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.