Second essay Topic: Monopoly in the united state of America 800 words Note: This assignment is an essay (not a research paper), which will detail your point of view concerning a current economic problem. frame the problem, analyze the problem, and develop a proposed solution to the problem using economic knowledge and critical thinking skills. Key Provisions of the Patient Protection and Affordable Care Act (ACA): A Systematic Review and Presentation of Early Research Findings Michael T. French, Jenny Homer, Gulcin Gumus, and Lucas Hickling Objectives. To conduct a systematic literature review of selected major provisions of the Affordable Care Act (ACA) pertaining to expanded health insurance coverage. We present and synthesize research findings from the last 5 years regarding both the imme- diate and long-term effects of the ACA. We conclude with a summary and offer a research agenda for future studies. Study Design. We identified relevant articles from peer-reviewed scholarly journals by performing a comprehensive search of major electronic databases. We also identi- fied reports in the “gray literature” disseminated by government agencies and other organizations. Principal Findings. Overall, research shows that the ACA has substantially decreased the number of uninsured individuals through the dependent coverage provi- sion, Medicaid expansion, health insurance exchanges, availability of subsidies, and other policy changes. Affordability of health insurance continues to be a concern for many people and disparities persist by geography, race/ethnicity, and income. Early evidence also indicates improvements in access to and affordability of health care. All of these changes are certain to ultimately impact state and federal budgets. Conclusions. The ACA will either directly or indirectly affect almost all Americans. As new and comprehensive data become available, more rigorous evaluations will pro- vide further insights as to whether the ACA has been successful in achieving its goals. Key Words. Affordable Care Act (ACA), health insurance, health care, systematic review On March 23, 2010, following a long and controversial political and legislative process, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law, ushering in the most significant changes to the U.S. health care system since the passage of Medicare and Medicaid in 1965. The ACA © Health Research and Educational Trust DOI: 10.1111/1475-6773.12511 POLICY-MANAGERIAL IMPACTARTICLE 1735 Health Services Research includes a series of ambitious reforms that build upon the existing system of employer-sponsored insurance (ESI) and creates new requirements for indi- viduals, employers, health care providers, and insurance companies. It is intended to address three main areas: access to health insurance, health care costs, and the delivery of care (Blumenthal, Abrams, and Nuzum 2015). Cer- tain elements of the law became active soon after i.

1. Second essay
Topic: Monopoly in the united state of America
800 words
Note: This assignment is an essay (not a research paper), which
will detail your point of view concerning a current economic
problem.
frame the problem,
analyze the problem, and
develop a proposed solution to the problem using economic
knowledge and critical thinking skills.
Key Provisions of the Patient Protection
and Affordable Care Act (ACA):
A Systematic Review and Presentation of
Early Research Findings
Michael T. French, Jenny Homer, Gulcin Gumus, and
Lucas Hickling
Objectives. To conduct a systematic literature review of
selected major provisions of
the Affordable Care Act (ACA) pertaining to expanded health
insurance coverage. We
present and synthesize research findings from the last 5 years
regarding both the imme-
diate and long-term effects of the ACA. We conclude with a

2. summary and offer a
research agenda for future studies.
Study Design. We identified relevant articles from peer-
reviewed scholarly journals
by performing a comprehensive search of major electronic
databases. We also identi-
fied reports in the “gray literature” disseminated by government
agencies and other
organizations.
Principal Findings. Overall, research shows that the ACA has
substantially
decreased the number of uninsured individuals through the
dependent coverage provi-
sion, Medicaid expansion, health insurance exchanges,
availability of subsidies, and
other policy changes. Affordability of health insurance
continues to be a concern for
many people and disparities persist by geography,
race/ethnicity, and income. Early
evidence also indicates improvements in access to and
affordability of health care. All
of these changes are certain to ultimately impact state and
federal budgets.
Conclusions. The ACA will either directly or indirectly affect
almost all Americans.
As new and comprehensive data become available, more
rigorous evaluations will pro-
vide further insights as to whether the ACA has been successful
in achieving its goals.
Key Words. Affordable Care Act (ACA), health insurance,
health care, systematic
review
On March 23, 2010, following a long and controversial political
and legislative
process, President Obama signed the Patient Protection and

3. Affordable Care
Act (ACA) into law, ushering in the most significant changes to
the U.S. health
care system since the passage of Medicare and Medicaid in
1965. The ACA
© Health Research and Educational Trust
DOI: 10.1111/1475-6773.12511
POLICY-MANAGERIAL IMPACTARTICLE
1735
Health Services Research
includes a series of ambitious reforms that build upon the
existing system of
employer-sponsored insurance (ESI) and creates new
requirements for indi-
viduals, employers, health care providers, and insurance
companies. It is
intended to address three main areas: access to health insurance,
health care
costs, and the delivery of care (Blumenthal, Abrams, and
Nuzum 2015). Cer-
tain elements of the law became active soon after its passage in
2010, but most
provisions took effect in 2014 (see Table 1 for the ACA
timeline).1
The ACA includes multiple strategies to target different groups
and
increase overall insurance coverage. Young adults are now able
to remain on
their parents’ insurance plans as dependents until age 26

4. (dependent coverage
provision). Larger employers are required to offer affordable,
comprehensive
health insurance to full-time employees (employer mandate).
Individuals who
do not have ESI must purchase insurance on their own or pay a
penalty (indi-
vidual mandate), and premium tax credits are available to some.
These indi-
viduals and small businesses can purchase plans through state-
level exchanges
or the federal marketplace. To assist low-income individuals,
the ACA
expands Medicaid eligibility to all individuals under age 65
(nonelderly) with
annual incomes up to 133 percent of the federal poverty level,
but not all states
have agreed to participate. These provisions aim not only to
expand insurance
coverage but also to improve the affordability of insurance
plans.
The ACA also imposes new regulations on insurance companies
and
their policies. For example, insurance companies can no longer
charge higher
premiums or deny coverage due to preexisting conditions, and
insurance poli-
cies have to provide a minimum amount of preventive services
without any
cost-sharing. The ACA calls for changes in various taxes
pertaining to insur-
ance policies and overall financing. Other provisions focus on
improving the
delivery of care by streamlining services, incorporating health
information

5. technology, strengthening the health care workforce, reducing
fraud and
waste, and altering payments in a way that incentivizes
providers to contain
costs while improving the quality of care.2
Assessing the full and lasting impacts of the ACA is
challenging because
the provisions are multifaceted and the potential outcomes
extend to
Address correspondence to Michael T. French, Ph.D.,
Departments of Sociology, Health Sector
Management and Policy, Economics, and Public Health
Sciences, University of Miami, 5202
University Drive, Merrick Building, Room 121F, P.O. Box
248162, Coral Gables, FL 33124-
2030; e-mail: [email protected] Jenny Homer, M.P.A., M.P.H.,
and Lucas Hickling, B.A., are
with the Health Economics Research Group, University of
Miami, Coral Gables, FL. Gulcin
Gumus, Ph.D., is with the Department of Management
Programs, Florida Atlantic University,
Boca Raton, FL; IZA, Bonn, Germany.
1736 HSR: Health Services Research 51:5 (October 2016)
Table 1: Timeline for Implementation of Major Provisions of
the ACA
2010 Employers are provided funding to cover individuals
retiring between the ages of 55
and 65

6. Federal government offers tax credits to cover a portion of the
employer’s contribution
for small businesses with less than 25 employees†
Establishes a new Patient’s Bill of Rights‡
Requires all plans to include certain preventive services without
cost-sharing‡
Insurance companies cannot deny coverage to children under
age 19 with preexisting
conditions‡
Creates a new process to monitor premium rate increases and
report the minimum
medical loss ratio†
*Young adults are covered by their parent’s health insurance
until age 26 (dependent
coverage provision)‡
Provides financial incentives to PCPs, nurses, and physician
assistants, and increases
payments to PCPs in rural communities, underserved areas, and
community health
centers§
2011 Provides a 10% bonus payment from Medicare to PCPs for
5 years
2012 Imposes new annual fees on the pharmaceutical
manufacturing sector†
Creates a Medicare Value-Based Purchasing program¶
2013 *Initial open enrollment in the individual health insurance
marketplace begins¶

