Changes to the healthcare coverage mandate

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Smaller employers purchase health insurance for their employees through the small-group market, which is more expensive than health insurance sold through the large-group market because small employers have fewer employees among whom to spread the health-expenditure risk.

The smaller populations in these plans make them more vulnerable to adverse selection—the tendency for those with higher expected health-care expenditures both to sign up for health insurance and to select plans that have more generous coverage. The same is true of the individual market, in which people can purchase private insurance directly from some insurers. Before the ACA, individual insurance plans were considered to pose a high risk to insurers because people who had higher expected utilization were more likely to sign up for health insurance, and this would result in severe adverse selection.

When that occurred, insurers raised premiums to cover the higher claims costs, which in turn caused healthier people to leave the plans. That cycle repeated until only high-cost participants remained and the plans terminated. The risk of adverse selection motivates many structural features of private health insurance that are designed to ensure that health plans have large risk pools with sufficient healthy, low-cost participants.

In the individual market, insurance companies would protect themselves financially by using medical underwriting charging higher premiums for those who have chronic conditions and by precluding benefits for pre-existing medical conditions for a fixed period.

Adverse selection is also why most states have created high-risk pools as a way of guaranteeing that the sickest, highest-cost people, who would otherwise be uninsurable, have access to health insurance coverage.

High-risk insurance plans have higher premiums than regular insurance plans, but premiums are regulated and subject to caps KFF, c. In , the year before passage of the ACA, about 52 million people, or 15 percent of the US population, lacked health insurance.

This included low-income people who did not meet Medicaid income limits or categorical eligibility and working people, usually those who were self-employed or working for a business that did not offer health insurance as a benefit. EMTALA guarantees universal emergency care access for all Americans, but it is an unfunded mandate that is partially addressed through Medicaid disproportionate share hospital DSH payments.

EMTALA ensures access to care for the uninsured, but ED visits are expensive and tend to result in people flowing back into the hospital for reasons that could have been avoided with adequate primary and specialty care. A major goal of the ACA was to extend health insurance coverage to 32 million uninsured people in the United States. The ACA had two major components: expansion of the Medicaid program and new structures to support the individual and small-group health insurance markets.

The ACA eliminated the concept of categorical eligibility and replaced it with standard eligibility criteria of percent of the federal poverty level. In , the Supreme Court ruled that the federal government could not force the states to expand Medicaid coverage. For the individual and small-group markets, the ACA established health insurance exchanges in states to allow individuals and small groups to buy standard insurance policies with income-based subsidies from percent up to percent of the federal poverty level KFF, b.

The ACA eliminated medical underwriting and imposed a legal mandate to purchase health insurance with a penalty for those who did not comply. Before the ACA, insurance companies used medical underwriting to determine whether to offer a person coverage, at what price, and with what exclusions or limits based on the person's health status; the purpose was to ensure a healthy risk pool by requiring people to pay premiums that reflected their expected medical costs.

Because of medical underwriting in the individual and small-group markets, people who were sick often paid higher premiums or were denied coverage.

The ACA's individual mandate, in contrast, was designed to compel healthier people to purchase insurance so as to balance the risk pool and lower premiums for everyone. States could establish their own health insurance exchanges or use the one created by the federal government.

However, access to care except for increases in insurance coverage did not show improvement until the time period between and June KFF, c. The health-care delivery system in the United States consists of an array of clinicians, hospitals and other health-care facilities, insurance plans, and purchasers of health-care services, all operating in various configurations of groups, networks, and independent practices IOM, The health-care delivery system has historically been organized around the concept of fee-for-service medicine.

Under the fee-for-service payment model, patients or their insurers pay physicians and hospitals for any covered services delivered on a per-unit basis without particular regard for price, patient outcomes, or quality.

Because provider revenues increase as more services are provided—and insured and some uninsured patients do not bear the full cost of the additional services—the fee-for-service model creates incentives to increase utilization of health-care services, which in many cases lead to overutilization of physician and hospital visits. In some segments of the market, health plans have been designed around alternative incentive structures by using a concept of fixed payment for a set of services.

