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Issue: About three-quarters of nonelderly adult Medicaid patients get their primary care from independent office-based practices, rather than hospital outpatient departments or health centers. But many independent physicians don't accept Medicaid, in part because of its low payment rates. Medicaid-covered care is concentrated in a small share of independent, typically underresourced practices, and this potentially has implications for the quality of care delivered. The Affordable Care Act's Medicaid eligibility expansion and physician fee bump, however, may have changed the distribution or care of patients across independent practices. Goals: Examine the distribution of Medicaid patients across office-based primary care physicians and the impact of a practice's Medicaid patient share on care quality. Methods: Analysis of National Ambulatory Medical Care Survey findings for 2006-2016 and 2018-2019. Key Findings and Conclusions: Medicaid visits have remained concentrated in a minority of practices since Medicaid expansion. From 2014 to 2019, about onethird of sampled office-based primary care physicians accounted for 90 percent of Medicaid office visits. Patients are as likely to receive guideline-recommended care at Medicaid-dominated practices as they are at practices with more non-Medicaid patients, but the former are much less likely than the latter to have adopted electronic health records. This suggests that low payment rates may affect practices' ability to invest in technology that promotes high-quality care. [ABSTRACT FROM AUTHOR]

Issue: A persistent concern about health insurance coverage expansions is that the supply of care providers is already so constrained that any increase in service use would reduce the quality of care for all Americans. Based on the experience of the Affordable Care Act (ACA) expansions, is this concern valid? Goals: Assess changes in the content of primary care visits, comparing the pre- and post-ACA periods. Methods: Analysis of the National Ambulatory Medical Care Survey, 2006-2016. Key Findings: The duration of physician visits, a direct measure of supply constraints, has increased substantially since 2006. While the Choosing Wisely campaign appears to have led to modest reductions in the provision of unnecessary care when it first rolled out, these effects have since been reversed. Rates of preventive screening and counseling saw a general pattern of decline between the 2006-2010 and 2011-2013 periods, followed by recovery in 2014-2016. Conclusion: The primary care system has been able to absorb increases in utilization generated by the ACA without jeopardizing care quality or intensity. There is also evidence that further expansions in demand can be accommodated, as providers in the post-ACA period have not reduced use of inappropriate or unnecessary care. [ABSTRACT FROM AUTHOR]

ISSUE: Many studies report that high out-of-pocket health spending is an increasing problem, despite expanded insurance coverage under the Affordable Care Act (ACA). Little is known about how Americans' out-ofpocket spending has changed over time. GOALS: To observe trends in high out-of-pocket spending and describe the distribution and composition of out-of-pocket spending over time, focusing on the top 5 percent and 1 percent of spenders. METHODS: Analysis of Medical Expenditure Panel Survey (MEPS) data. KEY FINDINGS AND CONCLUSIONS: Expansions in insurance coverage and in the quality of coverage through the ACA have protected most Americans from high out-of-pocket costs. Recently, however, outof- pocket costs for the highest out-of-pocket spenders (the 99th percentile) have been increasing. In 2017, one in 100 Americans under age 64 spent $5,000 or more out of pocket for medical services, and about one in 20 spent more than $1,700. High out-of-pocket spending mostly affects those with employer coverage and those with incomes above 400 percent (and, in particular, above 600 percent) of the federal poverty level. The plurality of this spending is for physician services. High deductibles and out-of-pocket maximums in private insurance, combined with exposure to out-of-network bills for physician services, leave many Americans facing very high out-of-pocket costs. [ABSTRACT FROM AUTHOR]

ISSUE: The Affordable Care Act (ACA) has substantially lowered uninsured rates nationwide. Previous research has documented that these overall declines also led to reductions in racial and ethnic disparities in health coverage rates. GOAL: To use the most recent data available to determine the extent to which the ACA has reduced disparities in insurance coverage among different racial and ethnic groups. METHODS: Analysis of the American Community Survey (ACS) for 2013 to 2017. KEY FINDINGS: All racial and ethnic groups saw gains in health coverage between 2013 and 2016, but these gains were especially pronounced for minority groups and individuals with incomes below 139 percent of the federal poverty level. In 2017, gains for minority groups generally flattened. The ACA's disparity-reducing effects have been strongest in states participating in the Medicaid expansion. CONCLUSION: Gaps in insurance coverage among racial and ethnic groups narrowed the most in states that expanded Medicaid, suggesting that expansions of Medicaid in additional states would likely reduce disparities further. [ABSTRACT FROM AUTHOR]