7. The Bundled Payments for Care Improvement Initiative begins
to test models for
reimbursement
*Increases Medicaid reimbursement rates for primary care
services provided by PCPs
to 100% of the Medicare rates for 2013 and 2014
Increases Medicare Part A tax rate from 1.45% to 2.35% on
individuals earning over
$200,000 and couples earning $250,000, as well as a 3.8% tax
on unearned income
for high-income tax payers
Imposes 2.3% excise tax on the sale of any taxable medical
device
Modifies tax treatment of health savings and flexible spending
accounts
2014 Insurance companies cannot deny coverage based on
preexisting conditions and can
only vary rates based on rating area, family size, tobacco use,
and age (but not on health
status, previous claims history, or gender)
Risk adjustment, reinsurance, and risk corridor programs go
into effect to help stabilize
premiums and reduce adverse selection
*Increases small business tax credits for those participating in
the state insurance
exchanges†
*Provides tax credits to individuals or families earning between
100% and 400% of the

8. federal poverty level who purchase their health insurance
through the exchanges
All health insurance plans must provide an “essential health
benefits package”
*Expands federally funded Medicaid coverage to cover
individuals earning up to 133%
of the federal poverty level in certain states
Initial enrollment in the Small Business Health Options Program
(SHOP) begins on
November 15
Imposes annual fees on the health insurance sector†
*U.S. citizens without health insurance pay a tax penalty
(individual mandate)†
2015 *Employers with 100 or more full-time employees pay a
penalty if they fail to offer health
insurance coverage (employer mandate)
Continued
The ACA’s Key Provisions: A Systematic Review 1737
taxpayers, patients, health care providers, insurance companies,
and govern-
ments. Preimplementation projections of the ACA’s effects were
largely based
on simulation models of earlier Medicaid enrollment or the
Massachusetts
health insurance expansion (e.g., Gruber 2011a). In 2010, the
Congressional

9. Budget Office (CBO 2010) projected that by 2019, 32 million
people would
gain health insurance coverage, ESI coverage would decline
slightly, and signif-
icant increases in federal spending due to the ACAwould be
offset by increased
revenue. Making precise predictions is daunting, however, as
many factors
affect successful implementation of the ACA, such as
enrollment levels, insurer
participation, and providers’ willingness to accept Medicaid
patients.
While the ACA is comprised of 10 titles and hundreds of
sections, this
review focuses on key provisions related to expansion of health
insurance cov-
erage through dependent coverage provisions and ESI, health
insurance
exchanges, employer and individual mandates, and Medicaid
expansion.
Unlike other summaries of the existing literature (e.g., Hall and
Lord 2014;
Blumenthal, Abrams, and Nuzum 2015), we conduct a structured
and system-
atic review of research findings regarding the effects of the
ACA since 2010
and focus on the key provisions listed above. Besides a
summary and synthesis
of current findings, we also offer suggestions for future
research.
METHODS
Literature Search

10. We used three methods to identify relevant studies for our
analysis. First, we
performed structured and systematic searches using the
Thomson Reuters’
Table 1. Continued
2016 *Employers with 50 or more full-time employees pay a
penalty if they fail to offer health
insurance coverage (employer mandate)
2018 Excise tax of 40% imposed on employer-sponsored private
health insurance plans above
a certain value (“Cadillac tax”)
Notes. Provisions went into effect on January 1, unless noted
otherwise. The provisions discussed
in this review are marked with an asterisk (*). PCP stands for
primary care physician.
†Assessed annually.
‡Effective for plans beginning on or after September 23, 2010.
§Effective dates vary.
¶Effective October 1.
Source: Compiled by the authors using information from the US
Department of Health and
Human Services
(http://www.hhs.gov/healthcare/facts/timeline/timeline-
text.html) and Kaiser
Family Foundation (http://kff.org/health-reform/fact-
sheet/summary-of-the-affordable-care-act/)
websites.
1738 HSR: Health Services Research 51:5 (October 2016)
http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html
http://kff.org/health-reform/fact-sheet/summary-of-the-

11. affordable-care-act/
Web of Science, the National Library of Medicine’s Medline
(PubMed), and
the American Economic Association’s EconLit. We searched for
the phrase
“Affordable Care Act” in titles, abstracts, or topics without any
additional key-
words to avoid inadvertently excluding relevant studies. These
searches
yielded a total of 1,375 studies from Web of Science, 1,656
studies from Med-
line, and 97 studies from EconLit. We focused on published
articles in the Eng-
lish language that appeared in peer-reviewed scholarly journals
as well as
reports that appeared in the “gray literature.” Second, we
augmented our sys-
tematic searches to include relevant reports from various
research organiza-
tions and government agencies. Third, we browsed the reference
sections of
the retrieved articles. The entire search process was conducted
from July to
September 2015, and it was limited to studies appearing since
2010.
Inclusion Criteria and Screening
Our inclusion criteria are essentially based on whether the study
provides a
systematic evaluation of one or more elements of the ACA’s
implementation.
Given the vast number of studies on this topic, we focus on
those provisions

12. related to the expansion of health insurance coverage. Both
quantitative and
qualitative studies were included, but we excluded studies that
merely
describe the legislation or examine data from prior to the
implementation
(i.e., to establish a baseline). We also eliminated any studies
that simply use
projections or extrapolations based on data prior to
implementation of the
ACA. Finally, we excluded studies pertaining to ethical, legal,
or political
aspects of the ACA.
During the first round of screening, two coauthors
independently
screened the title and abstract of each study to identify those
that poten-
tially met the inclusion criteria. After a comparison of the two
sets of rat-
ings, any inconsistencies were resolved through discussions.
When
necessary, a third coauthor was asked to render a judgment. As
a result, we
obtained 162 full-text articles for a final examination pertaining
to rele-
vance and to eliminate any inappropriate items such as opinion
pieces.
Ultimately, we selected a total of 72 studies through our
elaborate screening
process. These were augmented by 24 reports and articles found
in the gray
literature. While Table 2 lists the final set of 96 studies together
with brief
descriptions, given space limitations, we do not cover all in the
results sec-

13. tion. The discussion below includes only those studies that were
deemed
most relevant or provide more recent evidence, and they are
organized by
groupings of key ACA provisions.
The ACA’s Key Provisions: A Systematic Review 1739
T
ab
le
2:
S
u
m
m
ar
y
o
fS
el
ec
te
d
R
es
ea
rc
h
S
tu

14. d
ie
s
R
es
ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds
B
ri
ef
D
es
cr
ip
ti
on
A
b
ra
h
am

15. ,
Fe
ld
m
an
,a
n
d
S
im
o
n
(2
01
4)
*
N
at
io
n
al
A
ss
o
ci
at
io
n
o
fI
n

16. su
ra
n
ce
C
o
m
m
is
si
o
n
er
s;
C
P
S
;
K
F
F
;D
es
cr
ip
ti
ve
st
at
is
ti
cs

17. to
d
es
cr
ib
e
ea
ch
st
at
e’
s
in
su
ra
n
ce
m
ar
ke
ta
n
d
to
te
st
th
e
d
if
fe
re

18. n
ce
s
in
at
tr
ib
u
te
s
b
et
w
ee
n
ex
ch
an
ge
p
ar
ti
ci
p
an
ts
an
d
n
o
n

19. p
ar
ti
ci
p
an
ts
;M
u
lt
iv
ar
ia
te
re
gr
es
si
o
n
an
al
ys
is
w
it
h
an
in
cu
m

20. b
en
ti
n
su
re
r’
s
d
ec
is
io
n
to
p
ar
ti
ci
p
at
e
in
th
e
ex
ch
an
ge
s
as

21. th
e
o
u
tc
o
m
e
m
ea
su
re
In
su
re
r
p
ar
ti
ci
p
at
io
n
in
ex
ch
an
ge
s
is
re
la