Often called managed care, these plans aim to reduce overutilization of hospital and physician services through such arrangements as full-risk capitation payment models which involve sharing of financial risk among all participants and place providers at risk not only for their own financial performance but also for the performance of other providers in the network , some forms of bundled payment in which a single payment covers a hospital stay or all services related to a specific diagnosis or procedure , and a more modest approach called pay-for-value an incentive structure that includes bonuses or penalties that are based on cost and quality metrics.

Pay-for-value managed-care arrangements are used in Medicare Advantage, Medicaid managed care, and some commercial health insurance plans. In the Medicare program, around 30 percent of beneficiaries are enrolled in Medicare Advantage plans in which Medicare makes payments to private insurers that are responsible for delivering the Medicare benefit package, and payment arrangements between plans and providers are determined contractually and are thus difficult to describe because they are proprietary KFF, a.

In sharp contrast with Medicare, managed-care enrollment has greatly expanded during the past two decades, rising from just over one-half of all beneficiaries enrolled in managed care in to 77 percent in KFF, Medicaid-managed care plans cover a broad array of Medicaid benefits, including acute, primary, and specialty care and in some states, behavioral health and LTSS CMS, Although the fee-for-service model remains the most common payment form in the private health insurance market, private insurers have integrated aspects of the managed-care model into broader efforts to address the incentive problems created by the fee-for-service payment structure, such as utilization management and performance metrics for providers.

If managed care is defined by the use of capitated payments to providers that are responsible for the total cost of care, then very few people are covered by managed care KFF, b.

If, however, anything other than unconstrained fee-for-service is defined as managed care, most people who are covered by private health insurance are enrolled in some form of managed care. Managed care in any form usually involves restricting the set of providers from whom patients might obtain covered care to so-called in-network providers. Insurers can adjust network breadth to limit patient access to preferred hospitals and physicians. Figure illustrates that dramatic shift over time.

In , 73 percent of employees enrolled in health plans had conventional fee-for-service coverage; by , fewer than 1 percent had unconstrained fee-for-service coverage. The figure also shows the dramatic growth in HDHPs since Distribution of health plan enrollment of covered workers, by plan type, — A portion of the change in plan type enrollment for is likely attributable more The ACA included payment-reform provisions to incentivize the adoption of more effective care-delivery models Abrams et al.

The new models involve some combination of shared risk among providers to enhance collaboration and coordination of care so as to reduce avoidable hospitalizations, ED visits, and other forms of expensive or unnecessary care.

To protect against stinting, quality metrics are often used to evaluate provider performance. Beyond payment models, the ACA encouraged perhaps unintentionally the narrowing of provider networks and reshaped the delivery of long-term services and supports, all of which have implications for the ways in which people who have disabilities receive care and for the documentation of that care in the medical record.

We discuss each in turn. The payment, contractually determined in advance, is intended to encourage better coordination among the various providers involved in a given patient's care. Some 7, post-acute care providers, hospitals, and physician organizations have signed up to participate in bundled-payment demonstrations Abrams et al. Early evidence suggests that bundled payments can reduce medical costs and improve patient satisfaction CMS, The ACA also incentivized the development of alternative delivery models, such as accountable care organizations.

Those involve collaboration among physicians, hospitals, and other health-care entities in a shared-risk arrangement. The alternative delivery models were intended to encourage provider organizations to address patient health needs better, to reduce the amount of hospital and ED care, and to meet quality goals.

Their effectiveness and their effects on clinical practice, however, are still matters of considerable debate Schulman and Richman, ; Song and Fisher, The primary goal of the PCMH is to keep people ambulatory in the community, in addition to aligning provider financial incentives with the best interests of patients.

The PCMH is not a physical home but rather a care delivery system in which each patient's care is coordinated through his or her primary care physician PCP. The PCP manages and coordinates care with the goals of having each patient receive the necessary care when and where he or she needs it, and in a manner that the patient can understand and that is consistent with and respectful of the patient's preferences, needs, and values Blumenthal et al.

