the District of Columbia), while six states used an alternative to expansion and 22 states did not expand Medicaid.

Table 7.

Enrollment in the Affordable Care Act's qualified health plans, Medicaid and Children's Health Insurance Program.

State [26]	Population [27]	Total uninsured [28]	Eligible for exchange QHP (n) [29]	Enrolled in exchange QHPs (n) [30]	Enrolled (%) [30]	Enrolled and paid (n) [30]	Eligible for medicaid (n) [26,31]	Medicaid gap [30,32 –33]	Eligible for Medicaid and QHP (n) [30]	Enrolled in Medicaid and CHIP (n) [30,31]	Increase over pre-ACA Medicaid and CHIP (%)
A	B	C	D	E	F	G	H	I	J	K	L
Alabama	4,833,000	660,000	450,000	171,641	38.1	151,044	107,000	191,000	557,000	873,954	9
Alaska	735,000	129,000	87,000	21,260	24.4	18,709	28,000	17,000	115,000	121,867	0
Arizona	6,626,000	1,140,000	628,000	205,666	32.8	180,986	469,000	0	1,097,000	1,482,316	23
Arkansas	2,959,000	510,000	254,000	65,684	25.9	57,802	281,000	0	535,000	824,529	48
California	38,332,000	6,993,000	3,245,000	1,412,200	43.5	1,242,736	2,979,000	0	6,224,000	12,170,138	33
Colorado	5,268,000	737,000	571,000	141,639	24.8	133,140	332,000	0	903,000	1,195,042	53
Connecticut	3,596,000	286,000	224,000	109,839	49.0	96,658	107,000	0	331,000	733,590	N/A
Delaware	925,000	92,000	48,000	25,036	52.2	22,032	38,000	0	86,000	235,775	6
Dist. of Colum.	646,000	50,000	33,000	19,321	58.6	17,002	27,000	0	60,000	256,383	9
Florida	19,552,000	3,867,000	2,504,000	1,596,296	63.8	1,404,740	457,000	764,000	2,961,000	3,404,156	10
Georgia	9,992,000	1,849,000	1,091,000	541,080	49.6	476,150	314,000	409,000	1,405,000	1,724,033	12
Hawaii	1,404,000	103,000	55,000	12,625	23.0	11,110	58,000	0	113,000	314,503	9
Idaho	1,612,000	258,000	217,000	97,079	44.7	85,430	37,000	55,000	254,000	288,402	14
Illinois	12,882,000	1,772,000	954,000	349,487	36.6	307,549	801,000	0	1,755,000	3,101,946	18
Indiana	6,570,000	801,000	680,000	219,185	32.2	192,883	140,000	182,000	820,000	1,198,066	7
Iowa	3,090,000	301,000	225,000	45,162	20.1	39,743	143,000	0	368,000	512,533	4
Kansas	2,893,000	369,000	245,000	96,197	39.3	84,653	58,000	78,000	303,000	404,608	7
Kentucky	4,395,000	647,000	261,000	106,330	40.7	93,570	350,000	0	611,000	1,099,327	81
Louisiana	4,625,000	866,000	524,000	186,277	35.6	163,924	132,000	242,000	656,000	1,053,090	3
Maine	1,328,000	130,000	124,000	74,805	60.3	65,828	11,000	24,000	135,000	282,359	N/A
Maryland	5,928,000	756,000	458,000	122,778	26.8	108,045	299,000	0	757,000	1,152,248	35
Massachusetts	6,692,000	242,000	385,000	144,362	37.5	125,402	89,000	0	474,000	1,619,824	25
Michigan	9,895,000	1,111,000	689,000	341,183	49.5	300,241	500,000	0	1,189,000	2,233,070	17