22. te
d
to
p
re
se
n
ce
in
th
e
re
gi
o
n
an
d
si
ze
o
ft
h
e
in
su
re
r.
A
ko
sa

23. A
n
tw
i,
M
or
iy
a,
an
d
S
im
o
n
(2
01
3)
*
S
IP
P
;D
D
w
it
h
in
su
ra
n

24. ce
co
ve
ra
ge
an
d
la
b
o
r
m
ar
ke
t
o
u
tc
o
m
es
as
o
u
tc
o
m
e
m
ea
su
re

25. s
D
ep
en
d
en
tc
ov
er
ag
e
p
ro
vi
si
on
is
as
so
ci
at
ed
w
it
h
in
cr
ea
se
s

26. in
co
ve
ra
ge
an
d
p
ar
en
ta
lc
ov
er
ag
e
am
on
g
yo
u
n
g
ad
ul
ts
re
la
ti
ve

27. to
co
m
p
ar
is
o
n
gr
o
up
.
A
ko
sa
A
n
tw
ie
t
al
.
(2
01
5)
*
N
at
io

28. n
al
E
m
er
ge
n
cy
D
ep
ar
tm
en
tS
am
p
le
;D
D
w
it
h
E
D
vi
si
ts
as
th
e

29. o
u
tc
o
m
e
m
ea
su
re
D
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed

30. w
it
h
m
o
d
es
td
ec
li
n
e
in
E
D
vi
si
ts
fo
r
yo
u
n
g
ad
u
lt
s
re
la

31. ti
ve
to
co
m
p
ar
is
o
n
gr
o
u
p
.
A
ko
sa
A
n
tw
i,
M
or
iy
a,
an
d
S
im

32. o
n
(2
01
5)
*
N
at
io
n
w
id
e
In
p
at
ie
n
tS
am
p
le
,H
ea
lt
h
ca
re
C
os
ta
n

33. d
U
ti
li
za
ti
o
n
P
ro
je
ct
;D
D
w
it
h
n
u
m
b
er
an
d
so
u
rc
es
o
f
in

34. p
at
ie
n
ta
d
m
is
si
o
n
s,
fr
ac
ti
o
n
o
fa
d
m
is
si
o
n
s
in
su
re
d
,a
n
d
th
e

35. in
te
n
si
ty
o
ft
re
at
m
en
ta
s
o
u
tc
o
m
e
m
ea
su
re
s
D
ep
en
d
en
tc
o

36. ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
in
cr
ea
se
s
in
m
en
ta
l
h
ea
lt

37. h
vi
si
ts
an
d
in
p
at
ie
n
tv
is
it
s
b
y
yo
u
n
g
ad
u
lt
s
re
la
ti
ve
to
co

38. m
p
ar
is
o
n
gr
o
u
p
.
A
n
gi
er
et
al
.
(2
01
5)
*
L
o
n
gi
tu
d
in
al
st

39. u
d
y
o
fc
o
ve
ra
ge
st
at
u
s
fo
r
ad
u
lt
en
co
u
n
te
rs
in
co
m
m
u
n
it
y

40. h
ea
lt
h
ce
n
te
rs
(C
H
C
s)
;m
u
lt
iv
ar
ia
te
re
gr
es
si
o
n
an
al
ys
is
o
fC
H

41. C
vi
si
ts
b
y
in
su
ra
n
ce
an
d
M
ed
ic
ai
d
ex
p
an
si
o
n
st
at
u
s
T
h
e

42. p
ro
p
o
rt
io
n
o
fu
n
in
su
re
d
vi
si
ts
d
ec
re
as
ed
an
d
M
ed
ic
ai
d
-c
o
ve
re

43. d
vi
si
ts
in
cr
ea
se
d
in
M
ed
ic
ai
d
ex
p
an
si
o
n
st
at
es
in
2
01
4
co
m

44. p
ar
ed
to
2
01
3.
A
rt
ig
a,
R
ud
o
w
it
z,
an
d
R
an
ji
(2
01
5)
*
Fo
cu
s
gr

45. o
u
p
s
w
it
h
ei
th
er
p
re
vi
o
u
sl
y
u
n
in
su
re
d
ad
u
lt
s
w
h
o
en
ro
ll

46. ed
in
th
e
A
C
A
M
ed
ic
ai
d
ex
p
an
si
o
n
(O
h
io
an
d
A
rk
an
sa
s)

47. o
r
th
o
se
w
h
o
w
o
u
ld
b
e
el
ig
ib
le
if
th
ei
r
st
at
e
h
ad
ex
p
an
d
ed

48. M
ed
ic
ai
d
(M
is
so
u
ri
)
S
ta
te
s’
d
ec
is
io
n
w
h
et
h
er
to
ex
p
an

49. d
M
ed
ic
ai
d
o
r
h
o
w
th
ey
w
en
ta
b
o
u
tt
h
e
ex
p
an
si
o
n
im
p

50. le
m
en
ta
ti
o
n
af
fe
ct
ed
ex
p
er
ie
n
ce
s
o
fl
o
w
-i
n
co
m
e
ad
u
lt
s,
in

51. cl
u
d
in
g
th
ei
r
ac
ce
ss
to
ca
re
as
w
el
la
s
th
ei
r
ab
il
it
y
to
w
o
rk
.

52. A
rt
ig
a,
S
te
p
h
en
s,
an
d
D
am
ic
o
(2
01
5)
*
C
P
S
;D
es
cr
ip
ti
ve

53. st
at
is
ti
cs
o
n
th
e
u
n
in
su
re
d
an
d
th
o
se
w
h
o
fa
ll
w
it
h
in
th
e

54. “c
o
ve
ra
ge
ga
p
”
af
te
r
im
p
u
ti
n
g
el
ig
ib
il
it
y
fo
r
A
C
A
su
b
si
d
ie

55. s,
u
n
au
th
o
ri
ze
d
im
m
ig
ra
n
ts
ta
tu
s,
an
d
E
S
I
o
ff
er
st
at
u
s

56. E
st
im
at
e
th
er
e
ar
e
3.
7
m
il
li
o
n
ad
u
lt
s
in
th
e
co
ve
ra
ge
ga
p
in

57. 2
2
st
at
es
th
at
h
av
e
n
o
te
x
p
an
d
ed
M
ed
ic
ai
d
as
o
fM
ar
ch

58. 2
01
5.
B
ac
h
ra
ch
,
B
o
o
za
n
g,
an
d
G
la
n
z
(2
01
5)
*
In
te
rv
ie
w
s
w

59. it
h
st
at
e
o
ffi
ci
al
s;
es
ti
m
at
es
o
ft
h
e
b
u
d
ge
ta
ry
im
p
ac
to
fM
ed
ic

60. ai
d
ex
p
an
si
o
n
in
a
sa
m
p
le
o
fe
ig
h
ts
ta
te
s
M
ed
ic
ai
d
ex
p
an

61. si
o
n
al
lo
w
s
st
at
es
to
re
al
iz
e
sa
vi
n
gs
(t
h
ro
u
gh
re
d
u
ct
io
n
s

62. in
sp
en
d
in
g
o
n
p
ro
gr
am
s
fo
r
th
e
u
n
in
su
re
d
)a
n
d
re
ve
n
u
e
ga
in
s

63. (t
h
ro
u
gh
ex
is
ti
n
g
in
su
re
r
o
r
p
ro
vi
d
er
ta
x
es
).
C
on
ti
nu
ed
1740 HSR: Health Services Research 51:5 (October 2016)

64. T
ab
le
2.
C
on
ti
nu
ed
R
es
ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds
B
ri
ef
D
es

65. cr
ip
ti
on
B
ar
b
ar
es
co
,
C
ou
rt
em
an
ch
e,
an
d
Q
i(
2
01
5)
*
B
R
F
S