In patient-centered models, there is greater potential for providers to identify people who have comorbidities and to coordinate their care. Visits for both ambulatory care sensitive and non-ambulatory care sensitive conditions were reduced; this suggests that steps taken by practices to attain PCMH recognition might decrease some of the demand for outpatient ED care van Hasselt et al.

NCQA also noted that PCMH recognition is associated with fewer inpatient hospitalizations and lower utilization of both specialist and emergency services Harbrecht and Latts, ; Raskas et al. Money was offered to physician practices to meet compliance with health information technology or so-called meaningful use criteria or face penalties in Medicare reimbursement. EMRs offer the promise of aggregating records from many providers into a single, legible medical record as long as all providers seen by a patient participate in the same EMR system; interoperability among systems is imperfect.

The HITECH Act offers the promise of a more complete medical record that details the full history of care provided to a patient who applies for disability benefits. The change in provider network size is another indicator of how the ACA has transformed the care that people get. So-called narrow networks existed before the implementation of the ACA, but they have grown more common as a result of it. Many consumer protection measures, such as the prohibition of medical underwriting, have made it difficult for many insurers to rely on traditional strategies to keep costs low.

Other elements of the law, such as the availability of the online marketplace where consumers can compare premiums, have made it possible for insurers to compete with each other. Plans that have narrow networks might benefit consumers by lowering premiums. Negotiations between insurers and providers on network participation might encourage more efficient delivery of care.

And the ability to contract selectively might allow insurers to attract a small group of providers that meet raised standards of quality and potentially would result in care of higher value Health Affairs, But narrow networks also pose risks to consumers.

For example, if a network gets too narrow, it will jeopardize the ability of consumers to obtain needed care in a timely manner. That can also happen if the network contains an unsatisfactory mix or insufficient number of providers. Network limitations can have the additional effect of turning away sicker patients who have more health needs and thus changing the risk pool.

One study notes that consumer advocates argue that narrow networks adversely affect access to care, especially for patients who have chronic illnesses. They claim that insurers structure the networks strategically to discourage the higher-cost patients from enrolling. Patients who have high needs will then have to go outside the network and possibly outside the EMR system and as a result tend to incur high expenses and receive surprise medical bills EBRI, Their medical documentation is also more likely to be missing elements.

The ACA included several provisions aimed at improving deficiencies in the nation's long-term care system to ensure that people can receive LTSS in their home or the community KFF, a.

In addition, in states that accepted the Medicaid expansion, funds were made available to pay for home- and community-based attendant services in connection with matching by the federal government KFF, a.

Nonetheless, Wiener has argued that despite the growing need for HCBS, not enough progress had been made in improving the financing of long-term care. A comprehensive review of the literature on the effects of the ACA Medicaid expansion on health-care use KFF, c found that health insurance coverage has expanded overall, access to and use of care have increased, self-reported health status has improved, and flow of federal health-care resources into expansion states has risen.

One study by Barakat et al. It did not, however, detect a substantial change in top diagnoses or in the overall rate of ED visits and hospitalizations. The authors argued that there appeared to be a shift in reimbursement burden from patients and hospitals to the government without a dramatic shift in patterns of ED or hospital utilization. In contrast, Sommers et al. Wherry and Miller observed an increase in office visits to physicians but also an increase in overnight hospital stays after the Medicaid expansion.

Chen et al. There is consensus among studies on the effects of the ACA on utilization of preventive services. Sommers et al. Similarly, Wherry and Miller found that Medicaid expansion under the ACA led to higher rates of preventive services, which resulted in more diagnoses of diabetes and high cholesterol.

Several studies have specifically identified ACA-related improvements in health-care utilization by people who had chronic conditions. They found improvements in multiple measures: affordability of care, regular care for the chronic conditions, medication adherence, and self-reported health.

A related study by Sommers et al. They echoed the findings in the report by suggesting that regular care for chronic conditions increased substantially after Medicaid expansion. The findings of those two studies were consistent with the findings of an earlier study by Sommers et al. Although evidence suggests that on average people who had chronic conditions experienced an increase in access to regular care for those conditions, coverage effects vary among diseases Baicker et al.