Minnesota	5,420,000	462,000	275,000	61,109	22.2	53,776	259,000	0	534,000	1,037,554	19
Mississippi	2,991,000	454,000	284,000	104,538	36.8	91,993	74,000	138,000	358,000	711,782	12
Missouri	6,044,000	834,000	639,000	253,430	39.7	223,018	179,000	193,000	818,000	863,651	2
Montana	1,015,000	178,000	121,000	54,266	44.9	47,754	28,000	40,000	149,000	165,604	11
Nebraska	2,790,000	234,000	235,000	74,152	31.6	65,254	37,000	33,000	272,000	235,523	−4
Nevada	2,790,000	621,000	256,000	73,596	28.8	64,764	304,000	0	560,000	541,334	63
New Hampshire	1,323,000	158,000	104,000	53,005	51.0	46,644	18,000	26,000	122,000	169,747	34
New Jersey	8,899,000	1,251,000	589,000	254,316	43.2	223,798	466,000	0	1,055,000	1,667,815	30
New Mexico	2,085,000	422,000	156,000	52,358	33.6	46,075	204,000	0	360,000	687,829	50
New York	19,651,000	2,221,000	1,246,000	408,841	32.8	359,780	950,000	0	2,196,000	6,247,440	10
North Carolina	9,848,000	1,593,000	1,097,000	560,357	51.1	493,114	168,000	319,000	1,265,000	1,835,638	15
North Dakota	723,000	70,000	78,000	18,171	23.3	15,990	27,000	0	105,000	86,220	23
Ohio	11,570,000	1,460,000	932,000	234,341	25.1	206,220	734,000	0	1,666,000	2,928,588	25
Oklahoma	3,850,000	632,000	398,000	126,115	31.7	110,981	71,000	144,000	469,000	808,807	2
Oregon	3,930,000	559,000	324,000	113,219	34.9	99,633	260,000	0	584,000	1,036,190	65
Pennsylvania	12,773,000	1,426,000	899,000	472,697	52.6	415,973	224,000	281,000	1,123,000	2,493,851	5
Rhode Island	1,051,000	126,000	73,000	31,513	43.2	30,001	54,000	0	127,000	267,466	40
South Carolina	4,774,000	765,000	441,000	210,331	47.7	185,091	134,000	194,000	575,000	983,275	11
South Dakota	844,000	110,000	101,000	21,393	21.2	18,826	16,000	25,000	117,000	117,687	2
Tennessee	6,495,000	850,000	579,000	231,440	40.0	203,667	147,000	162,000	726,000	1,433,932	15
Texas	26,448,000	6,167,000	3,061,000	1,205,174	39.4	1,060,553	874,000	1,046,000	3,935,000	4,651,139	5
Utah	2,900,000	407,000	376,000	140,612	37.4	123,739	61,000	58,000	437,000	293,359	0
Vermont	626,000	47,000	45,000	31,619	70.3	23,913	17,000	0	62,000	179,514	11
Virginia	8,260,000	1,021,000	831,000	385,154	46.4	338,936	98,000	191,000	929,000	968,216	4
Washington	6,971,000	948,000	503,000	165,436	32.9	165,436	449,000	0	952,000	1,645,727	47
West Virginia	1,854,000	267,000	106,000	33,421	31.5	29,410	143,000	0	249,000	524,569	48
Wisconsin	5,742,000	566,000	478,000	207,349	43.4	182,467	201,000	0	679,000	1,042,496	6
Wyoming	582,000	93,000	65,000	21,092	32.5	18,561	10,000	17,000	75,000	68,577	2
Total	317,027,000	47,611,000	28,244,000	11,704,177	41.4	10,324,747	13,964,000	4,829,000	42,208,000	69,975,289	19

