How did the changes affect the Affordable Care Act?

1. The Impact of the
Affordable Care Act
Since 2016
MARCH 2, 2021
UNIVERSITY OF MARYLAND GLOBAL CAMPUS
by
Carla Torres Saira Siddiqi Amberly Smith Audrey Quartey Nataliya Rakhmanina

2. Changes to Provisions of the
Affordable Care Act since 2016
○Individual Mandate eliminated
○The penalty for not having
insurance was reduced to $0
○States allowed to add “work
requirements” to Medicaid
○Medicaid beneficiaries
required to provide proof of work
or that they go to school
○Cost-sharing reduction
subsidies to insurers have ended
○“Trump administration suddenly
stopped paying these subsidies in
2017”
Access to short-term “skinny”
plans has been expanded
Short-term plans can now last 364
day and be renewed for 3 years
○Funds to facilitate
HealthCare.gov sign-ups slashed
○Federal funding was
significantly cut. (Simmons-Duffin,
2019)

3. What is the
status of
those who
were newly
covered by
the
Affordable
Care Act?
 Medicaid beneficiaries need to prove that they
either work or go to school (Simmons-Duffin,
2019)
 Due to this change, “tens of thousands of
people were kicked off Medicaid” because
they had trouble submitting the reporting
requirements – “dealing with websites, trying
to figure out how to report hours effectively
and all the rest.” (Simmons-Duffin, 2019)
 Access to short-term "skinny" plans has been
expanded (Simmons-Duffin, 2019)
 These plans are cheaper, but people are
not fully protected in the event of a serious
injury (Simmons-Duffin, 2019)
 "They may find that it doesn't cover
everything that they would have been
covered for under an ACA-compliant
plan.” (Simmons-Duffin, 2019)

4. What is the
status of
those who
were newly
covered by
the
Affordable
Care Act?
 ”Trump administration has prioritized skimpy coverage sold
through association health plans and short-term, limited-
duration insurance.” (Gee, 2020)
 These plans are not required to comply with the
ACA’s rules, and they charge people “higher
premiums based on preexisting conditions, set annual
limits on benefits, omit basic benefits such as mental
health care and prescription drugs, and rescind
coverage after treatment.” (Gee, 2020)
 Enrollees in non-ACA-compliant plans don’t realize
the limitations until it’s too late (Gee, 2020)
 The Government Accountability Office found sales
representatives of these plans used “potentially
deceptive practices, such as claiming the pre-existing
condition was covered when plan documents said
otherwise.” (Gee, 2020)

5. What is the
status of
those who
were newly
covered by
the
Affordable
Care Act?
 Health care premiums are higher due to Trump
administration (Gee, 2020)
 An estimated 6% increase was added to
premiums
 “Trump administration enacted through
administrative law in 2019, marketplace
enrollees who receive financial assistance will
owe 2.8 percent more toward their premiums
in 2021.” (Gee, 2020)
 Increases to out-of-pocket maximums was also
included (Gee, 2020)

6. What is the
status of
those who
were newly
covered by
the ACA?
 Trump administration plans to continue
pushing the health care lawsuit (Gee, 2020).
 The Supreme court will hear the health care
lawsuit case and decide the future of the
ACA (Gee, 2020).
 ”The court’s decision could take down
the entire law, including Medicaid
expansion, marketplace subsidies, and
protection for the 135 million Americans
with preexisting conditions.” (Gee, 2020)
 “Full repeal of the ACA would have
resulted in about 20 million more
Americans becoming uninsured.” (Gee,
2020)

7. Health Insurance Exchanges
 Insurance marketplaces in which individuals
and small business can compare and purchase
health plans. Individuals and marketplaces can
identify and apply for subsidies that they are
eligible for.
 ACA health exchanges were fully certified and
operational by January 1, 2014, under federal
law.
 The Marketplace is accessible through
websites, call centers, and in-person assistance.
Source: (Reynolds Center, 2011)

8. The role of
states in
exchanges
 States have either implemented a state-run health
insurance exchange or let the federal government
run the health insurance exchange for them
 The Affordable Care Act allows an exchange to
certify a health plan only if it "determines that
making available such health plan through such
Exchange is in the interests of qualified individuals
and qualified employers in the State or States in
which such Exchange operates.
 States must consider how selective an exchange
should be.
 States may eliminate insurance markets outside of
the exchange.
 Under the Affordable Care Act, new federal
standards will define minimum essential benefits
that must be offered by all insurance plans.

