How has the aca changed healthcare careers

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Each of these subsidized cost-sharing levels also corresponds to reduced deductible and copay amounts, as well as lower out-of-pocket limits Claxton and Panchal ; Claxton et al. In addition to these subsidies, the ACA also eliminated pre-existing condition clauses in insurance; lifted the maximum ceilings of coverage on insurance and established a maximum pricing ratio on insurance offered in exchanges to three to one across the full range of ages up to 64 groups; 3 and mandated coverage both through the imposition of a fine if an individual is not adequately covered and on larger firms if they do not offer coverage.

In order to encourage firms to offer health insurance, the ACA included tax credits to small firms with a low- to moderate-income workforce and penalties to large firms if they did not offer coverage. Original coverage projections for the ACA estimated that approximately 32 million Americans would obtain insurance by as a result of the law Congressional Budget Office As of , millions of Americans have gained coverage as a result of the legislation, with the Office of the Assistant Secretary for Planning and Evaluation reporting that Between July and September and October , However, only 2.

Furthermore, roughly 30 million Americans remained uninsured at the start of Garfield and Young Increasing coverage is only the starting point for a stream of potential impacts that could result from the ACA. The policy implications of the ACA are vast, affecting numerous social, economic, fiscal, and legal outcomes. As millions of Americans gain health insurance, the overall health of individuals may improve, particularly among those with pre-existing chronic conditions.

This may affect labor force participation and productivity, benefitting the economy as a whole. Furthermore, extending coverage to thousands of young adults may provide an incentive to these individuals to enroll in an educational program or seek self-employment. Additionally, adults near retirement age, who can now purchase coverage on exchanges under the ACA, face different work incentives and may adjust their behavior accordingly.

Disentangling the web of potential social and economic outcomes of the ACA is a daunting task, one limited by the timing of the provisions, natural life course of health outcomes, and quality of available data. To preview one of our insights, we find that researchers who have studied the expansions to young adults i. These devices are not as available for studying the effects of the broader ACA.

Furthermore, many dependents ages 19—25 are of higher SES backgrounds than the individuals taking coverage under Medicaid expansions or receiving subsidies, making the insights from this young adult group less generalizable to the overall population likely influenced by the ACA. And, since all states are affected by the ACA, though there are clear differences in the expansion, especially in whether Medicaid is expanded, the overall countrywide changes limit some types of comparisons.

We conclude by considering directions for future research and the challenges in assessing the full scope of impacts of this health care reform. The majority of social and economic research on the ACA to date has focused on young adults, as the dependent coverage provision was one of the first parts of the legislation to take effect.

Since this provision affected only a small subset of the US population, researchers have the opportunity to compare young adults ages 19—25 to teenagers and adults immediately above the dependent age threshold. Using these natural comparison groups has allowed researchers to study how young adults have been affected by the reform in terms of health and labor market outcomes. These outcomes have been most often examined with difference-in-differences methods, where researchers utilize readily available cross-sectional data sources, such as the American Community Survey ACS and Current Population Survey CPS.

In this section we present the currently available research findings on how the ACA has affected the coverage rates, health care access, health, and labor market outcomes of young adults.

Our findings result from a review of the literature that was conducted prior to October 1, , and reflects the body of research available at that time.

Although several studies have been published since then, our findings highlight the initial impacts of the legislation and prelude more recent research and that yet to come.

In reviewing the literature, we searched both EBSCOhost and Google Scholar databases for scholarly articles and independent research organization reports.

Furthermore, we conducted parallel searches for the Massachusetts reform, Oregon experiment, and early Medicaid expansions. We also include papers presented at the Association for Public Policy Analysis and Management meetings. Our review of the literature targets research focusing on the US population at large, highlighting both survey findings and causal empirical evaluations. Although there is an emergent body of literature focusing on state-level outcomes, we restrict our attention to the national scene to give an overview of the broader impacts of the legislation.

We do not include any discussion of responses of providers, including insurers, in an attempt to be both informative on consequences for the population but not tedious in a fully comprehensive review.

