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Year Two of the ACA Coverage Expansions: On-the-Ground Experiences from Five States

As of Spring 2015, states had completed the second open enrollment period for the new Health Insurance Marketplaces established by the Affordable Care Act (ACA) and most of the 30 states that have adopted the Medicaid expansion to low-income adults were well into their second year of implementation. Two years into implementation, interest remains high in understanding enrollment under the coverage expansions and the extent to which enrollment problems that plagued the initial open enrollment period have been resolved. A range of other questions also have emerged, including how Marketplaces are evolving and impacting consumer choices, the extent to which State-based Marketplaces (SBMs) have achieved financial stability, whether newly insured individuals are accessing care, and what the costs of care have been for Medicaid expansion adults. This brief provides insight into these questions through an on-the-ground view of ACA implementation in five states that identifies areas of progress as well as issues to be addressed. It is based on 40 in-person interviews conducted with a range of stakeholders during April and May 2015 in three states (Colorado, Kentucky, and Washington) that have a SBM and adopted the Medicaid expansion and two states (Utah and Virginia) that rely on the Federally-facilitated Marketplace (FFM) for enrollment of individuals into qualified health plans (QHPs) and have not adopted the Medicaid expansion to date.

Key findings from stakeholders in the study states are highlighted on Table 1. In sum, they show that, as of the second year, most major enrollment systems issues had been resolved. The states that expanded Medicaid continued to experience enrollment growth, and Marketplace enrollment goals were met or surpassed in four of the five states, although affordability remains a key enrollment challenge. In all five states, broad efforts are underway to increase health insurance and health care literacy among newly insured individuals. Per enrollee costs of care for expansion enrollees have been lower than anticipated in the three states that expanded Medicaid. Expansion enrollees generally are able to access needed care, although there are access challenges for some services. Access to care for individuals enrolled in QHPs varies based on their choice of plan.

Looking ahead, the states are focused on a range of priorities, including continued improvements to enrollment systems and efforts to enhance access to care and care coordination. Moreover, in Colorado and Washington, there is significant pressure on the Marketplaces to achieve financial sustainability; in Utah and Virginia, debate around the Medicaid expansion and the outcome of the King v. Burwell Supreme Court case remain the most significant issues; and, in Kentucky, the upcoming gubernatorial election could have significant implications for implementation given the opposition to the ACA among potential candidates.

Table 1: Key Findings on the Second Year of ACA Implementation from Stakeholders in Five States:
Colorado, Kentucky, Utah, Virginia, and Washington
Enrollment
  • In four of the states, most major enrollment system issues had been resolved (KY, UT, WA, and VA).
  • There was continued enrollment growth in the Medicaid expansion states (CO, KY, WA), with some slowing in the pace of growth (CO, KY) and some increases in children as a share of new enrollees (CO, WA).
  • Marketplace enrollment goals were met or surpassed in four of the five states (CO, KY, UT, and VA). In KY, the balance between new QHP and Medicaid enrollments was beginning to even out with an increase in the share of new enrollments among QHPs.
  • In all five states, many consumers successfully renewed QHP coverage, with about half of re-enrollees shopping for new plans. However, some renewal challenges remain, including the need for improved consumer outreach and education about renewal.
Marketplace Plans and Premiums
  • Three states saw new insurers enter the market (KY, VA, and WA), while two had high continuity among plan offerings (CO and UT).
  • Four states (CO, KY, UT, and VA) experienced changes in the second lowest cost silver, or benchmark plan, which affected the level of premium tax credits available for eligible consumers.
  • In two states (VA and KY), low-cost plans with a large market share adopted large premium increases, leaving consumers to renew their plan with a large increase or switch plans.
  • Despite attempts to educate consumers about total-out-pocket costs, many selected plans based on the lowest premium, leaving them with high deductibles and cost sharing. Some individuals who purchased bronze plans did not maintain their coverage due to high out-of-pocket costs.
  • Premiums remain unaffordable for some consumers even with subsidies.
Outreach
  • Messaging moved away from raising awareness to personal testimonials and emphasis on the importance and value of coverage.
  • Both mass marketing and local level outreach and enrollment assistance remained important, with some shifting away from mass marketing to community efforts.
  • As the group of uninsured individuals narrows, targeted strategies to reach specific groups have become increasingly important.
Access, Utilization, and Costs
  • Per enrollee costs of care for Medicaid expansion adults have been lower than anticipated in the three states that expanded Medicaid (CO, KY, and WA).
  • In the Medicaid expansion states, enrollees are generally able to access needed care, although there are access challenges for certain services and providers.
  • Access to care for individuals enrolled in QHPs varies based on their choice of plan. Some individuals who selected lower cost plans with limited networks experienced challenges accessing care, although some of these challenges have moderated over time.
  • In all five states, broad efforts are underway at multiple levels to increase health insurance and health care literacy among newly insured individuals.
  • In the Medicaid expansion states (CO, KY, and WA), clinics that historically served uninsured populations reported an increase in their share of patients with coverage, but a significant share of their patients still remains uninsured, leaving other funding streams important.
  • Clinics and hospitals in the non-expansion states (UT and VA) identified a range of financial challenges due to the coverage gap and reductions in funding.
Priorities Looking Ahead
  • All five states plan to continue to refine and enhance their enrollment systems.
  • Some stakeholders indicated that they anticipate more limited funding for marketing and outreach next year.
  • Stakeholders in all five states emphasized the need for continued work to increase individuals’ health insurance and health care literacy. All five states also are engaged in a range of delivery system reforms and care coordination initiatives.
  • In CO and WA, there is significant pressure on the Marketplaces to achieve financial sustainability.
  • In UT and VA, debate around adopting the Medicaid expansion remains the most significant issue as well as uncertainties related to the outcome of the King v. Burwell Supreme Court case.
  • In KY, stakeholders emphasized that the upcoming gubernatorial election could have significant implications, given opposition to the ACA among potential candidates.
Introduction

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.