ISSUE: The Affordable Care Act (ACA) made it easier for older adults and those with medical conditions to enroll in individual-market coverage by eliminating risk rating and limiting age rating. While the ACA also encourages young and healthy people to enroll through subsidies and the individual mandate, it's not clear whether these incentives have been sufficient to prevent the risk pool from becoming disproportionately old and sick. GOAL: To assess whether patterns in individual-market participation changed following ACA implementation. METHODS: Comparison of Medical Expenditure Panel Survey (MEPS) data for the periods 2003-09 and 2014-15. FINDINGS AND CONCLUSION: The analysis found few differences in individual-insurance market participation before and after the ACA. Adverse selection occurred during both: people switching into individual insurance coverage after being uninsured were higher utilizers prior to the switch than were those who remained uninsured. Those who disenrolled from individual plans tended to be lower utilizers of care before switching compared with those who kept their coverage. The main difference was that more people - especially young adults - switched from Medicaid to individual insurance, and vice versa, after the ACA. Adverse enrollment or disenrollment in the individual market did not increase following ACA implementation. The combination of easing rating rules and encouraging participation appears to have maintained market stability. [ABSTRACT FROM AUTHOR]

ISSUE: The Affordable Care Act (ACA) regulates the price of health plans sold in the nongroup market. Premiums cannot be based on gender or health status, and price increases related to age are limited. These changes have lowered premiums for older, sicker people but raised them for younger, healthier ones -- especially young men ineligible for premium subsidies. This has raised concerns that the latter have failed to gain coverage. GOAL: Compare the impact of the ACA's rating rules on the number of insured young men, older adults, and others. METHODS: We compared overall and nongroup coverage trends pre- and post-ACA among demographic groups, comparing residents of states where the rule changes had little effect on premiums to states where the rules had greater effect. FINDINGS: People whose premiums fell because of the ACA's rating rules were slightly more likely to get nongroup coverage than those whose premiums rose. All groups, including higher-income young men, gained coverage because of the combined effects of ACA changes. CONCLUSION: Coverage rose after the ACA took effect among all demographic groups. Taken together, the ACA's individual mandate, marketing efforts, and effects on how people perceive the value of having insurance outweighed the impacts of changes in rating and benefit rules. [ABSTRACT FROM AUTHOR]

ISSUE: Prior to the Affordable Care Act (ACA), people with preexisting health conditions could be denied insurance coverage or charged higher rates. If the law is repealed, these protections could be diluted or lost altogether. GOALS: Assess the ACA's impact on coverage and access for people with preexisting conditions and compare their coverage gains with state highrisk-pool enrollment pre-ACA. METHODS: Analysis of Behavioral Risk Factor Surveillance System data for the period 2011-13 to 2015. KEY FINDINGS AND CONCLUSIONS: Between 2013 and 2015, 16.5 million nonelderly adults gained coverage following full ACA implementation. Of those, 2.6 million had preexisting conditions that could have otherwise precluded them from coverage because of discriminatory denials and pricing; 9.4 million had conditions that could have otherwise affected insurance cost. We found strong correlations between these coverage gains and access to care. Coverage and access gains for people with preexisting conditions were unrelated to the size or existence of the state high-risk pools that 35 states funded for such individuals pre-ACA. Our findings suggest that proposals to replace current protections for people with preexisting conditions with high-risk pools are unlikely to be sufficient to maintain the ACA's gains. [ABSTRACT FROM AUTHOR]

ISSUE: The Affordable Care Act's (ACA) coverage provisions have extended health insurance coverage to millions of Americans. While the effects of the Medicaid expansion and marketplace establishments on coverage have been well studied, the resulting effects of coverage on access to health care remain unclear. GOAL: To examine how the 2014 coverage expansions affected health care access following the first open enrollment period of October 2013 to March 2014. METHODS: Analysis of data from the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS). FINDINGS AND CONCLUSIONS: We find that gaining insurance coverage through the expansions decreased the probability of not receiving medical care by between 20.9 percent and 25 percent. Gaining insurance coverage also increased the probability of having a usual place of care by between 47.1 percent and 86.5 percent. These findings suggest that not only has the ACA decreased the number of uninsured Americans, but has substantially improved access to care for those who gained coverage. [ABSTRACT FROM AUTHOR]