Coverage is the most direct outcome of the ACA expansion and perhaps the easiest to track. Most of the large national data sources used to study the ACA are well equipped to measure gains in insurance coverage over time. What is more difficult to study is the change in type of coverage and whether individuals who had preexisting conditions or high medical care costs have obtained more complete coverage. There is clear evidence that the ACA has increased coverage rates among young adults.

Prior to the ACA, 32 percent of young adults lacked health insurance Sommers et al. National survey estimates indicate that between 1.

Since the first-year expansion, the share of uninsured young adults has fallen yet further, with preliminary National Health Interview Survey NHIS data showing a decrease in the percentage uninsured from Overall coverage trends indicate that among young adults, males and individuals from higher income families experienced the largest coverage gains Antwi et al. Despite such gains, however, many young adults still lacked coverage immediately after the dependent coverage provision took effect: a study using the Commonwealth Fund Health Insurance Tracking Survey found that 39 percent of adults ages 19—29 were uninsured at some point in Collins et al.

This figure was even more striking for young adults living near the poverty line, as 70 percent of young adults with incomes below percent of the FPL were still uninsured.

Have the millions of young adults who gained health insurance as a result of the dependent coverage provision increased their access to primary care, routine and preventive care utilization, and inpatient services? This is a far more complicated question to answer than merely assessing coverage gains, and unfortunately national data often have limited capability to measure access outcomes.

Young adults are approximately 3 percentage points more likely to have a personal doctor than individuals just above the dependent provision age threshold Slusky ; Barbaresco et al. Early findings on routine and preventive care utilization have been inconsistent; though researchers have relied on the same data set, BRFSS, to assess these outcomes.

Kotagal et al. However, these findings were followed up by Wallace and Sommers , who expanded the time range of BRFSS data to — and found a 2. Furthermore, Lau et al. Early findings on preventive care suggest that the ACA dependent coverage provision is associated with higher cholesterol screening rates and blood pressure measurements Han et al. Lipton and Decker find significantly increased likelihoods of HPV vaccine initiation and completion rates among young adult women.

While Han et al. There is also some early evidence that the ACA has led to greater access to mental health care: mental health treatment rates have increased by 5. Inpatient visits due to mental illness have also increased, with Antwi et al. Regarding emergency department and inpatient visits, Antwi et al.

Emergency department visits appear to have declined among young adults, with Hernandez-Boussard et al. This last finding may suggest that the increase in care is reducing the need for emergency care. Given the changes in access patterns as a result of the ACA, it is worthwhile to note the related body of literature addressing how the law has affected health care spending.

As a result of gaining dependent coverage, young adults are faced with lower total and out-of-pocket expenditures, with Chua and Sommers reporting a 3. Furthermore, Busch et al. Chen et al. Assessing health, however, is complicated, as individual health outcomes related to accessing care may depend on lengthy diagnosis and treatment processes. Furthermore, much of the available data rely on self-reported health measures, which may lead to divergent findings.

For example, by increasing access to care for chronically ill individuals, one might suspect their conditions or symptoms would improve over time. However, increasing access to preventive or primary care services increases the likelihood that an individual will be diagnosed with a new condition, thereby causing him or her to indicate a decline in overall health.

Given the recentness of the law, it is still too early to understand the underlying mechanisms behind changes in health statuses. However, we can shed light on some of the preliminary research on self-reported health. Using cross-sectional CPS data and ordered logistic regression to isolate dependent coverage effects, Carlson et al.

However, Kotagal et al. Barbaresco et al. Using difference-in-differences methods, they find evidence of improvements in self-reported health among males ages 23—25 and in multiple measures of mental health for females in the same age group. Both groups are compared to matched-sex groups of slightly older individuals.

Chua and Sommers also find an increased likelihood of reporting excellent mental health among young adults in the MEPS data. While most of the early health evidence related to the ACA focuses on self-reported health, one study Scott et al. Using a population of patients in the — National Trauma Data Bank, they find no significant mortality changes for this group. Many researchers have examined how the ACA has affected labor market outcomes of the dependent-coverage age group, though the results have been mixed.

The tie is an easy one to conceptualize: since most people of working age have employer-based insurance ESI , their choices are likely influenced by a desire for coverage.