66. S
;D
D
w
it
h
o
u
tc
o
m
es
re
la
te
d
to
h
ea
lt
h
ca
re
ac
ce
ss
,
p
re
ve
n

67. ti
ve
ca
re
u
ti
li
za
ti
o
n
,r
is
ky
b
eh
av
io
rs
,a
n
d
se
lf
-
as
se
ss
ed
h

68. ea
lt
h
D
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
so
m
e

69. im
p
ro
ve
m
en
ts
in
h
ea
lt
h
ca
re
ac
ce
ss
an
d
h
ea
lt
h
-r
el
at
ed
o
u
tc

70. o
m
es
am
o
n
g
yo
u
n
g
ad
u
lt
s
re
la
ti
ve
to
co
m
p
ar
is
o
n
gr
o
u
p

71. .R
ep
o
rt
la
rg
e
ga
in
s
fo
r
m
en
an
d
co
ll
eg
e
gr
ad
u
at
es
.
B
ar
ce
ll
o

72. s
et
al
.(
20
14
)*
A
m
er
ic
an
L
if
e
P
an
el
;m
u
lt
iv
ar
ia
te
re
gr
es
si
o

73. n
an
al
ys
is
w
it
h
kn
o
w
le
d
ge
ab
o
u
tA
C
A
,h
ea
lt
h
in
su
ra
n
ce
li
te

74. ra
cy
,a
n
d
ex
p
ec
ta
ti
o
n
s
fo
r
ch
an
ge
s
in
h
ea
lt
h
ca
re
as
o
u
tc
o
m

75. es
K
n
o
w
le
d
ge
o
ft
h
e
A
C
A
an
d
h
ea
lt
h
li
te
ra
cy
is
lo
w
o
ve
ra
ll

76. ,e
sp
ec
ia
ll
y
am
o
n
g
lo
w
-i
n
co
m
e
in
d
iv
id
u
al
s.
B
ar
ke
r
et
al
.(
20

77. 14
a)
*
A
re
a
H
ea
lt
h
R
es
o
u
rc
e
F
il
e;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n

78. ge
o
gr
ap
h
ic
va
ri
at
io
n
in
m
ar
ke
tp
la
ce
p
re
m
iu
m
s
P
re
m
iu
m
s
fo
r

79. ex
ch
an
ge
p
la
n
s
ar
e
h
ig
h
er
in
le
ss
d
en
se
ly
p
o
p
u
la
te
d
ar
ea
s.

80. B
ar
ke
r
et
al
.(
20
14
b
)*
H
ea
lt
h
ca
re
.g
o
v
an
d
st
at
e
ag
en
ci
es
;o

81. ve
rv
ie
w
o
fi
m
p
o
rt
an
t
fa
ct
o
rs
th
at
in
fl
u
en
ce
th
e
d
if
fe
re
n
ce
s
in

82. m
ar
ke
tp
la
ce
p
la
n
s
ac
ro
ss
ge
o
gr
ap
h
ic
ar
ea
s
(u
rb
an
vs
.r
u
ra
l)
U

83. rb
an
co
u
n
ti
es
,o
n
av
er
ag
e,
h
av
e
m
o
re
p
la
n
s
an
d
p
la
n
s
w
it
h

84. h
ig
h
er
ac
tu
ar
ia
lv
al
u
es
av
ai
la
b
le
o
n
th
ei
r
ex
ch
an
ge
s.
B
la
vi

85. n
et
al
.(
20
15
)*
H
ea
lt
h
R
ef
o
rm
M
o
n
it
o
ri
n
g
S
u
rv
ey
;m
u
lt
iv

86. ar
ia
te
re
gr
es
si
o
n
an
al
ys
is
w
it
h
em
p
lo
ye
r
o
ff
er
ra
te
s,
em
p
lo
ye
e

87. ta
ke
-u
p
ra
te
s,
an
d
E
S
I
co
ve
ra
ge
as
o
u
tc
o
m
es
O
ff
er
,t
ak
e-
u
p
,a
n

88. d
co
ve
ra
ge
ra
te
s
fo
r
E
S
I
h
av
e
re
m
ai
n
ed
th
e
sa
m
e
u
n
d
er
th
e
A

89. C
A
.
B
lu
m
b
er
g
an
d
R
if
ki
n
(2
01
4)
*
C
as
e
st
u
d
y
u
si
n
g
st
ak
eh

90. o
ld
er
in
te
rv
ie
w
s
in
ei
gh
ts
ta
te
s
Id
en
ti
fy
re
as
o
n
s
fo
r
S
H

91. O
P
’s
sl
o
w
st
ar
ta
n
d
ar
ea
s
fo
r
im
p
ro
ve
m
en
t.
B
lu
m
en
th
al
an
d

92. C
ol
li
n
s
(2
01
4)
*
O
ve
rv
ie
w
an
d
as
se
ss
m
en
to
fe
x
is
ti
n
g
fi
n
d
in
gs

93. P
ro
vi
d
e
a
p
ro
gr
es
s
re
p
o
rt
o
n
A
C
A
as
o
fm
id
-2
01
4.
B
lu
m
en

94. th
al
,
A
b
ra
m
s,
an
d
N
u
zu
m
(2
01
5)
*
O
ve
rv
ie
w
an
d
as
se
ss
m
en

95. to
fe
x
is
ti
n
g
fi
n
d
in
gs
R
ev
ie
w
va
ri
o
u
s
ef
fe
ct
s
o
ft
h
e
A
C
A
at
th
e

96. 5-
ye
ar
m
ar
k.
B
ra
n
d
o
n
an
d
C
ar
n
es
(2
01
4)
*
C
as
e
st
u
d
ie
s
o

97. fm
ar
ke
tp
la
ce
la
u
n
ch
es
in
K
en
tu
ck
y
an
d
N
o
rt
h
C
ar
o
li
n
a

98. D
es
cr
ib
e
el
em
en
ts
o
fs
u
cc
es
sf
u
le
x
ch
an
ge
s.
B
ro
o
ks
(2
01
4)
*
D

99. es
cr
ip
ti
o
n
an
d
d
is
cu
ss
io
n
o
ft
h
e
“f
am
il
y
gl
it
ch
”
M
an
y
d
ep

100. en
d
en
ts
fa
ce
ch
al
le
n
ge
s
w
it
h
“a
ff
or
d
ab
le
”
ca
re
an
d
w
ill
re
m
ai
n

101. u
n
in
su
re
d
if
th
e
fa
m
ily
gl
it
ch
is
n
ot
fi
x
ed
.L
o
w
-i
n
co
m
e
fa
m

102. ili
es
an
d
th
os
e
w
h
o
liv
e
in
M
ed
ic
ai
d
n
on
ex
p
an
si
on
st
at
es

103. h
av
e
b
ee
n
d
is
p
ro
p
or
ti
on
at
el
y
af
fe
ct
ed
.
B
u
sc
h
,
G
o
lb
er

104. st
ei
n
,a
n
d
M
ea
ra
(2
01
4)
*
M
E
P
S
;D
D
w
it
h
in
su
ra
n
ce
co
ve
ra
ge

105. an
d
o
u
t-
o
f-
p
o
ck
et
m
ed
ic
al
ex
p
en
d
it
u
re
s
as
o
u
tc
o
m
e

106. m
ea
su
re
s
D
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
a

107. d
ec
re
as
e
in
th
e
p
ro
p
o
rt
io
n
o
fy
o
u
n
g
ad
u
lt
s
w
it
h
h
ig
h
o

108. u
t-
o
f-
p
o
ck
et
m
ed
ic
al
ex
p
en
se
s
re
la
ti
ve
to
co
m
p
ar
is
o
n
gr
o

109. u
p
.
C
on
ti
nu
ed
The ACA’s Key Provisions: A Systematic Review 1741
T
ab
le
2.
C
on
ti
nu
ed
R
es
ea
rc
h
St
ud
y

