From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare on Coverage and Costs

The expansion of Medicaid eligibility, financial assistance for purchasing private nongroup insurance, regulatory reforms, an individual responsibility requirement, and other components of the Affordable Care Act (ACA) led to substantial reductions in the number of uninsured, increased access to care, reduced uncompensated care, and eliminated explicit discrimination against the sick in private health insurance markets. However, three years after implementation of the full coverage reforms, significant problems remain. Though expanded coverage lowered costs for many people, many still found premiums and cost-sharing requirements too high to participate. A Supreme Court decision that made the Medicaid expansion optional for states left many poor adults in 17 states without any way to obtain affordable coverage. Adverse selection into the private nongroup market in some areas, and little to no provider and/or insurer competition in others, has led to high and, in certain years, rapidly growing premiums in some parts of the country. And some areas faced underinvestment in important administrative functions, including outreach and advertising and enrollment assistance.

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