Because of the many design features that are common to the ACA, the Massachusetts health-care reform of , and the Oregon Medicaid lottery of , the experiences of Massachusetts and Oregon are informative about potential effects, and in particular long-term effects, of the ACA on utilization. A study by Cole et al. It found no effect of Medicaid coverage on diagnoses or on the use of medication for blood pressure and high cholesterol, but Cole et al.

The Oregon Medicaid study Baicker et al. The evidence on cancer care is also mixed. One study of the Massachusetts health-care reform did not find any changes in breast-cancer stage at diagnosis Keating et al.

A third study of the Massachusetts reform echoed the improvement in cancer care by revealing that coverage expansion was associated with an increase in rates of treatment for colon cancer in low-income patients and a reduction in the number of patients waiting until the emergency stage for treatment Loehrer et al. In addition to health-care service utilization, the use of prescription drugs serves as an important measure of the ACA's effect, especially given their prominent role in the management of chronic conditions.

Mulcahy et al. They attributed the increase in treatment rates for chronic conditions and the reduction in out-of-pocket spending to the decrease in financial barriers to care under the ACA. The ACA has many provisions that are important for people who have disabilities. For example, denial of coverage because of pre-existing conditions is no longer allowed. Removal of a lifetime cap on benefits will enable people with disabilities to continue to receive care.

Perhaps most important, the expansion of health insurance coverage through the Medicaid program, the health insurance exchanges, and the dependent coverage provision will allow many Americans who have disabilities to obtain health insurance coverage without having to qualify for SSDI or SSI. And the ACA authorizes federally conducted or supported studies to collect standard demographic characteristics that include disability status Krahn et al.

In this section, we summarize the early literature on those effects. The ACA's dependent coverage provision appears to have benefited young adults who have disabilities.

Porterfield and Huang analyzed the periods before and after implementation of the dependent coverage provision in the ACA and compared adults who had disabilities and were 19—25 years old with adults who had disabilities and were 26—34 years old.

People in both age groups experienced coverage gains after the ACA dependent coverage provision took effect in , but for people in the older group who were unaffected by the dependent coverage provision, the coverage gains were entirely attributable to changes in public insurance.

In contrast, the coverage gains for people in the younger group who were affected by the dependent coverage provision were driven by changes in private insurance. By , low-income and moderate-income nonelderly adults—including both those who had and those who did not have chronic illnesses—also experienced coverage gains. The Kaiser Family Foundation KFF, c notes that in some states and the District of Columbia, those gains resulted from the Medicaid expansion to adults who had incomes up to percent of the federal poverty level.

In other states and the District of Columbia, the coverage gains for people who had disabilities resulted from subsidies for qualified health plans offered on the health insurance marketplaces combined with private insurance reforms, such as the prohibition of discrimination based on health status.

The ACA appears to have brought about improvements in treatment for mental disorders and substance abuse. Saloner and LeCook examined the effect of the ACA on young adults who had mental health or substance-use disorders by using data from the — National Survey of Drug Use and Health.

The authors found that after implementation of the ACA, mental health treatment of people who were 18—25 years old and had possible mental health disorders increased by 5. Uninsured visits by people who used mental health treatment decreased by Consistent with those findings, Ali et al. If those possibilities are fully realized, that would represent a 40 percent increase in behavioral services utilization, primarily for mental health services.

Golberstein et al. A recent study Hall et al. The authors noted that people who have disabilities often experience psychologic distress and comorbid health conditions and have low income and employment. New coverage options under Medicaid expansion that allow people to work more and accumulate assets could benefit people who have disabilities because they would no longer need to apply for SSI or live in poverty to qualify for Medicaid.

Results from the Hall et al. Those changes were not statistically significant, because of the small sample in the pre-ACA period. However, after the ACA, those who had disabilities and lived in expansion states were more likely to be employed The authors concluded that Medicaid expansion is an important policy for reducing disparities in access to care for people who have disabilities and for supporting their employment and financial independence.