9. How are different states approaching
health insurance exchanges?
► The official health insurance marketplace for
states not running their own exchange is
www.healthcare.gov.
 As of 2020, there are 38 states that use
HealthCare.gov as their exchange portal;
the remaining 12 states and DC have their
own state-run exchanges and enrollment
systems. Five of the states that use
HealthCare.gov are considered state-based
exchanges, but use the federal platform for
enrollment (Arkansas, Kentucky, New Jersey,
Pennsylvania, Oregon, and New Mexico).
 Some states have changed their exchange
models over the years. For 2021, there were
changes in Pennsylvania, New Jersey,
Virginia, and Maine. Source: (Brune, 2019)

10. Effect of the
Affordable
Care Act on
insurance
premiums
 The ACA has structured the marketplace to
provide affordable health insurance premiums for
Americans with various income levels.
 The Essential Health Benefits was created and
required for all health plans listed on the
marketplace (Block et al., 2020).
 Premiums are set by tax credit based on household
earnings and measure by the Federal Poverty Level
(FPL). The percentage an individual or family
would pay depends on the amount earned.
 Premium plans were labeled Platinum, Gold, Silver,
Bronze and Catastrophic. The bronze level covers a
value of 60% of the health care cost and the
platinum covers a value of 90% of health care cost
(Block et al., 2020).
 In 2019, 63 % of individuals enrolled in the silver plan
and 29% in bronze (KFF, 2019).

11. Insurance
premium
changes in
2019
 The repeal of tax penalty mandate of ACA
and change of legislation that loosely
controlled the marketplace had an upward
effect on premiums. Resulting on an
increase of 6% on health insurance
premiums (KFF, 2018).
 Cost-sharing reduction payments loss also
impacted premiums increasing silver
premium an average of 10% and up to 16%
higher in 2019.

12. Premiums and the Individual Mandate

13. The Role of
Medicaid
in the
Affordable
Care Act
 The Affordable Care Act (ACA) was signed into law
by President Barack Obama in 2010.
 The Affordable Care Act expanded Medicaid to all
Americans under age 65 with family income at or
below 133 percent of the federal poverty level.
 $14,484 for an individual
 $29,726 for a family of four
 The federal government helps pay for states to
expand Medicaid eligibility.
 Between 2014 to 2016, Medicaid expansion
states received full federal financing at 100
percent for the newly eligible.
 Under the law, states have options to choose to
expand Medicaid or keep their existing traditional
Medicaid.
 Most states chose to expand Medicaid to include
nearly 15 million new working-age adults.

14. States Who
Expanded
Medicaid
under the
Affordable
Care Act
As of 2020, 37 states and Washington D.C. have expanded
Medicaid under the Affordable Care Act.
Source: (The Fiscal Times Staff, 2020)

15. Mandatory
Requirements
of Medicaid
Expansion
 The law includes optional and mandatory benefits
such as:
 Coverage of free-standing birth clinics
 Tobacco cessation services for pregnant
women
 Full federal financing at 100 percent available
for those newly eligible for Medicaid for three
years and decrease in financing in
subsequent years.
 Requirements of Medicaid Expansion:
 Improve outreach and enrollment
 Coordinate Medicaid eligibility with the new
health benefit exchange
 Improve Medicaid program integrity through
fraud and abuse prevention, detection, and
recovery initiatives
 Increased transparency with applications and
renewals

16. Changes to
Medicaid
expansion
since 2016
 Under Trump, states can now require Medicaid
beneficiaries to prove with documentation that
they either work or go to school.
 Currently, 18 states have applied to the
federal government to implement work
requirements; but most such programs
have not yet gone into effect.
 Arkansas is the first to implement a work
requirement program.
 According to the U.S. Census Bureau, from
2016 to 2019, 2.3 million Americans,
including 726,000 children, have lost health
insurance coverage partly due to attacks
on Medicaid such as work requirements.
 If more states implement work
requirements, more will lose insurance
coverage

17. Positive
impact of
Medicaid
expansion
Source: (Guth et al., 2020)

18. The political debate over
the Affordable Care Act:
Access, Cost & Quality

19. Access
○More Americans have access to health insurance.
○Uninsured rate declined by 43%, from 16% in 2010 to 9.1% in 2015 (Manchikanti & Hirsch, 2016)
○16.4 million uninsured Americans have gained health insurance coverage (Manchikanti et al.,
2017)
○Protection for Americans with preexisting conditions.
○No time limits on medical care.
○Individual mandate utilized to increase insurance coverage due to potential fines.
●Health insurance coverage rates were mainly attributed to Medicaid expansion.
●Coverage rates have been uneven due to Medicaid expansion being optional.
● “Because of the Supreme Court’s decision making Medicaid expansion optional with the states,
we’re going to see some pretty significant differences in this country from one place to another in
terms of access to health care and access to health insurance” (Alonso-Zaldivar, 2013).
●Individual mandate was repealed in 2017 by the Trump Administration.
●Costs of paying individual mandate penalty was more affordable than buying insurance.
●Exchange policies characterized by narrow networks (e.g. limited access to care).
●Medicaid work requirements will cause many low-income Americans to lose coverage (Katch et al.,
2018). Enrollment is difficult due to technical issues on the website and short enrollment periods (Sullivan,
2019)
PROMISES
RESULTS

