Is America Ready for Pre-Affordable Care Act Insurance Markets?

Findings from a new survey suggest that the Affordable Care Act (ACA) made it easier for Americans to purchase health insurance on their own, and led to an increased insurance rate.

Before the passage of the ACA, purchasing individual health insurance was typically difficult for those who did not have employer-sponsored coverage, according to an analysis from the Commonwealth Fund. This market also resulted in large financial losses for insurers.

The 2010 Commonwealth Fund Biennial Health Insurance Survey demonstrated that one-third of patients who attempted to enroll in a health plan were denied, had higher premiums, or had a condition excluded from coverage. However, once the ACA was enacted, these practices were no longer allowed.

The number of Americans enrolling in individual plans has even doubled since 2010, which suggests that the process of purchasing and affording health coverage was streamlined.

Since the enactment of the ACA, more than 30 million individuals gained insurance via Medicaid expansion, outreach efforts, and new market regulations, according to the study.

With lawmakers discussing a full repeal of the health law, these improvements may be jeopardized.

The Commonwealth Fund survey analyzed long-term trends related to the stability of coverage, buying experiences, financial barriers, and inability to pay medical bills, and included 4186 individuals aged 19 to 64.

Notably, the uninsured rate dropped from 20% of the population in 2010 to only 12% by July 2016. The ACA also achieved great strides in insuring racial and ethnic minorities, and across different age and income groups.

The survey found that the uninsured rate of lower-income whites, blacks, and Latinos significantly decreased. Although the uninsured rate of Latinos has decreased, this population is still largely uninsured due to a lack of Medicaid expansion in some states, and not allowing undocumented immigrants to enroll in coverage.

Of all groups, young adults aged 19 to 34 made the most substantial gains in coverage since 2010, dropping from 27% to 15% in 2016, according to the survey.

Through the ACA, purchasing individual insurance has become less of a hassle due to market reforms and federal subsidies. Before the ACA, individuals had few choices that were affordable, and a majority were not eligible to receive coverage through Medicaid and CHIP.

At this time, individuals did not receive subsidies, and states were free to set their own rules for coverage. A majority of states charged premiums that took into account health, gender, and age, according to the Commonwealth Fund. Plans could refuse coverage for certain conditions or terminate coverage for any patient for the onset of a new condition.

Due to the perceived injustices faced by individuals enrolling in this type of coverage, the ACA set out to provide insurance for all Americans, regardless of health status or age. The survey found that 26 million individuals attempted to purchase a plan within the previous 3 months in 2010, compared with 44 million in 2016, suggesting that coverage under the ACA was easier to sign up for and became more desirable.

In 2010, 60% of those who looked into purchasing a plan found it difficult to afford, while only 34% of individuals indicated this difficulty in 2016 in ACA marketplaces. Both higher and lower income adults reported that it was easier to find an affordable plan in 2016 compared with 2010, according to the survey.

The preexisting condition provision also increased the likelihood an individual could find a plan that would meet their health needs. In 2010, 43% of participants with a preexisting condition had difficulties finding a plan, and only 25% reported these issues in 2016.

Remarkably, the amount of individuals not receiving needed care due to costs decreased from 80 million in 2012 to 63 million in 2016, which was the lowest rate seen in the survey’s history.

When asked about not receiving care for an illness, only 20% reported this behavior in 2016, decreasing from 29% in 2012. The survey also found that 27% of participants had difficulties paying for prescription drugs in 2012, while 19% did in 2016. The rate of individuals who did not receive recommended services due to cost also dropped under the ACA.

These widespread decreases in receiving necessary care due to costs reflect the substantial gains in coverage, according to the survey. Additionally, uninsured individuals faced fewer cost barriers when receiving care, which may indicate that economic conditions improved under the ACA, the authors noted.

The researchers found that 70 million study participants faced difficulties paying medical bills or were paying off debt in 2016, which decreased from 73 million in 2010.

The survey also discovered that uninsured individuals are less likely to receive cancer screenings, such as mammograms.

As suggested by the survey, the ACA has allowed millions of Americans to receive affordable health insurance. This coverage is now easy to enroll in due to the numerous provisions that prohibit practices previously used by insurers to exclude those with preexisting conditions or who were older.

While some weaknesses in the law were discovered, providing additional subsidies would likely remedy problems with medical bills and forgoing care. These findings suggest that repealing the ACA without a replacement plan would lead to significant changes in healthcare, which may force individuals to enroll in pre-ACA marketplaces that were notoriously difficult, the Commonwealth Fund concluded.