110. D
at
a/
M
et
ho
ds
B
ri
ef
D
es
cr
ip
ti
on
C
an
to
r
et
al
.(
2
01
2)
*
C
P
S
;D

111. D
w
it
h
in
su
ra
n
ce
co
ve
ra
ge
b
y
so
u
rc
e
as
o
u
tc
o
m
e
m
ea
su
re

112. E
st
im
at
e
ra
p
id
an
d
su
b
st
an
ti
al
in
cr
ea
se
in
th
e
n
u
m
b
er
o
fy

113. o
u
n
g
ad
u
lt
s
w
h
o
ga
in
ed
p
ar
en
ta
lc
o
ve
ra
ge
b
y
2
01
1.
C
ar

114. ls
o
n
et
al
.(
2
01
4)
*
C
P
S
;D
D
w
it
h
se
lf
-r
at
ed
h
ea
lt
h
as
o
u
tc

115. o
m
e
m
ea
su
re
D
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it

116. h
im
p
ro
ve
m
en
ts
in
se
lf
-
re
p
o
rt
ed
h
ea
lt
h
am
o
n
g
yo
u
n
g

117. ad
u
lt
s
re
la
ti
ve
to
co
m
p
ar
is
o
n
gr
o
u
p
.
C
M
S
(2
01
4)
*
C
M
S
p

118. re
ss
re
le
as
e
o
fd
at
a
o
n
m
ar
ke
tp
la
ce
s
R
ep
o
rt
s
th
at
m
o
re
is
su
er

119. s
an
d
h
ea
lt
h
p
la
n
s
ar
e
av
ai
la
b
le
th
ro
u
gh
ex
ch
an
ge
s
in
2
01
5
th

120. an
in
2
01
4.
C
h
an
d
ra
,H
o
lm
es
,
an
d
S
ki
n
n
er
(2
01
3)
*
V
ar

121. io
u
s
so
u
rc
es
;o
ve
rv
ie
w
o
ft
re
n
d
s
in
h
ea
lt
h
ca
re
sp
en
d
in
g
an

122. d
th
e
co
n
tr
ib
u
ti
n
g
fa
ct
o
rs
A
s
o
f2
01
3,
co
st
-s
av
in
g
fe
at
u
re
s
o
ft

123. h
e
A
C
A
w
er
e
n
o
ty
et
fu
ll
y
im
p
le
m
en
te
d
,s
o
th
ey
co
u
ld
n
o

124. te
x
p
la
in
th
e
sl
o
w
d
o
w
n
in
h
ea
lt
h
ca
re
ex
p
en
d
it
u
re
s
th
at
b

125. eg
an
in
2
00
6.
C
h
u
a
an
d
So
m
m
er
s
(2
01
4)
*
M
E
P
S
;D
D
w
it
h

126. in
su
ra
n
ce
co
ve
ra
ge
,s
el
ec
te
d
m
ea
su
re
s
o
f
h
ea
lt
h
ca
re
u
ti
li
za
ti
o

127. n
,a
n
d
se
lf
-r
ep
o
rt
ed
h
ea
lt
h
as
o
u
tc
o
m
e
m
ea
su
re
s
T
h
e
d

128. ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
im
p
ro
ve
m
en

129. ts
in
se
lf
-r
ep
o
rt
ed
h
ea
lt
h
st
at
u
s
an
d
p
ro
te
ct
io
n
ag
ai
n
st
m
ed

130. ic
al
ex
p
en
d
it
u
re
s
am
o
n
g
yo
u
n
g
ad
u
lt
s
ag
ed
19
–
2
5
ye
ar

131. s.
C
la
x
to
n
et
al
.
(2
01
2)
K
F
F
/H
R
E
T
S
u
rv
ey
o
fE
m
p
lo
ye

132. r
H
ea
lt
h
B
en
efi
ts
;
D
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
E
S
I
co
ve
ra
ge
,p

133. re
m
iu
m
s,
an
d
p
ar
en
ta
lc
o
ve
ra
ge
fo
r
yo
u
n
g
ad
u
lt
s
E
x
am

134. in
e
tr
en
d
s
in
E
S
I
co
ve
ra
ge
,p
re
m
iu
m
s,
an
d
p
ar
en
ta
lc
o
ve
ra
ge

135. fo
r
yo
u
n
g
ad
u
lt
s.
C
la
x
to
n
et
al
.(
2
01
4a
)*
K
F
F
/H
R
E
T

136. E
m
p
lo
ye
r
H
ea
lt
h
B
en
efi
tS
u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
E

137. S
I
o
ff
er
s,
en
ro
ll
m
en
t,
p
re
m
iu
m
s,
co
st
-s
h
ar
in
g,
an
d
w
o
rk
er
co

138. n
tr
ib
u
ti
o
n
s
T
h
e
E
S
I
m
ar
ke
th
as
ex
p
er
ie
n
ce
d
li
tt
le
ch
an
ge

139. si
n
ce
th
e
p
as
sa
ge
o
ft
h
e
A
C
A
.
C
oh
en
an
d
M
ar
ti
n
ez
(2
01

140. 5)
*
E
ar
ly
re
le
as
e
o
fN
H
IS
es
ti
m
at
es
fo
r
h
ea
lt
h
in
su
ra
n
ce
co
ve

141. ra
ge
an
d
th
e
o
ve
rt
im
e
tr
en
d
s
P
ro
vi
d
e
es
ti
m
at
es
o
fh
ea
lt
h

142. in
su
ra
n
ce
co
ve
ra
ge
fo
r
2
01
4
b
y
ag
e,
ra
ce
/
et
h
n
ic
it
y,
ge
o
gr
ap
h

143. y,
ty
p
e
o
fi
n
su
ra
n
ce
,a
n
d
p
o
ve
rt
y
le
ve
l.
C
ol
li
n
s
et
al
.(
2
01
2)

144. C
F
H
ea
lt
h
In
su
ra
n
ce
T
ra
ck
in
g
S
u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o

145. n
in
su
ra
n
ce
co
ve
ra
ge
an
d
b
u
rd
en
o
fm
ed
ic
al
b
il
ls
an
d
d
eb
t
T

146. h
e
h
ea
lt
h
an
d
m
o
n
et
ar
y
co
n
se
q
u
en
ce
s
o
fu
n
in
su
ra
n
ce
ar
e

147. si
gn
ifi
ca
n
tf
o
r
yo
u
n
g
ad
u
lt
s,
p
ar
ti
cu
la
rl
y
th
o
se
w
h
o
ar
e
p

148. o
o
r.
C
ol
li
n
s
et
al
.(
2
01
3a
)*
C
F
H
ea
lt
h
In
su
ra
n
ce
T
ra
ck
in
g
S

149. u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
u
n
in
su
ra
n
ce
an
d
en
ro
ll
m
en

150. tu
n
d
er
p
ar
en
ts
’
p
o
li
cy
am
o
n
g
th
e
yo
u
n
g
ad
u
lt
s
R
ep

151. o
rt
in
cr
ea
se
in
th
e
n
u
m
b
er
o
fy
o
u
n
g
ad
u
lt
s
o
n
a
p
ar
en
ts

152. ’
p
o
li
cy
b
et
w
ee
n
2
01
1
an
d
2
01
3,
in
p
ar
ti
cu
la
r
am
o
n
g
th
o
se

153. w
it
h
lo
w
in
co
m
es
.
C
ol
li
n
s
et
al
.(
2
01
3b
)
C
F
A
C
A
T
ra
ck
in
g

154. S
u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
co
n
su
m
er
s’
ex
p
er
ie
n
ce
s
in

155. m
ar
ke
tp
la
ce
at
th
e
en
d
o
ft
h
e
fi
rs
t
m
o
n
th
M
aj
o
ri
ty
o
fp

156. o
te
n
ti
al
ly
el
ig
ib
le
ad
u
lt
s
ar
e
aw
ar
e
o
ft
h
e
m
ar
ke
tp
la
ce
as
a

157. so
u
rc
e
o
fc
o
ve
ra
ge
b
u
tf
ew
re
p
o
rt
ed
vi
si
ti
n
g
it
at
th
is
p
o
in
ti
n