He or she might also be less likely to be a full-time student 13 and less likely to marry in order to acquire health insurance. Several researchers deny there is any significant evidence that the dependent coverage provision has affected labor market outcomes Antwi et al.

However, others find a reduction in employment Gollu and labor force participation Depew Early findings suggest that young adults have shifted their employment status as a result of the ACA. Antwi et al. Furthermore, Bailey finds a 13 percent to 24 percent increase in self-employment among young adults and that those receiving coverage through a parent were more likely to start a small business. Preliminary research on educational and marital findings is sparse.

Depew finds that young adults are 1. However, Heim et al. One source of consistency in the literature is that females under age 26 are less likely to marry as a result of the legislation Depew ; Abramowitz Given that the first open enrollment period of the ACA happened over 3 years after the dependent coverage mandate, it is not surprising that we have only recently seen studies on how the ACA has affected the broader adult population.

It is important to stratify the findings between the young adult and general adult population groups, as the overall population of adults that has gained coverage does not mirror the socioeconomic profile of young adults. These individuals tend to not have coverage through ESI and often cannot afford to purchase insurance on the private market.

Therefore, a primary target population for the broader ACA is lower income individuals, those who may receive subsidies or gain coverage under Medicaid expansion. It is therefore not unreasonable to infer that the health care access, health, and labor market outcomes related to the ACA will differ between these two groups.

In the sections that follow, we highlight the early findings surrounding how the law has affected coverage gains, access to care, health, and labor market outcomes of American adults. A key policy aim of the ACA is to expand coverage to millions of uninsured adults below age 65, and millions of Americans have gained coverage as a result of the legislation. Census Bureau The uninsurance rate from to remained relatively stable, so the decline after the first open enrollment period is interpreted as evidence of the influence the legislation has had on coverage rates.

More adults gained coverage after the second open enrollment period, with results from the RAND Health Reform Opinion Study revealing a net increase of The ACA has improved the coverage rate across different racial and ethnic subgroups, though differences among these populations have persisted DHHS a ; Smith and Medalia However, these minority populations lagged behind Whites prior to the ACA and subsequently did so in , with non-Hispanic Whites having the lowest uninsurance rate 7.

Some research has also highlighted the coverage gains among individuals with high medical needs. Developing a simulation model of adult cancer survivors, Davidoff et al.

Considering adults with HIV, Kates et al. Furthermore, Sommers et al. Despite these coverage gains, NHIS estimates indicate that Similarly, Sommers et al.

Given that millions of Americans have received coverage as a result of the ACA, one would expect that the law has affected health care access patterns. There has been an uptick of recent literature suggesting that this is the case. Clemans-Cope et al. Recent literature has been published looking at more specific access patterns and changes among individuals with certain medical conditions.

For example, Aitken et al. However, their estimates do not attempt to disentangle the effects of the ACA, Medicaid expansion, and broader economic conditions, so it is unclear how much of this effect can be attributed to the health reform itself. Among adults with hypertension, Li et al. Wagner et al. As with the young-adult-population extended coverage under the dependent coverage provision, the ACA has been associated with lower cost-related access problems among the general adult population.

Commonwealth Fund Biennial Health Insurance Survey estimates suggest a 7 percentage point reduction in the number of adults reporting they did not get needed care due to cost Collins et al. Findings on how the ACA has affected health outcomes are relatively sparse, though we anticipate this body of literature to grow in the future. Early research has exploited state differences in Medicaid expansion status to see how the health of individuals in expansion states has changed as a result of gaining coverage.

Using a private clinical laboratory database, Kaufman et al. Furthermore, Li et al. Research on how the ACA has affected demand-side labor market outcomes among working-age adults has been slow to emerge. However, Gooptu et al. Similarly, Garrett and Kaestner also do not find in CPS data that the ACA affected labor force participation among the broader adult population; however, they do find that the law has resulted in a 1.

The national health care reforms of the ACA were preceded by several reforms and Medicaid expansions at the state level. While a comprehensive review of this literature is beyond the scope of this article, we use this section to highlight some of the key findings of this research and discuss how they may inform future research on the ACA.