Summary is current to February–March 2015

ACA: Affordable Care Act; CHIP: Children's Health Insurance Program; QHP: Qualified health plan

Macroparticipation in exchange QHPs & Medicaid/CHIP: all in?

Overall enrollment in Exchange QHPs was 41.4% nationally (Table 7), but differed in various states (state average = 38.8% /lowest = 20.1% (Iowa)/highest =70.3% (Vermont)/median = 37.5%). Paid enrollments were running at 88% in nearly all states as of 25 March 2015. Of the eight states that had >50% of those eligible enroll, two were through state exchanges (Vermont & District of Columbia) and six were through Healthcare.gov, either directly (Florida, Maine, Pennsylvania, North Carolina) or through state marketplace exchanges (Delaware, New Hampshire), Table 7. Only three of these eight states (Vermont, District of Columbia, Delaware) were participating in Medicaid Expansion, Table 7. These eight states averaged a 13% increase in Medicaid enrollment over Pre-ACA Medicaid enrollment as compared 19.9% for the all state average. Thus, high enrollment above the national average in exchange QHPs equated with enrollments below the all state average for increased Medicaid/CHIP enrollment.

Kentucky had the greatest increase in Medicaid/CHIP enrollments over Pre-ACA enrollment (81%: Table 7 , column L). Nebraska was the only state that had a decrease over Pre-ACA Medicaid enrollment (-4%). The all state median enrollment was 12% and the lowest increase in Medicaid enrollment occurring in South Dakota (2%), Table 7 , column L. Of the 8 states with >40% increases over Pre-ACA Medicaid enrollment (Kentucky, Oregon, Nevada, Colorado, New Mexico, West Virginia, Arkansas, Washington), seven were participating in Medicaid Expansion, while one had a Medicaid Expansion Alternative (Arkansas), Table 7. Only one of these eight states did not have its own state health insurance marketplace (Arkansas, Table 7 ). These eight states averaged 31.6% enrollments in Exchange QHPs which was below the state-by state average of 38.8% [34] and the national average of 41.4% [35] ( Table 7 , column F) with only Kentucky (40.7%) above these averages. Thus, high increased Medicaid/CHIP enrollment was matched with below average enrollment in Exchange QHPs with the exception of the state of Kentucky.

Enrollment ( Table 7 , columns E and K) relative to estimates of overall eligibility ( Table 7 , column D and H) shows that participation in both Exchange QHPs and Medicaid/CHIP is well over 100% nationally (>190%) and has exceeded estimated expectations significantly. Medicaid-CHIP enrollment nationally was ∼6x greater than exchange QHP enrollment and was highest in Hawaii (24.9x), Minnesota (17x), West Virginia (15.7x), New York (15.3x), District of Columbia (13.3x), New Mexico (13.1x), Arkansas (12.6x), Ohio (12.5x), Iowa (11.3x), Massachusetts (11.2x) and Kentucky (10.3x). It was higher in states that expanded Medicaid (mean = 10.6x), relative to those that had not (mean = 4.9x).

Economics & paying for it all!

The original ACA legislation appropriated US $100 billion over the period 2010–2019 in mandatory funding and another US$100 billion in discretionary funding over the same period [36]. Grant funding to individual states of US$4.99 billion [37,38] has been made to implement the ACA with California and New York receiving the most. Kentucky received the fifth most and Minnesota the 13th most. Moving forward in the long-term, Federal spending for Social Security and the government's major healthcare programs – Medicare, Medicaid, the Children's Health Insurance Program, and subsidies for health insurance purchased through the exchanges created under the ACA – would rise sharply, to a total of 14% of gross domestic product (GDP) by 2039, twice the 7% average seen over the past 40 years. That boost in spending is expected to occur because of the aging of the population, growth in per capita spending on healthcare and an expansion of federal healthcare programs [39]. With such a substantial increase, it is reasonable to ask: what will be its effects? No answer exists at present because there are so many moving parts to the assumptions made for healthcare projections involving a strengthening economy, constraints on federal spending, lowering of federal deficits, while unknowns include: pressures from an aging population, rising healthcare costs, expansion of federal subsidies for health insurance, increases in interest rates, and so on. However, the investment market may provide surrogate indicators of where this is all going. Regardless of personal or programmatic politics, the financial sectors independently grow where investors perceive the best rewards and the lowest risks. Figure 1 presents the share value over the last 3 years of four exchange traded funds (ETFs) composed of different individual healthcare providers and services, including UnitedHealth Group Incorporated, Express Scripts Holding Company, Anthem, Aetna Inc, Cigna Corporation, Humana Inc., HCA Holdings Inc., DaVita HealthCare Partners Inc, Laboratory Corporation of America, Quest Diagnostics Incorporated, etc. Each of these ETFs is on a significant upward trend, shows little evidence of pull-back and has averaged >35% annual appreciation. What can be said at present is that investor confidence in the healthcare services and providers sector has been high, increasing the value of the underlying holdings. This confidence occurs in the face of highly elevated price-to-earnings ratios and very high debt-to-equity ratios in many of the underlying healthcare holdings of these ETFs. However, the purchasing of health insurance accelerated by the ACA and the ultimate backing of the health insurance by the US government reflects an investor view that the healthcare sector is presently considered to be solid. While this present view does not predict the future, it does present a case for investor confidence in American healthcare businesses that has been on-going for several years (2013–present).