Despite the many positive benefits of the ACA, there remain barriers to access to care among people who have disabilities. The Total category includes Black, Latino, and White population groups. Usual source of care is a global measure that does not differentiate types of care. However, inequities persist. It is important to continue assessing its progress in improving insurance coverage for all US residents and to monitor health care inequities. We analyzed National Health Interview Survey NHIS data 5 and compared observations with prior periods to examine whether improvements in insurance coverage and access to care continued for Black, Latino, and White populations after the elimination of the individual mandate.

In this cross-sectional study, we grouped NHIS data by the period before the national ACA implementation , the start of the ACA implementation , the implementation of the health insurance mandate , and the year the individual mandate was eliminated We limited the sample to participants aged 18 to 64 years.

All results were nationally representative. Since NHIS is publicly available with deidentified observations, the Drexel University human research protection program deemed it exempt from institutional review board approval. We estimated weighted predictive probabilities for the following 4 measures according to self-reported race and ethnicity during the 4 periods: 1 being currently uninsured, 2 having a usual source of care, 3 any emergency department ED visit in the past year, and 4 any delay of care due to cost in the past year.

Confidence intervals were used to measure uncertainty. Data analyses were performed using Stata statistical software, version The unweighted sample for consisted of The percentage of uninsured individuals decreased from the period before the ACA was implemented However, in , the year the mandate was eliminated, there was a 3—percentage-point increase from the prior period in the probability of being uninsured for everyone from Between the periods of and , Latino persons had a 5—percentage-point increase in the probability of being uninsured from For ED visits, Black and Latino populations experienced a 3—percentage point and 2—percentage point increase between and Black individuals, from Latino populations had a 5—percentage-point increase in the probability of having a usual source of care between and from They also had an increase in the probability of any delay of care due to cost between these periods from When we compared observations from the period when the health insurance mandate penalty was in full effect and the year the mandate was eliminated , we observed that the Latino population had an increase in the probabilities of being uninsured, having an ED visit, and delaying care due to cost, despite an increase in the probability of having a usual source of care.

However, usual source of care did not differentiate by types of care. A reversal in these health care equity indicators for Latino populations is evident from these findings. The elimination of the ACA health insurance mandate may partially explain the increase in the probability of being uninsured for everyone. Policies to reduce out-of-pocket costs, including the continued availability of cost-sharing reductions and enhanced premium tax credits from the American Rescue Plan, should be continued to address delays in care due to costs.

Nevertheless, the findings of this cross-sectional study suggest that encouraging states to expand Medicaid and bolster the health care safety net to improve community-based services will also be beneficial in reversing health care inequities for Latino populations.

Published: March 8, Corresponding Author : Alexander N. Author Contributions : Dr Ortega had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Administrative, technical, or material support: Mortensen, Vargas Bustamante. No other disclosures were reported. Download PDF Comment.

View Large Download. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Impact of the Affordable Care Act on health care access and utilization among Latinos. National Center for Health Statistics.

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In 11 states and DC, there are no short-term plans available. And there are numerous other states where short-term plans are available but must meet stricter rules than those imposed by the Trump administration. In Idaho, " enhanced short-term plans " debuted for and continue to be available for These plans are much more robust than traditional short-term plans, and can be thought of as a middle-ground between short-term coverage and ACA-compliant coverage.

Most of the healthcare reform debates in recent years have centered around the individual market, the small group market, and Medicaid expansion under the ACA which accounts for more than 21 million people, but still just a fraction of the total Medicaid population. For people who get their insurance from large employers, Medicare, or Medicaid taken together, that's most of the population , the changes for are generally the same sort of changes that happen each year.

But Medicaid eligibility redeterminations and disenrollments will resume in April , after being paused for three years due to the COVID pandemic. Medicaid enrollees will want to pay close attention to communications they receive from the state Medicaid agency in , as renewals will need to be processed for all enrollees in the month window that begins in April Open enrollment for Medicare Advantage and Medicare Part D ran from October 15 to December 7, with all changes effective January 1, this is the same schedule that's been used for several years.

And the Medicare Advantage open enrollment period runs from January 1 to March 31, giving people enrolled in Medicare Advantage an opportunity to switch to a different Advantage plan or switch to Original Medicare.