While our focus is on the effects of the Oregon experiment and Massachusetts reform, we will introduce this section with a brief summary of the effects of the early Medicaid expansions that occurred in the s. The studies of these reforms and expansions may be particularly useful in studying the effects of Medicaid expansion under the ACA, in which the state variation in deciding whether to extend coverage to low-income childless adults presents the opportunity to compare the differential effects of expansion decisions and see how Medicaid coverage affects the access, health, and labor market outcomes of this population.

As a precursor and potential model for Medicaid reform, several states implemented Section waivers in the early s to extend coverage to certain groups of individuals previously without health insurance. Many of these waivers granted coverage to low-income childless adults who were previously not eligible for Medicaid. Seventeen states received Section waivers between January and , resulting in a net coverage gain of over , individuals Artiga and Mann Sommers et al.

For example, individuals extended coverage under the ACA are hypothesized to include many relatively healthy people, as well as significant numbers with comorbidities and high medical needs and utilization. Focusing on specific state-level outcomes, Kominski et al. They find that the program expanded coverage to over , individuals and was associated with a decrease in hospitalizations and emergency room visits, increased use of outpatient services, and significant improvements in diabetes and hypertension care.

DeLeire et al. However, emergency department visits were found to have increased 46 percent after the plan was implemented. California, Connecticut, Minnesota, New Jersey, Washington, and the District of Columbia were among the first to expand coverage to low-income childless adults prior to Golberstein et al.

Although not the focus of this review, researchers have looked into isolated state impacts of these expansions. For example, Golberstein et al. Together these studies suggest that expanding Medicaid to low-income childless adults is likely to have positive impacts at least on coverage. This notion has been corroborated by recent CMS data, indicating that In anticipating what we can expect to learn about the ACA, particularly its effects on the broader adult population, we can look to the literature surrounding the recent health insurance changes in Massachusetts and Oregon.

Both states underwent changes to their health insurance systems prior to the ACA, with Massachusetts implementing a comprehensive reform similar to the ACA and Oregon allowing adults to apply for Medicaid through a lottery.

The Massachusetts expansion is more similar to that of the ACA, so we can gain insights from it. Indeed, it would be possible to use this reform as a basis of a simulation model, 20 but, the existing medical care system of Massachusetts, the coverage in effect prior to the expansion, and the labor market all make simulation from the experience of only this state somewhat difficult.

The experience of the Oregon lottery can also provide insight into the expected effects of the Medicaid expansion, though in the implementation of the ACA, many components of the health care system changed, not just Medicaid. On the whole, both states experienced increased coverage rates and consequently saw an increase in access to and utilization of care and improved health outcomes.

These detailed findings and how they can help us learn more about the ACA are discussed below. In April Massachusetts enacted its third health reform legislation since the previous two were an adoption of an employer mandate in and Medicaid expansion in — Its reform closely resembles the ACA, though there are critical differences that may limit the applicability of empirical studies of the effect of the Massachusetts reform in predicting the effects of the ACA.

Key provisions of the ACA that are similar to those of the Massachusetts reform include subsidized insurance for low-income uninsured adults, an individual mandate requiring adults over age 18 to have health insurance, employer responsibility to provide fair and reasonable insurance, Medicaid expansion, and insurance market changes through the connector, which are similar to ACA exchanges McDonough et al. A recent study evaluated the individual mandate and finds that those who signed up via the small group or individual market in response to the mandate were lower users of health care suggesting positive selection and that the tax penalty was likely too low to maximize population well-being Hackmann et al.

Several studies have focused on how the Massachusetts reform has affected health care access rates. Individuals living in Massachusetts in were approximately 7 percent more likely to have a personal doctor than those living in neighboring states Pande et al. Hospital stay lengths and inpatient admission rates among mentally ill individuals decreased post-reform Kolstad and Kowalski ; Wong et al.

Individuals were also more likely to access preventive care, including pap screenings, colonoscopies, and cholesterol testing Van der Wees et al. Based on this research, in the coming years we can expect to learn more about changes in access and overall health that are attributable to the ACA.