Figure 1.

3 years performance of four exchange traded funds dealing in publically traded healthcare companies. Total 3 years growth as a percentage increase was obtained from the Wall Street Journal at [40].

Discussion

What are the innovations that the ACA brings to Americans seeking healthcare coverage?

The consumer-based perspective presented here can be considered in terms of five consumer applications (app) that the ACA brings to Americans as follows:

Consumer App #1 removes access barriers to health insurance and hence healthcare. Previously, the ACA's pre-existing conditions could prevent all coverage for the specific pre-existing condition, premium discrimination could raise premiums for certain conditions on individual policies issued to prevent enrollment of individuals with these conditions, and insurers could change the terms of coverage at any time after enrollment to exclude or limit coverage on certain conditions (rescissions). The ACA has since removed these barriers.

Consumer App #2 implements choices with regard to price and plan benefits. Online access provides what the consumer wants at the price that they decide to pay. Bronze, Silver, Gold and Platinum plans provide step-wise coverage of healthcare costs that are covered (60, 70, 80, 90%, respectively), as well as stepped deductibles and out-of-pocket costs.

Consumer App #3 makes coverage of Essential Health Services [41] universal to all ACA QHPs, as well as to private insurance plans created or purchased after 23 March 2010 [42]. At least 15 free preventive services and one wellness visit are covered by ACA QHPs without copayments (a fixed amount the consumer pays for covered services, typically at the time of the service) and coinsurance (the share of costs of the allowed amount for a covered service after reaching the deductible), regardless of whether the deductible has been met. It does not include premiums, or costs that are not covered by a plan. Once the deductible is met, the plan will pay its share of the plan's coinsurance. These essential health services must be done in-network, and there are costs to the consumer otherwise.

Consumer App #4 provides affordability through federal financial assistance with cost of QHPs to consumers, expansion of Medicaid and consumer selection of their share of covered services payment responsibilities. The ACA provides variable assistance that discounts the cost of QHPs to those with MAGIs that are up to 400% of the federal poverty level and expands Medicaid in participating states to 133% of the federal poverty level. In addition, individuals can decide on QHPs with a monthly premium that is acceptable and in line with their anticipated healthcare needs, which would be least expensive for individuals that will need little or no medical care.

Consumer App #5 mitigates financial ruin by removing caps on annual benefits and on lifetime benefits and by placing maximums on out-of-pocket expenses for covered services. Prior to the ACA QHPs, healthcare bankruptcy loomed when annual or lifetime dollar limits had been exceeded so that coverage no longer applied. In addition, catastrophic illness during the deductible phase could impose extreme out-of–pocket expenses and be financially ruinous [43]. The ACA qualifies out-of-pocket limits based on income and family size. For the healthcare consumer at ground zero, these applications of the ACA have enormous impact.

Is health insurance coverage affordable for Americans?