20. Cost
○Insurance companies must spend at least 80% of insurance premiums on medical
care and improvements (Sullivan, 2019)
●ACA aimed to prevent insurers from unreasonable rate increases.
●Marketplace offers a wide range of coverage options with varying costs.
●ACA aimed to decrease health care expenditures.
●ACA rendered medical care more expensive due to high premium and out-of-pocket (e.g.,
deductible, coinsurance) rates (Kaiser Family Foundation, 2016).
●Total health expenditures continued to increase after ACA.
●ACA subsidy formula restricts subsidies to people with incomes between 100% and 400% of the
federal poverty level who have no other affordable source of coverage (Eibner, 2021).
●Medicaid expansion will add pressure to the already-strained state budgets due to the required
contributions from state to their Medicaid expansion, which is currently funded at 100% by the
federal government.
PROMISES
RESULTS

21. US Total Health
Expenditures
The Affordable Care Act was
projected to decrease total
healthcare spending.
After the implementation of the
Affordable Care Act, health
care spending continued to
increase. Source: (Keehan et al., 2017)

22. Quality
○ACA promised to improve quality of care.
■Adverse drug events, infections and pressure ulcers have declined by 17% from
2010 to 2014 (Latner, 2018)
■Rate of hospital acquired conditions prevention 87,000 deaths over 4 years
(Latner, 2018).
●ACA has failed to improve quality due to minimal contributions to preventive services
and increased waiting time.
●Quality improvements have not increased, and may have even deteriorated, with
electronic health records and increased regulatory burdens.
PROMISES
RESULTS

23. So, what is the
verdict on the
Affordable Care
Act?

24. Promise: Increase coverage rates
The net reduction in the uninsured
is almost entirely attributable to
making non-disabled adults
eligible for Medicaid (Badger,
2017).
Pushed those with incomes
too high to qualify for
subsidies out of the market
(Antos & Capretta, 2020).
About half of the new Medicaid
enrollees met eligibility standards
that were in place before the ACA
(Badger, 2017).
Medicaid expansion is not
mandatory for states. As of
2020, 14 states continue to
resist expansion.
Fewer insurance choices
(narrow networks).
Lack of limits on care increases
costs for consumers because
payers must pay more (Moore,
2018).
Deductibles and maximum out-of-
pocket limits have increased across all
payers - putting a higher financial
burden on patients (Physicians for Fair
Coverage, 2018).
Health insurance premiums
have increased
significantly - about 10% in
2020 and 6% in 2019
(Morse, 2019).
Employers often choose to pay a
penalty versus providing insurance for
employees (BHM Marketing, 2017.
Medicaid work requirement provisions
threaten coverage for many Americans.
Potentially 1.4 to 4 million people living in
rural areas would lose coverage (Center on
Budget and Policy Priorities, 2018).
Nearly 30 million
Americans are still
uninsured (Belluz,
2017).
Pre-existing conditions
increase premiums
because payers must
cover costs of sicker
patients.
By 2018, uninsured rates have dropped to 8.5% (prior at ACA, uninsured rate was
about 15%) (Berchick et al., 2018) …BUT…

25. Promise: Decrease health care costs
•The ACA failed to
control the high and
rapidly rising health care
costs for Americans.
•“Delivery systems reforms advanced by
the Centers for Medicare & Medicaid
Services Innovation Center have shown
disappointing results, and mechanisms
intended to rein in federal costs have
been dropped” (Antos & Capretta, 2020).
•Consumers continue to
report that medical
expenses as their No. 1
economic concern
(Cancryn, 2020).
Studies show that the
ACA was the "primary"
reason why healthcare
costs rose at an unusually
high rate (Martin et al.,
2016).