Issue: While the number of uninsured has decreased substantially since the Affordable Care Act (ACA) expanded coverage in 2014, questions remain about how much the economic recovery and other changes might have influenced this decline. Goal: Assess the direct impact of the ACA marketplaces and the Medicaid expansion on the uninsured rate among nonelderly adults. Methods: Analysis of insurance coverage rates before and after the ACA's first open enrollment period (fall 2013 to spring 2014) using the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance Survey (BRFSS). Key findings: Based on NHIS data, enrollment in ACA-related coverage options explains about 76 percent of the 4-percentage-point decline in the uninsured rate during the first open enrollment period. Marketplace enrollments reduced the adult uninsured rate by an estimated 1.7 percentage points to 2.3 percentage points. The effects were substantially more pronounced among adults eligible for income-related subsidies. Medicaid expansions in participating states further reduced the uninsured rate by an estimated 0.76 points to 1.0 points. Conclusion: The great majority of nonelderly adults who enrolled during the first open enrollment period would likely not have held health coverage without the ACA expansions. [ABSTRACT FROM AUTHOR]

Issue: One important benefit gained by the millions of Americans with health insurance through the Affordable Care Act (ACA) is protection from high out-ofpocket health spending. While Medicaid unambiguously reduces out-of-pocket premium and medical costs for low-income people, it is less certain that marketplace coverage and other types of insurance purchased to comply with the law's individual mandate also protect from high health spending. Goal: To compare out-of-pocket spending in 2014 to spending in 2013; assess how this spending changed in states where many people enrolled in the marketplaces relative to states where few people enrolled; and project the decline in the percentage of people paying high amounts out-of-pocket. Methods: Linear regression models were used to estimate whether people under age 65 spent above certain thresholds. Key findings and conclusions: The probability of incurring high out-of-pocket costs and premium expenses declined as marketplace enrollment increased. The percentage reductions were greatest among those with incomes between 250 percent and 399 percent of poverty, those who were eligible for premium subsidies, and those who previously were uninsured or had very limited nongroup coverage. These effects appear largely attributable to marketplace enrollment rather than to other ACA provisions or to economic trends. [ABSTRACT FROM AUTHOR]

One effect of the Affordable Care Act's "Cadillac tax" (now delayed until 2020) is to undo part of the existing federal tax preference for employer-sponsored insurance. The specific features of this tax on high-cost health plans--notably, the inclusion of tax-favored savings vehicles such as health savings accounts (HSAs) in the formula for determining who is subject to the tax--are designed primarily to maximize revenue and minimize coverage disruptions, not to reduce health spending. Thus, at least initially, these savings accounts, rather than enrollee cost-sharing or other plan features, are likely to be affected most by the tax as employers act to limit their HSA contributions. Because high earners are the ones benefiting most from tax-preferred accounts, the high-cost plan tax will probably be more progressive than prior analyses have suggested, while having only a modest impact on total health spending. [ABSTRACT FROM AUTHOR]

The Congressional Budget Office (CBO), a nonpartisan agency of Congress, made official projections of the Affordable Care Act's impact on insurance coverage rates and the costs of providing subsidies to consumers purchasing health plans in the insurance marketplaces. This analysis finds that the CBO overestimated marketplace enrollment by 30 percent and marketplace costs by 28 percent, while it underestimated Medicaid enrollment by about 14 percent. Nonetheless, the CBO's projections were closer to realized experience than were those of many other prominent forecasters. Moreover, had the CBO correctly anticipated income levels and health care prices in 2014, its estimate of marketplace enrollment would have been within 18 percent of actual experience. Given the likelihood of additional reforms to national health policy in future years, it is reassuring that, despite the many unforeseen factors surrounding the law's rollout and participation in its reforms, the CBO's forecast was reasonably accurate. [ABSTRACT FROM AUTHOR]

In January 2014, the Affordable Care Act extended access to health insurance coverage to an estimated 30 million previously uninsured people. This issue brief provides state-level estimates of the increased demand for physician and hospital services that is expected to result from expanded access and assesses the sufficiency of the existing supply of providers to accommodate the anticipated increase in demand. We project that primary care providers will see, on average, 1.34 additional office visits per week, accounting for a 3.8 percent increase in visits nationally. Hospital outpatient departments will see, on average, 1.2 to 11.0 additional visits per week, or an average increase of about 2.6 percent nationally. Increases of the magnitude likely to be generated by the Affordable Care Act will have modest effects on the demand for health services, and the existing supply of providers should be sufficient to accommodate this increased demand. [ABSTRACT FROM AUTHOR]