Affordability is the key promise of the ACA. Delivering this promise has several moving parts, including base price, usage costs (deductibles, out-of-pocket expenses), penalty for incomplete participation, reconciliation on federal income tax and increased cost over time. Cost average reports have placed increases at ∼5% nationally [18 –20], but the cost of health insurance premiums for 2015 range from 22% decreases to 35% increases [44]. Notably, average figures result from what is used to compute the average (all policies vs all policies expected to be purchased [i.e., weighted by the distribution that is purchased]), so that the average felt by consumers may differ from reported estimates. While the ACA does provide individual consumers the opportunity to re-enroll in less expensive plans, and more than half (54%) re-enrolling for 2015 switched plans, it is not known if the changes were to higher or lower cost plans [45]. Importantly, individuals will feel an increased cost of premiums due to age so that even in the absence of any increase in the cost of the policy held, the consumer will bear and perceive an increased cost to their health insurance. In the end, affordability is an issue that is personalized to the individual or family. Importantly, preparedness for making decisions related to participation in QHPs does require commitments to self-education and knowledge [46].

What is the greatest complication facing Americans that receive health insurance on ACA exchanges?

Tax implications for the consumer have been enumerated in the case of unanticipated increases in income that will result in a give-back at tax time either through a reduced refund or additional tax due [47,48]. Individuals that qualify for an exemption must use Form 8965 to calculate the Shared Responsibility Payment (SRP) and report any potential exemptions from the SRP. The IRS takes great care to avoid calling the SRP a tax penalty, although it serves the same purpose. In the event that the consumer has an unanticipated decrease in income, the taxpayer receives a reduction in their tax due or an increase of their tax refund through the Premium Tax Credit which essentially compensates for what their healthcare subsidy should have been using their 2014 income information. For taxpayers receiving the healthcare subsidy or claiming the Premium Tax Credit, form 8962 must be used to calculate any additional credit or credit repayment. When filing a tax return for the first year covered by the ACA, Form 8962 [49] must be submitted, which requires information that verifies participation in a QHP in order to avoid non-participation penalties. Verifying information for Form 8962 is provided on forms sent to participating individuals:

Form 1095-A [50] is required to be sent to individuals who have enrolled in a QHP through an exchange and for tax year 2014 must be prepared by 31 January 2015. Only those who go through an exchange qualify for the premium tax credit on QHP premiums.

Form 1095-B [51] is to be completed by a small employer insurance provider. It is for individuals who obtain their insurance through a small group employer (<50 employees), as well as individuals that seek insurance on their own but do not get it through an exchange. The preparation of this form is optional for 2014 and is to be phased in for future years.

Form 1095-C [52] – is to be completed by large employers, is also optional for 2014 and is to be phased in for future years.

As these forms are optional for 2014, individuals who are challenged by the IRS to verify participation may not be able to rely on forms 1095-B or C, and may have to resort to more rudimentary methods (receipts, pay stubs, employer statements) until these forms are phased in.

What can be said about the enrollment numbers for participation in insurance plans on ACA exchanges?

Updates in enrollment have been made monthly by state and government reports and consequently would be subject to ebb and flow of accruals governed by approved applications, payment and point of time in the enrollment cycle. Summaries presented here cover participation for the first year of ACA health insurance availability and include new and re-enrollments for 2015. Estimates of eligibility used in the figures reported here were from the original 2014 estimates prior to the start of 2014 and are in line with various agency, government and media reports of successful participation in the ACA healthcare insurance plans. 2015 projections for enrollment of 11.4 million uninsured individuals may have been too optimistic. Nevertheless, a robust number (4.67 million) of previously uninsured individuals enrolled for 2015 on exchanges [43,53].

What is the impact of health insurance coverage made available through the ACA?