Early evidence suggests that the Massachusetts reform has also been associated with a significant 2. Furthermore, we anticipate self-reported health data to become more prevalent see Zhu et al. Given the time needed for health care access and health outcomes to become evident, we would expect a similar trend in the research surrounding the ACA.

However, many of the Massachusetts studies took advantage of comparison groups in neighboring New England states in assessing access, health, and labor market outcomes. Without a similar natural comparison group for the overall ACA target population, it will be difficult to mimic the methodological techniques employed in the Massachusetts literature in assessing the ACA.

Oregon offers insight on the possible gains in health and health care access for persons newly covered under the Medicaid expansion of the ACA.

In , over 35, uninsured low-income adults in Oregon were selected by lottery to be given the chance to apply for Medicaid Finkelstein et al. This experiment functioned as a natural randomized control design, giving researchers the unique opportunity to study the effects of public health insurance coverage on health care use, financial barriers to care, and overall health.

The design allows researchers to learn more about causal connections between Medicaid expansion and access to health care and to health improvements than similar studies without access to a carefully constructed control group.

Individuals receiving coverage as a result of the Oregon lottery had significantly higher rates of health care utilization, lower out-of-pocket medical expenditures, and less medical debt than those not selected by the lottery Finkelstein et al.

However, Taubman et al. This finding has proven contentious among researchers, as it is inconsistent with the mixed findings of the early Medicaid expansion literature DeLeire et al. Golberstein et al. Findings regarding health outcomes attributable to the Oregon lottery have been both positive and inconclusive. Lottery winners obtaining coverage had better self-reported physical and mental health one year following the lottery Finkelstein et al.

Baicker et al. However, they indicated no impact on the prevalence or diagnosis of hypertension or on related prescription medication use. Obtaining coverage through the lottery has not been associated with changes in employment, individual earnings, or earnings above the FPL Baicker et al. As with assessing the Massachusetts health care reform, it is worth noting that these Oregon findings emerged several years after the lottery took place, corroborating the idea that it takes time for the full impacts of such a policy change to become evident.

Additionally, the data used in the Oregon studies were either collected in-person, via surveys, or gathered through administrative data Finkelstein et al. The low take-up rate may also mean the analysis is underpowered. Extrapolating these methodologies to the ACA underscores the importance of developing specialized data sets to assess access and utilization, health, and labor force outcomes. Early research on the ACA emphasizes that millions of Americans have gained coverage as a result of the legislation.

Among both dependents and the general adult population, these coverage gains have translated into a general increase in access rates, though these vary across service type and among individuals of varying demographic backgrounds and health needs.

Additionally, patterns of health outcomes and labor market trends remain less clear, but this is not surprising given current data capabilities and the relatively short amount of time that has elapsed since the full law went into effect. In this section we discuss the various research methodologies used to study the ACA and highlight the data availability for studying the legislation. Much of the variation in findings can be attributed to differences in study design, so it is important to note the various methodologies as we look to expand future research on the reform.

The primary approach used in studying the effects of the ACA, particularly the dependent coverage provision, has been difference-in-differences, which makes use of comparison groups that have not experienced changes under the ACA. The approach rests on the assumption that trends in place prior to the ACA would continue in the absence of the implementation of the ACA.

In most cases the target group is compared to a slightly older age group. The years studied begin prior to the implementation and continue through the early years of the implementation. The older subset of to year-olds is frequently studied to capture the effects to those most likely to gain from the added coverage.

For either age band, the entire targeted group or the older subset, individuals ages 26 or 27—29, or 27—32, has been employed as the comparison group. The larger the age band, the larger the sample used for the comparison but also the more likely the groups will differ in significant ways, raising legitimate questions regarding how appropriate they are as a comparison group.

The years studied using this technique also differ. The difference-in-differences approach prefers a longer time trend prior to the policy change, but the longer time trend may also contain years in which trends differed due to other factors. More post years are also preferred under this approach, but in cases such as policy eligibility based on age, this can be incorrect, as members of the treated group will be added to the comparison group over time. In using a difference-in-differences approach to study the young adult coverage provisions there is also the added complication of a changing economy; that is, the ACA was implemented at a time that overlapped with the economic recovery following the Great Recession in According to the National Bureau of Economic Research, the recession ended in June , though employment among men women ages 20 and older decreased from This creates a challenge in separating the effects of the improving economy from the impacts of the ACA; in somewhat more technical terms, it raises questions about the assumption that in the absence of the ACA, the existing trends would have continued.