26. Policy
Challenges
the ACA
Faces Today
Since the implementation of ACA in 2010 many
challenges and have arose to challenge it. Court
cases to repeal the ACA have been as follows:
 California v. Texas: individual mandate is
unconstitutional
 King v. Burwell: does a State that establishes its
own exchange considered an “exchange
established state” eligible for subsidies.
 National Federation of Independent Business v.
Sebelius
 Contraception Cases
 Burwell v. Hobby Lobby
 Zubik v. Burwell
 Little sisters of the poor v. Pennsylvania (National
Conference of States Legislatures [NCSL], 2021)

27. Current
status of
challenges
The women’s abortion right has been scrutinized
and threatened for decades (Rovner, 2020). Ruth
Ginsburg supported and voted to uphold the law
for women to maintain the freedom to choose to
reproduce or not. With Ginsburg’s absence in the
Supreme Court the future of the ACA is in
jeopardy (Rovner, 2020).
Much of the repeal still awaits its fate in the
supreme court. The new administration presents
hope for a better reformed ACA and not one that
is stripped of all the benefits it has presented thus
far.

28. References I
Alonso-Zaldivar, R. (2013, July 2). Medicaid expansion uneven. Spokesman.Com. https://www.spokesman.com/stories/2013/jul/02/medicaid-expansion-uneven/
Antos, J., & Capretta, J. (2020, April 10). The ACA: Trillions? Yes. A revolution? No. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20200406.93812/full/
Badger, D. (2017, March 14). Doug badger: Have 20 million people gained coverage under the ACA? Twin Cities. https://www.twincities.com/2017/03/14/doug-badger-have-20-
million-people-gained-coverage-under-the-aca/
Belluz, J. (2017, April 7). What we know about the 30 million americans who are still uninsured. Vox. https://www.vox.com/2017/4/7/15225800/30-million-americans-are-still-uninsured-
inequality
Berchick, E., Barnett, J., & Upton, R. (2018). Health insurance coverage in the united states: 2018. United States Census Bureau.
https://www.census.gov/content/dam/Census/library/publications/2019/demo/p60-267.pdf
BHM Marketing. (2017, April 2). ACA – the good, the bad, and the ugly. BHM Healthcare Solutions. https://bhmpc.com/2013/04/aca-the-good-the-bad-and-the-ugly/
Block, A. E., Cardenas, S., & Kittleson, M. J. (2020). The Affordable Care Act - From Health Policy to Implementation: Lessons Learned. Health Behavior & Policy Review, 7(1), 3–
12. https://doi-org.ezproxy.umgc.edu/10.14485/HBPR.7.1.1
Brune, N. (2019, November 20). Open enrollment for health insurance in 2020: Big changes and new opportunities in nevada. Guinn Center For Policy Priorities.
https://guinncenter.org/5693-2/
Cancryn, A. (2020, February 24). Health care costs are top priority heading into elections. POLITICO. https://www.politico.com/news/2020/02/19/poll-health-care-election-115866

29. References II
Center on Budget and Policy Priorities. (2018, August 22). How medicaid work requirements will harm rural residents – and communities. https://www.cbpp.org/research/health/how-
medicaid-work-requirements-will-harm-rural-residents-and-communities
Garfield, R. (2021, January 21). The coverage GAP: UNINSURED poor adults in states that do not expand medicaid. Retrieved from https://www.kff.org/medicaid/issue-brief/the-
coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/
Gee, E. (2020, September 25). Less coverage and higher costs: The trump’s administration’s health care legacy. Center for American Progress.
https://www.americanprogress.org/issues/healthcare/news/2020/09/25/490756/less-coverage-higher-costs-trumps-administrations-health-care-legacy/
Goodnough, A. (2018, November 07). Idaho, Nebraska and UTAH vote to expand Medicaid. /2018/11/07/health/medicaid-expansion-ballot.html
Guth, M., Garfield, R., & Rudoqitz, R. (2020, March 17). The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. Kaiser Family Foundation.
https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/
Hansen, M., & Tobler, L. (2011, June). Medicaid and the Affordable Care Act. Retrieved from https://www.ncsl.org/documents/health/HRMedicaid.pdf
Kaiser Family Foundation (2018, October 11). 2019 premium changes on ACA exchanges. https://www.kff.org/health-costs/issue-brief/tracking-2019-premium-changes-on-aca-
exchanges/
Kaiser Family Foundation (2018, October 26). How repeal of the individual mandate and expansion of loosely regulated plans are affecting 2019 premiums.
https://www.kff.org/health-costs/issue-brief/how-repeal-of-the-individual-mandate-and-expansion-of-loosely-regulated-plans-are-affecting-2019-premiums