For health coverage, there are additional insurers offering health plans through the marketplaces in many states. And the American Rescue Plan's subsidy enhancements remain in effect for , making coverage more affordable than it was prior to The "family glitch" has been fixed, and standardized health plans are once again available through HealthCare.

Insurers can no longer require applicants to pay past-due premiums before effectuating new coverage, and the de minimus ranges for health plan metal levels have been tightened up as of If you buy your own health insurance or are currently uninsured, the annual open enrollment period is your opportunity to secure coverage for Premium subsidies are larger and available to more people than they were prior to , thanks to the American Rescue Plan and Inflation Reduction Act.

You may find that you're eligible for premium-free coverage, or for coverage that costs just a few dollars a month, depending on your financial situation. If you missed open enrollment, you may find that you can still enroll later in , if you experience a qualifying life event. Kaiser Family Foundation.

Health Insurance Coverage of the Total Population. Norris, Louise. Does the IRS change how much I'll have to pay for my health insurance each year? Treasury Department, Internal Revenue Service. October Centers for Medicare and Medicaid Services. April 28, Explaining health care reform: questions about health insurance subsidies. Cox, Cynthia; McDermott, Daniel. Gaba, Charles. ACA Signups. Rate Hikes. Rate Changes. October 26, Is short-term health insurance right for you?

Short-term health insurance in Idaho. Department of Health and Human Services. April 29, Tolbert, Jennifer; Ammula, Meghana.

Jan 11, By Louise Norris Louise Norris has been a licensed health insurance agent since after graduating magna cum laude from Colorado State with a BS in psychology. Health Insurance. By Louise Norris. Louise Norris. Louise Norris has been a licensed health insurance agent since after graduating magna cum laude from Colorado State with a BS in psychology. Learn about our editorial process. Fact checked Verywell Health content is rigorously reviewed by a team of qualified and experienced fact checkers.

Fact checkers review articles for factual accuracy, relevance, and timeliness. We rely on the most current and reputable sources, which are cited in the text and listed at the bottom of each article. Content is fact checked after it has been edited and before publication.

Learn more. Marley Hall. Fact checked by Marley Hall. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles.

Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. See Our Editorial Process. Meet Our Medical Expert Board. Share Feedback. Was this page helpful? Thanks for your feedback! While the federal government no longer requires you to have health insurance, a handful of states have mandates on the books regarding coverage or are trying to pass laws to make health insurance mandatory. The states that require coverage include:.

Washington, D. Other states—including Connecticut, Hawaii, Maryland, Minnesota, and Washington—have also attempted to pass legislation that would make health insurance mandatory for their residents. In states where health insurance is mandatory, the rules for getting and maintaining coverage are similar to those under the ACA, with coverage available through state-run health insurance marketplaces. Of course, if your employer offers some type of health insurance coverage as part of your benefits package, you may be able to get affordable coverage without having to shop around for it.

It takes a very savvy healthcare consumer to score discounts from providers, not all of whom will necessarily go along with such requests.

Normally, insurance companies, not individuals, are the ones negotiating with hospitals and doctors to lower prices for large member groups. Even a minor health issue could result in a financial setback. Additionally, illness and medical bills are known contributors to bankruptcy. Applying for Medicaid may also be an option, but whether you qualify is dependent on your income and family size. Each state has different guidelines with regard to the income and asset thresholds allowed for eligibility for Medicaid coverage.

The federal government no longer requires individuals to have health insurance. However, a handful of states and the District of Columbia have instituted a health insurance coverage mandate, and most carry a penalty for not doing so.

For example, a broken leg can cost you thousands of dollars, even if no surgery is needed. In addition, most health insurance plans give you access to preventive services—like shots or screening tests—for free. The number has fluctuated over the past few years, but the number of Americans without insurance has generally been trending lower since the enactment of the Affordable Care Act ACA.

Put simply, the ACA has made it much easier for uninsured Americans to obtain health insurance. In , when the ACA was enacted, 48 million Americans were without health insurance. In , that number had decreased to 30 million.

See if you'll owe a fee. Uninsured Population, — Health Insurance. Your Money. Personal Finance. Your Practice. Popular Courses. Table of Contents Expand.

Table of Contents. ACA Coverage Mandate.