158. ti
m
e.
So
m
e
in
d
iv
id
u
al
s
w
h
o
vi
si
te
d
b
u
td
id
n
o
te
n
ro
ll
ye
tr
ep

159. o
rt
ed
te
ch
n
ic
al
p
ro
b
le
m
s
w
it
h
m
ar
ke
tp
la
ce
w
eb
si
te
s.
C
on
ti

160. nu
ed
1742 HSR: Health Services Research 51:5 (October 2016)
T
ab
le
2.
C
on
ti
nu
ed
R
es
ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds

161. B
ri
ef
D
es
cr
ip
ti
on
C
o
ll
in
s
et
al
.
(2
01
4a
)*
M
E
P
S
;d
es
cr
ip
ti
ve

162. st
at
is
ti
cs
o
n
th
e
n
at
io
n
al
tr
en
d
s
in
E
S
I
co
ve
ra
ge
,p
re
m
iu

163. m
s,
co
st
-s
h
ar
in
g,
an
d
w
o
rk
er
co
n
tr
ib
u
ti
o
n
s
E
S
I
p
re
m
iu
m
s,

164. d
ed
u
ct
ib
le
s,
an
d
em
p
lo
ye
e
co
n
tr
ib
u
ti
o
n
s
in
cr
ea
se
d
b
et
w
ee

165. n
2
00
3
an
d
2
01
3
b
u
ta
ta
sl
o
w
er
ra
te
af
te
r
2
01
0.
C
o
ll
in
s
et

166. al
.
(2
01
4b
)
C
F
A
C
A
T
ra
ck
in
g
S
u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs

167. o
n
co
n
su
m
er
s’
ex
p
er
ie
n
ce
s
in
m
ar
ke
tp
la
ce
at
th
e
en
d
o
ft
h

168. e
fi
rs
t
3
m
o
n
th
s
C
o
n
su
m
er
s’
ab
il
it
y
to
co
m
p
ar
e
b
en
efi
ts

169. an
d
p
re
m
iu
m
s
in
th
e
m
ar
ke
tp
la
ce
h
as
im
p
ro
ve
d
si
n
ce
th
e
ro

170. ll
o
u
t,
b
u
tm
an
y
re
p
o
rt
ed
d
if
fi
cu
lt
ie
s
w
it
h
p
la
n
se
le
ct
io
n
.

171. C
o
ll
in
s
et
al
.
(2
01
5a
)*
C
F
B
ie
n
n
ia
lH
ea
lt
h
In
su
ra
n
ce
S
u
rv

172. ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
h
ea
lt
h
in
su
ra
n
ce
co
ve
ra
ge
,a
ff
o
rd
ab

173. il
it
y,
b
u
rd
en
o
f
m
ed
ic
al
b
il
ls
an
d
d
eb
t,
ac
ce
ss
to
ro
u
ti
n

174. e
h
ea
lt
h
ca
re
R
ep
o
rt
re
su
lt
s
o
fs
u
rv
ey
sh
o
w
in
g
im
p
ro
ve
m
en

175. ts
in
co
ve
ra
ge
an
d
af
fo
rd
ab
il
it
y.
C
o
ll
in
s
et
al
.
(2
01
5b
)*
C

176. F
A
C
A
T
ra
ck
in
g
S
u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
co
n
su
m
er
s’

177. ex
p
er
ie
n
ce
s
w
it
h
m
ar
ke
tp
la
ce
an
d
M
ed
ic
ai
d
co
ve
ra
ge
R
ep
o

178. rt
re
su
lt
s
o
fs
u
rv
ey
sh
o
w
in
g
sa
ti
sf
ac
ti
o
n
w
it
h
h
ea
lt
h
p
la
n
s
an

179. d
im
p
ro
ve
m
en
ts
in
co
ve
ra
ge
an
d
ac
ce
ss
.
C
B
O
(2
01
4)
*
V
ar
io

180. u
s
so
u
rc
es
;e
st
im
at
es
o
ft
h
e
n
u
m
b
er
o
fu
n
in
su
re
d
su
b
je
ct

181. to
A
C
A
-r
el
at
ed
p
en
al
ti
es
E
st
im
at
es
4
m
il
li
o
n
o
u
to
f3
0

182. m
il
li
o
n
u
n
in
su
re
d
w
il
lb
e
su
b
je
ct
to
p
en
al
ti
es
in
2
01
6.
C
B

183. O
(2
01
5a
)*
V
ar
io
u
s
so
u
rc
es
;e
st
im
at
es
th
e
b
u
d
ge
ta
ry
an
d
ec
o

184. n
o
m
ic
co
n
se
q
u
en
ce
s
th
at
w
o
u
ld
ar
is
e
fr
o
m
re
p
ea
li
n
g
th
e

185. A
C
A
P
ro
vi
d
es
es
ti
m
at
ed
ef
fe
ct
s
o
fr
ep
ea
lo
n
h
ea
lt
h
in
su
ra
n

186. ce
co
ve
ra
ge
an
d
th
e
fe
d
er
al
b
u
d
ge
tb
o
th
in
th
e
sh
o
rt
an
d
lo
n

187. g
te
rm
,w
it
h
a
w
ar
n
in
g
th
at
th
ey
ar
e
su
b
je
ct
to
su
b
st
an
ti
al
u
n
ce

188. rt
ai
n
ty
.
C
B
O
(2
01
5b
)*
V
ar
io
u
s
so
u
rc
es
;f
ed
er
al
b
u
d
ge
tp
ro

189. je
ct
io
n
s
fo
r
2
01
5–
2
0
2
5
T
h
e
ap
p
en
d
ix
p
ro
vi
d
es
es
ti
m

190. at
ed
b
u
d
ge
ta
ry
ef
fe
ct
s
o
ft
h
e
in
su
ra
n
ce
co
ve
ra
ge
p
ro
vi
si
o
n
s

191. o
ft
h
e
A
C
A
.
C
o
x
et
al
.(
2
01
4)
*
M
ar
ke
tp
la
ce
en
ro
ll
m
en
td
at

192. a
fr
o
m
se
ve
n
st
at
es
;c
al
cu
la
te
st
at
e-
sp
ec
ifi
c
m
ea
su
re
s
o
fm
ar
ke
tc
o

193. m
p
et
it
io
n
fo
r
in
d
iv
id
u
al
p
la
n
m
ar
ke
ts
an
d
th
e
ex
ch
an
ge
s
T

194. h
er
e
ar
e
so
m
e
in
st
an
ce
s
in
w
h
ic
h
in
su
re
rs
’
m
ar
ke
ts
h
ar
es
h
av
e

195. ch
an
ge
d
si
gn
ifi
ca
n
tl
y
u
n
d
er
th
e
A
C
A
,w
it
h
so
m
e
n
o
ta
b
le

196. ex
am
p
le
s
d
u
e
to
n
ew
en
tr
an
ts
.
C
o
x
et
al
.(
2
01
5)
*
H
ea
lt

197. h
in
su
re
r
ra
te
fi
li
n
gs
in
10
st
at
e
d
ep
ar
tm
en
ts
an
d
W
as
h
in
gt
o
n

198. ,D
C
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
m
ar
ke
tp
la
ce
p
re
m
iu
m
s
an
d
in

199. su
re
r
p
ar
ti
ci
p
at
io
n
In
su
re
r
p
ar
ti
ci
p
at
io
n
in
2
01
6
is
si
m
il
ar
to

200. 2
01
5.
A
ve
ra
ge
in
cr
ea
se
in
p
re
m
iu
m
s
fo
r
si
lv
er
p
la
n
s
b
et
w
ee
n
2

201. 01
5
an
d
2
01
6
is
4.
4%
.
C
u
n
n
in
gh
am
,
G
ar
fi
el
d
,a
n
d
R
u
d

202. o
w
it
z
(2
01
5)
*
A
sc
en
si
o
n
H
ea
lt
h
d
at
a
o
n
d
is
ch
ar
ge
s
an
d
h
o

203. sp
it
al
fi
n
an
ce
s;
p
re
-p
o
st
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
d
is
ch
ar
ge

