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Early Data Show ACA Provisions Gaining Traction, But Problems Persist

Eastman, Peggy

doi: 10.1097/01.COT.0000453661.35167.68


WASHINGTON—Patient advocacy groups such as the National Coalition for Cancer Survivorship have praised the Affordable Care Act (ACA) for provisions that protect cancer patients from health insurance discrimination due to a pre-existing condition, expand insurance coverage, and other benefits. Data from many sources, including the American Cancer Society, show that uninsured cancer patients fare far worse than cancer patients with health insurance.

Now early data from the Urban Institute presented at a news briefing here on the ACA's net effects on America's uninsured population show that after a rocky start consumers were signing up for health insurance plans under the ACA's marketplace open enrollment in higher numbers. Overall, eight million more American adults obtained health insurance coverage between September 2013 and June 2014, according to the Urban Institute's Heath Reform Monitoring Survey (HRMS) data.

The greatest gains were among low-income and middle-income adults—the groups specifically targeted by the ACA's new Medicaid and marketplace provisions. Enrollment gains were greater in states that implemented the ACA's Medicaid expansion provision, where those without health insurance dropped by 37.7 percent.

“The Medicaid piece of this is very important... I think the first year is pretty much of a success,” said Stephen Zuckerman, PhD, Urban Institute Senior Fellow and Co-Director of its Health Policy Center.

Despite initial ACA website glitches and crashes, frustration, and acrimony, “it really is an impressive rollout—not perfect, but good,” agreed Sharon Long, PhD, a Senior Fellow in the Urban Institute's Health Policy Center.

But the data also show that persistent health insurance enrollment problems remain, especially among Hispanics; Americans with low health literacy and less than a high school education; and among those who believe they cannot afford health insurance even with new provisions in the ACA. And even after enrollment in health plans, many Americans are confused by the complexity of health insurance plans and by unfamiliar terms such as “deductibles” and “co-pays,” and are not sure what they have actually purchased.

Some people don't understand the concept of co-pays, believing that a health insurance should cover everything,” Long said. “People don't quite know what kind of insurance they have—we see those confusions in the data.” She noted that America's Health Insurance Plans (AHIP), a national organization representing approximately 1,300 member companies, has expressed concern, for example, about what Americans who purchased high-deductible health plans don't understand (see box on next page).

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Other Findings

Early data on health insurance under the ACA released at the briefing also show that:

  • The estimated rate for American adults without health insurance fell from 17.9 percent to 13.9 percent between September 2013 and June 2014;
  • Men and women, young and old, and all races and ethnicities benefited from the ACA's coverage expansions, with the largest gains for population groups that have historically had high uninsurance rates: young, male, and minority adults;
  • Compared with the uninsured population in September 2013, uninsured adults were more concentrated in Medicaid non-expansion states in June 2014;
  • Two-thirds of uninsured adults in June 2014 had family incomes at or below 138 percent of the federal poverty level, and two-fifths were both low-income and lived in states that had not expanded Medicaid under the ACA;
  • Three out of five uninsured adults in June 2014 had heard some or a lot about the new ACA health insurance marketplaces and the individual insurance mandate, but fewer than two out of five had heard about the marketplace subsidies; and
  • Most uninsured adults in June 2014 said they were uninsured for financial reasons, despite new provisions in the ACA, and seven in 10 adults who remain uninsured even after spending time looking for information on health insurance cited financial barriers as a reason for not signing up for coverage. Part of the perceived financial barriers may be living in a state without Medicaid expansion. Some may even be living with debt. In fact, another new Urban Institute report shows that 77 million Americans (35 percent of U.S. adults with a credit file) have a report of debt in collections, with an average debt of $5,178. (Debt in collections is a non-mortgage bill such as a credit card balance or medical or utility bill that is more than 180 days past due).

“The elephant in the room is the [Medicaid] non-expansion states,” said Katherine Hempstead, PhD, a director of the Robert Wood Johnson Foundation and a coauthor of two of three new HRMS data reports released at the Urban Institute briefing. As of June 2014, Medicaid expansion had occurred in 25 states and the District of Columbia. New financial assistance for health insurance coverage through federal and state marketplaces had occurred in all states. (However, two recent conflicting court decisions now put the fate of health care subsidies under the ACA in doubt.)

“Some of the people who cite financial barriers are aware of the subsidies and some are not,” Hempstead said, adding that among some Americans who “live paycheck to paycheck,” the price of health insurance comes with “sticker shock” even under the ACA.

Zuckerman stressed that due to the complexity of the new health insurance provisions, many adults who enrolled gained health insurance coverage through the help of navigators, who can play an important facilitation role. He said there need to be continuing outreach and education efforts to reach Americans with low health literacy and low educational attainment to explain to them why health insurance is valuable and to walk them through the process of becoming enrolled.

For many consumers, health insurance is intangible, unlike “getting something delivered to your door in a nice Amazon box,” Zuckerman said. The data also show that some Americans need a non-website approach to health insurance information and education: “There's a lot of complexity here... not always clicking on a screen is going to help them.”

Asked by OT who should bear the responsibility for consumer education on health insurance coverage under the ACA, Zuckerman said that in terms of getting people through the door and enrolled in health plans, the ACA health insurance exchanges bear the responsibility. Once people have enrolled, though, he said, “I do think the insurance carriers bear the responsibility for education.”

Long noted that family and friends are currently a major source of education for consumers on new health insurance plans under the ACA, and Hempstead predicted that a kind of “organic outreach” on the part of enrolled Americans will take place to others who are not yet insured.

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ASCO's Educational Efforts on the ACA

In late May, the American Society of Clinical Oncology launched an online ACA Resource Center to help patients and oncologists better understand the Affordable Care Act. Information on how patients can navigate the ACA is available on Cancer.Net, ASCO's patient information website, directly at, and resources for oncologists can be found at

© 2014 by Lippincott Williams & Wilkins, Inc.
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