30. References III
Katch, H., Wagner, J., & Arone-Dine, A. (2018). Taking medicaid coverage away from people not meeting work requirements will reduce Low-Income families’ access to care and
worsen health outcomes. Center on Budget and Policy Priorities. https://www.cbpp.org/research/health/taking-medicaid-coverage-away-from-people-not-meeting-work-
requirements-will-reduce
Katch, H. (2018, February 28). Medicaid work requirements will harm families, including workers. Center on Budget and Policy Priorities.
https://www.cbpp.org/research/health/medicaid-work-requirements-will-harm-families-including-workers
Keehan, S. P., Stone, D. A., Poisal, J. A., Cuckler, G. A., Sisko, A. M., Smith, S. D., Madison, A. J., Wolfe, C. J., & Lizonitz, J. M. (2017). National health expenditure projections, 2016–25:
Price increases, aging push sector to 20 Percent of economy. Health Affairs, 36(3), 553–563. https://doi.org/10.1377/hlthaff.2016.1627
Latner, A. (2018, December 20). Hospital-acquired conditions have decreased since Affordable Care Act implemented. Clinical Advisor. https://www.clinicaladvisor.com/home/my-
practice/legal-advisor/hospital-acquired-conditions-have-decreased-since-affordable-care-act-implemented/
Martin, A. B., Hartman, M., Benson, J., & Catlin, A. (2016). National health spending in 2014: Faster growth driven by coverage expansion and prescription drug spending. Health
Affairs, 35(1), 150–160. https://doi.org/10.1377/hlthaff.2015.1194
Manchikanti, L., Helm, S., Benyamin, R., & Hirsch, J. (2017). A critical analysis of obamacare: Affordable Care or insurance for many and coverage for Few? Pain Physician, 3(20;3),
111–138. https://doi.org/10.36076/ppj.2017.138</div>
Manchikanti, L., & Hirsch, J. (2016). Repeal and replace of affordable care: A complex, but not an impossible task. Pain Physician, 8;19(8;11), E1109–E1113.
https://doi.org/10.36076/ppj/2016.19.e1109

31. References IV
Moore, S. (2018, June 5). 8 reasons to still hate obamacare. The Heritage Foundation. https://www.heritage.org/health-care-reform/commentary/8-reasons-still-hate-obamacare
Morse, S. (2019, May 6). Affordable care act premium rates projected to increase by 10 percent. Healthcare Finance News.
https://www.healthcarefinancenews.com/news/affordable-care-act-premium-rates-projected-increase-10-percent
National Conference of State Legislatures. (2021, February 12). Legal cases and state legislative actions related to the ACA.
https://www.ncsl.org/research/health/state-laws-and-actions-challenging-ppaca.aspx
Physicians for Fair Coverage. (2018, July 19). Higher premiums, higher deductibles, and narrower networks in exchange markets. Physicians for a National
Health Program. https://pnhp.org/news/higher-premiums-higher-deductibles-and-narrower-networks-in-exchange-markets/
Reynolds Center. (2011, August 15). Health insurance exchanges: Open marketplace. https://businessjournalism.org/2011/08/health-insurance-exchanges-
open-marketplace-for-consumers-companies/
Rovner, J. (2020, September 22). Without ginsburg, judicial threats to the ACA, reproductive rights heighten. Kaiser Health News. https://khn.org/news/without-
ruth-bader-ginsburg-judicial-threats-to-the-aca-reproductive-rights-heighten/
Simmons-Duffin, S. (2019, October 14). Trump is trying hard to thwart Obamacare. How’s that going? NPR.
https://choice.npr.org/index.html?origin=https://www.npr.org/sections/health-shots/2019/10/14/768731628/trump-is-trying-hard-to-thwart-obamacare-hows-that-going
Status of state Medicaid expansion decisions: Interactive map. (2021, February 22). Retrieved from https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-
decisions-interactive-map/

32. References V
Sullivan, D. (2019, August 16). The pros and cons of obamacare. Healthline. https://www.healthline.com/health/consumer-healthcare-guide/pros-and-cons-obamacare#outlook
Wachino, V., Artiga, S., & Rudowitz, R. (2014, May 5). How is the ACA Impacting Medicaid Enrollment? Kaiser Family Foundation.
https://www.kff.org/medicaid/issue-brief/how-is-the-aca-impacting-medicaid-enrollment/
Wagner, J., & Schubel, J. (2018, December 18). States’ experiences confirm harmful effects of medicaid work requirements. Center on Budget and Policy Priorities.
https://www.cbpp.org/research/health/states-experiences-confirm-harmful-effects-of-medicaid-work-
requirements#:%7E:text=Between%20June%202018%20and%20March,80%20hours%20per%20month%2C%20unless