Studies of the two precursors to the ACA, namely the Massachusetts reform and Oregon experiment, have had the advantage of making comparisons to 49 other states. The Massachusetts reform has been the most extensively studied and has the advantage of being very similar to the ACA. Questions regarding how useful the Massachusetts studies are for predicting the likely effects of the ACA include the higher than average insurance rates in the state prior to the reform; 24 the high ratio of physicians to population All of these differences raise questions of whether the experiences of Massachusetts will be repeated in the rest of the country under the ACA.

The Oregon experiment has the advantage of focusing on one of the groups that is likely to experience the greatest change under the ACA, namely the low-income population, of which many are newly eligible for Medicaid coverage. The nature of the change — a randomized experiment — made the expansion easier to study and largely eliminated concerns of finding appropriate control groups. However, two characteristics reduce its usefulness somewhat: 1 the limited ability to study long-term effects prior to the introduction of the more major changes of the ACA, and 2 the relatively small sample size that makes it very difficult to study subgroups, including those with preexisting conditions or of different racial and ethnic backgrounds.

Additionally, the lower than expected signup increased the concern that the Oregon Medicaid experiment was underpowered. Research on the social and economic outcomes associated with the ACA is still in its nascent stages. In this paper we have outlined the preliminary findings with regard to coverage, access to care, health, and labor market outcomes, though we acknowledge that there remain several avenues open to exploration.

In particular, there are policy implications for understanding the profile of individuals falling into the coverage gap and how enrollment trends vary with respect to state Medicaid expansion decisions. Furthermore, there remains a need to assess the coverage patterns of individuals with preexisting conditions, a group that may in the long run see an improvement in health care utilization rates and overall quality of health as a result of the legislation.

Regarding access to care, we still know relatively little about overall patterns of health care utilization. Although there appears to be an increase in office and inpatient visits Abraham ; Antwi et al. We also have learned little in terms of potential changes in the types of providers accessed or the time to treatment following the ACA.

Before the passage of the Affordable Care Act, getting adequate and reliable health coverage was a challenge for millions of Americans. Since , the ACA has made health coverage more accessible and affordable for many Americans.

Thanks to the ACA,. And more importantly, the ACA ensures all Americans have access to health coverage. Through the marketplace, you can find and compare coverage options, so you can decide which is best for you. And you may qualify for a tax credit that lowers your monthly premium, as well as for reductions in the amount you pay for deductibles, coinsurance and copayments.

By making these plans available and affordable, the marketplace has reduced the number of uninsured by about 80 percent over the last dozen years. You can apply for marketplace coverage by visiting www. At the Employee Benefits Security Administration, we also have some great resources available to help you make the most of your health benefits.

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The Affordable Care Act established health insurance marketplaces, including Healthcare. The ACA has reduced the number of uninsured people to historically low levels and helped more people access health care services, especially low-income people and people of color. Gaining insurance coverage also increased the probability of having a usual place of care by between 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.

The ACA was designed to reduce the cost of health insurance coverage for people who qualify for it. The law includes premium tax credits and cost-sharing reductions to help lower expenses for lower-income individuals and families. This raised questions about whether the ACA was still constitutional. Affordable Care Act. The law also expands the Medicaid program to cover more people with low incomes.

Medicaid expansion: The ACA has improved health outcomes for many Americans by enabling states to expand Medicaid, the source of health care serving low-income populations.

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This piece was developed in collaboration with one or more of our writers The Affordable Care Act completely changed the U. Here's what the ACA means for nurses and the nursing shortage. Graduation Cap As a Nurse, Your Vote is Important Because of their profession, nurses have a unique perspective on the healthcare system. Debra Sullivan Ph. Debra Sullivan is a nurse educator. She graduated from the University of Nevada with a Ph.

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