It is likely that it is too early to assess the impact of the ACA on healthcare services. However, it has been reported that expansion of Medicaid coverage through the ACA did not result in long waiting times for provider appointments while appointment availability increased 7.7% [54]. Importantly, many states were estimated to have significant shortages of healthcare providers (45,000 primary care physicians and 46,000 specialists by 2020) for expanded healthcare [55]. Kentucky had a shortage assessment of 13,076 healthcare providers of which 3709 (36%) were physicians and 30% were physician assistants [56]. Considering the expansion of near-universal insurance coverage to 94% of the residents in Massachusetts (2002–2010), breast and cervical cancer screening increased 4–5% for mammograms and 6–7% for Pap tests [57]. While these early signs of expanded healthcare are encouraging, it is inevitable that as expansion continues more healthcare providers will be needed to deliver services.

It is impossible to ignore the unpopularity of the ACA [58]. Approval was highest at the time of the 2012 elections and has steadily fallen to an all-time low of 37% approval and 56% disapproval [59]. However, new enrollees and re-enrollees have not abandoned the marketplace exchanges and as already discussed represent successes in reducing the ranks of uninsured Americans. Some explanation for falling popularity could come from those that were forced to buy a more expensive product with coverage that they did not need, especially maternity benefits for individuals beyond reproductive age or of male gender. The perception of a broken promise that those who want to keep their insurance or doctor will be able to do so also may be contributory. To many the ACA is synonymous with ‘Obamacare’ so that the President's plummeting approval ratings [60] can carry over to feelings about the ACA. This is supported by ideology and politic since only 8% of Republicans indicate approval of the ACA, while 74% of Democrats indicate approval. With only 33% of independent voters indicating approval of the ACA, the connection to low Presidential approval is apparent [57] With these factors in mind, it is clear that only efforts to take the ACA away will make it more popular.

Conclusion

Enrollments in the ACA offerings have exceeded projections; however, the greatest enrollments have been in expanded Medicaid, which is premium-free. The concept of affordable premiums is less real to older Americans with low incomes. In addition, information on how Americans who are enrolled in ACA QHPs view their deductible and out-of-pocket expenses when using health insurance has not yet been comprehensively compiled. However, in summary, there can be little doubt that the ACA has brought considerable reform to American healthcare insurance.

Future perspective

A new President, a new legislative majority and a Supreme Court decision all could bring change altering the ACA. Political decisions are hard to predict at the individual level, but the reality of the large numbers of Americans now enrolled in an ACA plan make moves of repeal very questionable from the stand point of electability. Candidates in states that have refused Medicaid expansion may realize that they have a substantial constituency that wants participation through expansion. The Supreme Court has agreed to hear King versus Burwell on the question of the IRS ruling that the ACA subsidies could be granted to individuals purchasing health insurance in federally operated exchanges [61]. Provisions that are unpopular with the public may be the most vulnerable targets in the courts, such as the mandate for individuals to obtain health insurance or pay a penalty, the mandate that larger employers offer health insurance coverage to workers or pay a penalty and the tax on medical devices [30]. The Supreme Court has rendered a ruling in mid–2014 that was unfavorable to the ACA, holding that the federal government cannot lawfully mandate that closely held for-profit corporations provide contraception coverage if the exercise of religion is a compelling factor for the business [62].

Fiscal sustainability of the ACA by the government will likely carry through 2020, but may impact affordability by restricting subsidies if the government budget is stressed. In the face of an improving economic recovery where many more employers offer health insurance coverage to their employees, the role of individual participation in purchasing their own coverage could recede, but this would only be of neutral effect on the ACA. Lastly and of great significance will be the voice of Americans, who having taken advantage of the ACA's opportunity for healthcare access, will want this access to remain or widen.

Acknowledgements

The authors appreciate the time and information provided by C Banahan (Executive Director of the Office of the Kentucky Health Benefit Exchange), SK Mayfield (Kentucky Commissioner of Public Health in the Cabinet for Health and Family Services), J Midkiff (Executive Director Communication and Administrative Review in the Office of the Secretary of the Cabinet for Health and Family Services), B Hurley (Staff Assistant to the Kentucky Commissioner of Public Health) and K Cantrell (Cabinet for Health and Family Services Office of Health Policy).