204. vo
lu
m
es
,
u
n
co
m
p
en
sa
te
d
ca
re
,a
n
d
h
o
sp
it
al
fi
n
an
ce
s
E
va
lu

205. at
e
ch
an
ge
s
in
h
o
sp
it
al
d
is
ch
ar
ge
s
an
d
fi
n
an
ci
al
o
u
tc
o
m
es

206. fo
r
A
sc
en
si
o
n
H
ea
lt
h
sy
st
em
in
M
ed
ic
ai
d
ex
p
an
si
o
n
an
d

207. n
o
n
ex
p
an
si
o
n
st
at
es
im
m
ed
ia
te
ly
b
ef
o
re
an
d
af
te
r
th
e

208. A
C
A
im
p
le
m
en
ta
ti
o
n
.
D
ep
ew
an
d
B
ai
le
y
(2
01
5)
*
M
E
P

209. S
;D
D
w
it
h
to
ta
lp
re
m
iu
m
s
an
d
em
p
lo
ye
e
co
n
tr
ib
u
ti
o
n
s
fo

210. r
fa
m
il
y
o
r
si
n
gl
e
p
la
n
s
as
o
u
tc
o
m
es
P
re
m
iu
m
s
fo
r
fa
m
il
y

211. h
ea
lt
h
p
la
n
s
in
cr
ea
se
d
b
y
2.
5–
2.
8%
d
u
e
to
th
e
d
ep
en
d
en

212. tc
o
ve
ra
ge
p
ro
vi
si
o
n
.
C
on
ti
nu
ed
The ACA’s Key Provisions: A Systematic Review 1743
T
ab
le
2.
C
on
ti
nu
ed

213. R
es
ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds
B
ri
ef
D
es
cr
ip
ti
on
D
ic
ks
te
in
et
al
.

214. (2
01
5)
*
H
ea
lt
h
ca
re
.g
o
v;
U
.S
.C
en
su
s;
M
u
lt
iv
ar
ia
te
re
gr
es
si
o
n

215. an
al
ys
is
w
it
h
n
u
m
b
er
o
fi
n
su
re
rs
an
d
h
ea
lt
h
in
su
ra
n
ce
p
re
m

216. iu
m
s
as
o
u
tc
o
m
es
E
x
am
in
e
w
h
et
h
er
th
e
d
efi
n
it
io
n
o
ft
h

217. e
co
ve
ra
ge
re
gi
o
n
af
fe
ct
s
m
ar
ke
t
o
u
tc
o
m
es
in
th
e
A
C
A
in
su
ra
n

218. ce
ex
ch
an
ge
s.
D
o
ty
,R
as
m
u
ss
en
,
an
d
C
ol
li
n
s
(2
01
4)
*
C

219. F
A
C
A
T
ra
ck
in
g
S
u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
in
su
ra
n
ce
co

220. ve
ra
ge
an
d
m
ar
ke
tp
la
ce
ex
p
er
ie
n
ce
s
am
o
n
g
L
at
in
o
s
U
n
in
su
re

221. d
ra
te
am
o
n
g
L
at
in
o
s
d
ec
re
as
ed
in
st
at
es
ex
p
an
d
in
g
M
ed
ic
ai

222. d
.
O
ve
ra
ll
ra
te
o
fu
n
in
su
re
d
ad
u
lt
s
d
ec
re
as
ed
fr
o
m
2
0%
in

223. 2
01
3
to
15
%
in
2
01
4.
G
ab
el
et
al
.
(2
01
3)
*
S
u
rv
ey
o
fp
ri

224. va
te
fi
rm
s
w
it
h
3–
5
0
em
p
lo
ye
es
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
in

225. su
ra
n
ce
p
la
n
s
in
th
e
sm
al
l-
gr
o
u
p
m
ar
ke
ta
n
d
sm
al
le
m
p
lo
ye
rs

226. ’
ex
p
er
ie
n
ce
s
w
it
h
S
H
O
P
ex
ch
an
ge
s
B
o
th
sm
al
lfi
rm
s
th
at

227. d
ec
id
ed
to
o
ff
er
h
ea
lt
h
in
su
ra
n
ce
b
en
efi
ts
an
d
th
o
se
th
at
d
id

228. n
o
tr
at
ed
m
o
st
fe
at
u
re
s
o
fS
H
O
P
ex
ch
an
ge
s
h
ig
h
ly
.T
h
es

229. e
d
ec
is
io
n
s
w
er
e
ve
ry
p
ri
ce
se
n
si
ti
ve
.
G
ey
m
an
(2
01
5)
O
ve

230. rv
ie
w
an
d
as
se
ss
m
en
to
fe
x
is
ti
n
g
fi
n
d
in
gs
A
ss
es
se
s
th
e
A
C
A
’s

231. fi
rs
t5
ye
ar
s
an
d
p
re
se
n
ts
ar
gu
m
en
ts
fo
r
re
p
la
ci
n
g
it
w
it
h
si

232. n
gl
e-
p
ay
er
n
at
io
n
al
h
ea
lt
h
in
su
ra
n
ce
.
G
A
O
(2
01
4a
)*
C
M
S
an

233. d
st
at
e
d
at
a;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
th
e
n
u
m
b
er
an
d
ty
p

234. es
o
fi
ss
u
er
s
p
ar
ti
ci
p
at
in
g
in
ex
ch
an
ge
s
an
d
p
ri
o
r
to
th
e

235. ex
ch
an
ge
s
M
os
ts
ta
te
ex
ch
an
ge
s
h
ad
m
u
lt
ip
le
is
su
er
s
in
2
01
4,

236. w
it
h
va
ri
at
io
n
ac
ro
ss
st
at
es
.
G
A
O
(2
01
4b
)*
C
M
S
,s
ta
te
d
at
a,
an

237. d
in
te
rv
ie
w
s
w
it
h
st
ak
eh
o
ld
er
s;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
an
d
st

238. ak
eh
o
ld
er
s’
vi
ew
s
re
ga
rd
in
g
S
H
O
P
ch
ar
ac
te
ri
st
ic
s
D
is
cu
ss
es

239. fa
ct
o
rs
co
n
tr
ib
u
ti
n
g
to
lo
w
er
th
an
ex
p
ec
te
d
en
ro
ll
m
en
ti
n
th

240. e
S
H
O
P.
G
A
O
(2
01
5)
*
V
ar
io
u
s
so
u
rc
es
;s
tr
u
ct
u
re
d
li
te
ra
tu

241. re
se
ar
ch
;s
ta
ke
h
o
ld
er
in
te
rv
ie
w
s;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
p
re

242. m
iu
m
s
E
x
am
in
es
th
e
ef
fe
ct
s
o
ft
ax
cr
ed
it
s
an
d
th
e
av
ai
la
b

243. il
it
y
o
fa
ff
o
rd
ab
le
h
ea
lt
h
p
la
n
s.
R
ev
ie
w
s
th
e
va
ri
at
io
n
s
in
p
re

244. m
iu
m
co
st
s
b
y
in
co
m
e,
ag
e,
an
d
ge
o
gr
ap
h
y.
G
io
va
n
n
el
li
,
L

245. u
ci
a,
an
d
C
or
le
tt
e
(2
01
5)
*
R
ev
ie
w
o
fs
ta
te
-s
p
ec
ifi
c
p
ro
vi
d
er
n

246. et
w
o
rk
ad
eq
u
ac
y
st
an
d
ar
d
s
fo
r
m
ar
ke
tp
la
ce
p
la
n
s
in
th
e

247. 5
0
st
at
es
an
d
W
as
h
in
gt
o
n
,D
C
S
ta
te
re
gu
la
to
rs
se
ek
to
en
h

248. an
ce
n
et
w
o
rk
tr
an
sp
ar
en
cy
fo
r
co
n
su
m
er
s
an
d
to
m
o
n
it
o
r

