Prior to the Affordable Care Act being implemented, many Americans were without health coverage – amounting to one out of every six people nationwide at that time.
The Affordable Care Act (ACA) expanded coverage by creating state-based health exchanges and expanding Medicaid eligibility to low-income individuals and families, while also offering subsidies to help people afford health insurance policies.
1. Uninsured
Prior to the Affordable Care Act, millions of Americans were uninsured due to being unable to afford health insurance plans, with delays often seen when trying to access treatment.
Since the Affordable Care Act (ACA) took effect, coverage gains have been considerable. People with lower incomes have seen dramatic reductions in their uninsured rates (Exhibit 2).
These gains were enabled by various policy initiatives, including the establishment of health insurance exchanges and subsidies to help make coverage affordable. Medicaid expansions enabled many lower income families to obtain coverage.
Early in the life of the Affordable Care Act (ACA), many eligible for premium subsidies were not able to purchase plans through marketplaces or employers due to a set income threshold (400 percent of poverty level for subsidies) that disqualified enrollees from purchasing plans with premium subsidies.
2. Underinsured
Prior to the Affordable Care Act, many people were underinsured or had gaps in coverage; often having lower incomes and being sicker than their fully insured peers.
As the Affordable Care Act has taken hold, millions have gained coverage through marketplace plans or Medicaid expansions.
However, the uninsured rate in some parts of the country still remains high; rising premiums being one of the primary culprits behind this trend.
In 2019, more than eight out of ten (82%) adults with family incomes below 400% poverty were underinsured – this being the group most at risk.
Underinsured adults are twice as likely to report having difficulties paying medical bills and medical debt than adults with full coverage, in part because their deductibles are more stringent.
3. Uncompensated Care
Before the Affordable Care Act was implemented, many people with preexisting conditions could not access coverage in the private market. They often found themselves denied coverage altogether or having to buy plans with higher premiums and annual or lifetime caps on benefits.
The Affordable Care Act has revolutionized private health insurance by setting minimum federal consumer protections, such as no lifetime or annual limits; prohibiting discrimination against people with preexisting medical conditions; mandating that all plans cover 10 essential health benefits categories; and offering dependent coverage that allows children up to age 26 to remain on their parents’ policies.
The Affordable Care Act also established a co-op, or nonprofit health insurer offering coverage on exchanges. Funded through low-interest government loans and risk corridor payments, co-ops were intended to alleviate concerns that insurers would become stuck with an unusually large group of enrollees that might lead them to overprice their products.
4. Disparities
Prior to the Affordable Care Act (ACA), minorities and lower-income Americans faced greater barriers to healthcare access, leading to worse health outcomes than their higher-income counterparts. Although health insurance coverage expanded as part of the ACA, evidence indicates that disparities continue.
We examined the role of Affordable Care Act coverage in reducing disparities by surveying adults nationally. We asked respondents how it had affected their perception of quality healthcare, access and affordability of health care provision under ACA.
Model 2 revealed that when adjusted for health insurance status, disparities in perceived healthcare quality decreased somewhat but not entirely. People in lower income groups reported significantly worse quality care compared to higher-income groups for both national and 7-state samples; more so when blacks than whites were in those samples.