Executive summary

Purchasing health insurance

Buying health insurance differs on various state-run exchanges and on the federal exchange.

Obtaining cost estimates is facile from state-run IT platforms or the federal IT platform.

Subsidies that are applied to monthly premiums on a means tested scale are administered as a tax credit.

Penalties for not participating or for increases in income that disqualify some or all subsidization are collected on the annual income tax.

Cross-sectional survey of health insurance cost

Premiums vary from state to state and from city to city within states, changing with income, age and family size.

Premiums were highest at age 64 years and could vary by more than three-fold between the least expensive bronze plan and the most expensive platinum plan.

Information on network providers was difficult to obtain without going to the provider's website. State-by-state summaries of participation

Organizational differences could be explained by 29 states in the federal exchange, 14 states on exchanges that were state-operated, five states operating as State-Partnership Marketplaces and three states operating as federally-supported state-based market places.

Medicaid enrollment nationally was approximately six-times higher than in qualifying health plans (QHPs), but varied from state to state and was higher in states that expanded Medicaid (10.6x) than in those that did not (4.9x).

Affording the Affordable Care Act provisions

Unknowns in affordability are due to cost of premiums, deductibles, out-of-pocket expenses, penalties for incomplete participation and increased premiums over time.

Changes in premiums ranged from a 22% decrease to a 35% increase for year 2.

Age-adjusted premiums cause an annually increased cost even when plans do not increase in cost.

Investors in the healthcare industry indicate confidence due to annual growth appreciation >35%. Questions worthy of discussion

What are the innovations that the Affordable Care Act (ACA) brings?

– There are five innovations: 1 removal of access barriers; 2 implementation of choice of price and plan benefits through online comparisons; 3 universal coverage of essential health services; 4 affordability through financial assistance subsidies and Medicaid expansion; 5 mitigation of financial ruin by removing caps on annual benefits and lifetime benefits and by placing maximums on out-of-pocket expenses for covered services.

Is health insurance coverage affordable for Americans?

– Since premiums are very low for young Americans aged 20–25 years, affordability is achieved; however older Americans in the years just prior to eligibility for Medicare have high premiums and may not feel that health insurance is affordable.

What is the greatest complexity facing users of ACA exchanges?

– Obtaining and providing accurate and precise documentation in order to enroll with subsidies in ways that avoid penalties is daunting.

Has enrollment been good?

– Enrollment for year one was on target, while 4.7 million previously uninsured Americans enrolled for 2015.

What is the impact and future of ACA?

– Political contentiousness is likely to focus on unpopular provisions, but rather than being election issues are likely to be pursued in courts.

Footnotes

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

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39.

Interactive: a state-by-state look at how the uninsured fare under the ACA. http://kff.org/interactive.

40.

Marketplace Enrollment as a Share of the Potential Marketplace Population. http://kff.org/health-reform.

41.

Oberlander J. Unraveling Obamacare – can congress and the Supreme Court undo health care reform?

N. Engl. J. Med. 371(26), 2445–2447 (2015).

42.

View of the legislative and judicial future of the Affordable Care Act.

43.

A 50-State Look at Medicaid Expansion. http://familiesusa.org.

44.

Artiga

Stephens

Damico

. The impact of the coverage gap in states not expanding Medicaid by race and ethnicity. http://kff.org/disparities-policy/.

45.

Total Monthly Medicaid and CHIP Enrollment. http://kff.org/health-reform.

46.

The state by state average represents an unweighted average of each state's enrollments = $ [enrolledstate /populationstate]/ [50 states + DC].

47.

The national average = $ enrolledstates / $ populationstates].

48.

Federal Funding Under the Affordable Care Act. https://kaiserfamilyfoundation.files.wordpress.com.

49.

Total Health Insurance Exchange Grants. http://kff.org/health-reform.

50.

Mach

Redhead

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51.

