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

In sum, these findings show that, as of the second year of ACA implementation, most major enrollment system 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. Overall, costs of care for Medicaid 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 increase 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.

The authors gratefully acknowledge Michael Perry, Sean Dryden, and Naomi Mulligan Kolb with Perry Undem Research/Communication for their work managing the fieldwork logistics, conducting the interviews, and assisting in identifying key themes for this project. They also extend their deep appreciation to all the participants for sharing their time and perspectives to inform this project.

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