Congressional Budget Office. The 2014 Long-Term Budget Outlook. www.cbo.gov/publication/45471.

52.

View of the long term budget affecting the Affordable Care Act.

53.

The Wall Street Journal. iShares US Healthcare Providers ETF. http://online.wsj.com/public/quotes/etf_snapshot.html?symbol=IHF.

54.

For ETFs other than IHF, substitute XHS or VHT or IYH.

55.

ObamaCare Essential Health Benefits. http://obamacarefacts.com.

56.

View of essential health benefits of the Affordable Care Act. ObamaCare Essential Health Benefits. Ambulatory patient services, emergency services, hospitalization (including surgery), maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment (counseling and psychotherapy), prescription drugs, rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or chronic conditions to gain or recover mental and physical skills), laboratory services, preventive and wellness services and chronic disease management, pediatric services.

57.

Grandfathered Health Plan. www.healthcare.gov.

58.

HealthCare.gov. Out-of-pocket maximum/limit. www.healthcare.gov/glossary.

59.

US Policy Gateway. Expected Premium Increases under ACA, 2014 to 2015. http://ushealthpolicygateway.com.

60.

ASPE Issue Brief. Health insurance marketplaces 2015 open enrollment period: March enrollment report. http://aspe.hhs.gov/health.

61.

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Wupperman

Carman

Preparedness of Americans for the Affordable Care Act. Proc. Natl Acad. Sci. USA 111(15), 5497–5502 (2014).

62.

Armour

Radnofsky

. Affordable Care Act Creates a Trickier Tax Season. Wall Street Journal 1 Jan 2015. www.wsj.com/articles.

63.

Cox

Damico

Claxton

Levitt

. Repayments and Refunds: Estimating the Effects of 2014 Premium Tax Credit Reconciliation. Kaiser Foundation Report March 24. (2015). http://kff.org/health-reform.

64.

Instructions for Form 8962 (2014) Premium Tax Credit (PTC). www.irs.gov/instructions/i8962.

65.

Form 1095-A, Health Insurance Marketplace Statement. www.irs.gov/uac/About-Form-1095-A.

66.

Form 1095-B, Health Coverage. www.irs.gov/uac/About-Form-1095-B.

67.

Form 1095-C, Employer-Provided Health Insurance Offer and Coverage Insurance. www.irs.gov/uac/About-Form-1095-C.

68.

Roy

. Contra White House, Obamacare Exchanges Enroll Roughly 5 Million Uninsured, Not 11.4 Million. Forbes, 18 February (2015). www.forbes.com/.

69.

Polsky

Richards

Basseyn

Appointment availability after increases in Medicaid payments for primary care. N. Engl. J. Med. 372(6), 537–545 (2015).

70.

Ollove

. Are there enough doctors for the newly insured? Kaiser Health News January 3. (2014). http://kaiserhealthnews.org.

71.

Spaulding

. Developing the Healthcare Workforce: Growing Need Is an Opportunity for Kentucky (2015). http://kypolicy.org.

72.

Sabik

Bradley

. The impact of near-universal insurance coverage on breast and cervical cancer screening: evidence from Massachusetts. Health Econ. doi:10.1002/hec.3159 (2015) (Epub ahead of print).

73.

Wilensky

. Why does the Affordable Care Act remain so unpopular? J. Am. Med. Assoc. 313(10), 1002–1003 (2015).

74.

McCarthy

. As New Enrollment Period Starts, ACA Approval at 37%. www.gallup.com.

75.

Saad

. US Satisfaction Dips Back Below 30% in April. www.gallup.com.

76.

Gostin

. Access to health care for millions in the balance as US Supreme Court reviews federal subsidies for insurance. J. Am. Med. Assoc. 313(5), 454 (2015).

77.

Gostin

. The ACA's contraceptive mandate – religious freedom, women's health and corporate personhood. J. Am. Med. Assoc. 312(8), 785–786 (2014).