249. co
m
p
li
an
ce
.
G
o
lb
er
st
ei
n
et
al
.(
2
01
5)
*
N
at
io
n
al
in
p
at
ie
n
ts

250. am
p
le
s;
C
al
if
o
rn
ia
st
at
e
d
at
a;
D
D
w
it
h
in
p
at
ie
n
ta
d
m
is
si
o
n
s

251. an
d
E
D
vi
si
ts
fo
r
p
sy
ch
ia
tr
ic
d
ia
gn
o
se
s
as
o
u
tc
o
m
es
A
C
A
’s

252. d
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
in
cr
ea
se
d
in

253. p
at
ie
n
ta
d
m
is
si
o
n
s
an
d
d
ec
re
as
ed
E
D
vi
si
ts
fo
r
19
-t
o
2
5-
ye
ar

254. o
ld
s,
re
la
ti
ve
to
co
m
p
ar
is
o
n
gr
o
u
p
.
G
ra
et
z
et
al
.
(2
01
4)
*

255. P
re
m
iu
m
d
at
a
fr
o
m
al
lm
ar
ke
tp
la
ce
s;
d
es
cr
ip
ti
ve
st
at
is
ti
cs

256. o
n
af
fo
rd
ab
il
it
y
o
fp
re
m
iu
m
s
(b
y
ag
e,
in
co
m
e,
ge
o
gr
ap
h
ic
ar
ea

257. )
M
an
y
p
eo
p
le
w
it
h
in
co
m
es
ju
st
ab
o
ve
th
re
sh
o
ld
fo
r
su
b

258. si
d
ie
s
w
il
ln
o
t
h
av
e
af
fo
rd
ab
le
co
ve
ra
ge
,a
n
d
h
en
ce
w
il
lb
e

259. ex
em
p
tf
ro
m
th
e
in
d
iv
id
u
al
m
an
d
at
e.
C
on
ti
nu
ed
1744 HSR: Health Services Research 51:5 (October 2016)
T
ab

260. le
2.
C
on
ti
nu
ed
R
es
ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds
B
ri
ef
D
es
cr
ip
ti
on

261. H
ae
d
er
an
d
W
ei
m
er
(2
01
3)
*
V
ar
io
u
s
so
u
rc
es
;q
u
al
it
at
iv
e

262. an
al
ys
es
to
id
en
ti
fy
th
e
co
m
m
o
n
th
em
es
in
in
su
ra
n
ce
ea
rl
y

263. ex
ch
an
ge
im
p
le
m
en
ta
ti
o
n
;
m
u
lt
iv
ar
ia
te
re
gr
es
si
o
n
an
al
ys

264. is
o
ft
im
el
y
ex
ch
an
ge
es
ta
b
li
sh
m
en
t
M
an
y
st
at
e
co
m
m
is
si
o

265. n
er
s
o
fi
n
su
ra
n
ce
h
av
e
p
la
ye
d
co
n
st
ru
ct
iv
e
ro
le
s
in
ex
ch
an
ge
p

266. la
n
n
in
g
d
es
p
it
e
st
ro
n
g
p
o
li
ti
ca
lo
p
p
o
si
ti
o
n
to
th
e
A
C
A
fr

267. o
m
st
at
e
go
ve
rn
o
rs
an
d
le
gi
sl
at
u
re
s.
H
al
la
n
d
M
o
o
re
(2
01
2)

268. S
ta
te
d
at
a;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
th
e
P
re
ex
is
ti
n
g
C
on
d

269. it
io
n
In
su
ra
n
ce
P
la
n
en
ro
ll
m
en
ta
n
d
co
st
s
E
x
am
in
e
th
e
ex

270. p
er
ie
n
ce
w
it
h
th
e
te
m
p
o
ra
ry
P
re
ex
is
ti
n
g
C
o
n
d
it
io
n
In

271. su
ra
n
ce
P
la
n
.
H
al
la
n
d
Sw
ar
tz
(2
01
2)
C
as
e
st
u
d
ie
s
o
fM
ar

272. yl
an
d
,C
al
if
o
rn
ia
,a
n
d
C
o
lo
ra
d
o
D
o
cu
m
en
tt
h
e
d
if
fe
re
n
ce

273. s
ac
ro
ss
st
at
es
in
te
rm
s
o
ft
h
ei
r
in
it
ia
la
p
p
ro
ac
h
es
an
d
ex
p
er
ie

274. n
ce
s
w
it
h
es
ta
b
li
sh
in
g
an
d
d
es
ig
n
in
g
ex
ch
an
ge
s.
H
al
la
n
d
L

275. o
rd
(2
01
4)
*
O
ve
rv
ie
w
an
d
as
se
ss
m
en
to
fe
x
is
ti
n
g
fi
n
d
in
gs
In

276. su
ra
n
ce
in
d
u
st
ry
’s
p
ro
fi
ta
b
il
it
y
d
o
es
n
o
ts
ee
m
to
b
e
h
u
rt
,i

277. n
d
iv
id
u
al
in
su
ra
n
ce
p
re
m
iu
m
s
h
av
e
b
ee
n
lo
w
er
th
an
ex
p
ec
te

278. d
,a
n
d
go
ve
rn
m
en
t
co
st
s
h
av
e
b
ee
n
le
ss
th
an
in
it
ia
ll
y
p
ro
je
ct
ed

279. .
H
am
el
et
al
.
(2
01
4)
*
K
F
F
S
u
rv
ey
o
fN
o
n
gr
o
u
p
H
ea
lt

280. h
In
su
ra
n
ce
E
n
ro
ll
ee
s;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
th
e
vi
ew
s
an

281. d
ex
p
er
ie
n
ce
o
f
n
o
n
gr
o
u
p
en
ro
ll
ee
s
M
aj
o
ri
ty
w
it
h

282. ex
ch
an
ge
co
ve
ra
ge
is
p
re
vi
o
u
sl
y
u
n
in
su
re
d
an
d
sa
ti
sfi
ed
w
it
h

283. co
ve
ra
ge
.
H
er
n
an
d
ez
-
B
o
u
ss
ar
d
et
al
.(
2
01
4)
*
S
ta
te
In
p
at

284. ie
n
ta
n
d
E
m
er
ge
n
cy
D
ep
ar
tm
en
tD
at
ab
as
es
fr
o
m
C
al
if
o
rn

285. ia
,F
lo
ri
d
a,
N
ew
Y
o
rk
;D
D
w
it
h
E
D
vi
si
ts
(b
y
va
ri
o
u
s
in
d
iv
id

286. u
al
ch
ar
ac
te
ri
st
ic
s)
as
th
e
o
u
tc
o
m
e
m
ea
su
re
R
at
e
o
fE
D
vi
si
ts
in

287. cr
ea
se
d
af
te
r
A
C
A
’s
d
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
im
p
le
m
en

288. ta
ti
o
n
b
u
ta
ta
sl
o
w
er
ra
te
fo
r
yo
u
n
g
ad
u
lt
s
re
la
ti
ve
to
co

289. m
p
ar
is
o
n
gr
o
u
p
.
H
o
la
h
an
,
B
u
et
tg
en
s,
an
d
D
o
rn
(2
01
3)

290. *
U
rb
an
In
st
it
u
te
’s
H
ea
lt
h
In
su
ra
n
ce
P
o
li
cy
S
im
u
la
ti
o
n
M

291. od
el
;
n
at
io
n
al
an
d
st
at
e-
le
ve
lp
ro
je
ct
io
n
s
o
fc
o
st
an
d
co
ve
ra

292. ge
u
n
d
er
th
e
A
C
A
M
ed
ic
ai
d
ex
p
an
si
o
n
fo
r
th
e
p
er
io
d
2
01

293. 3–
2
0
2
2
T
h
e
st
at
es
th
at
h
ad
n
o
te
x
p
an
d
ed
M
ed
ic
ai
d
as

294. o
fJ
u
ly
2
01
3
ge
n
er
al
ly
ar
e
th
e
o
n
es
th
at
w
o
u
ld
p
o
te
n
ti
al
ly

295. b
en
efi
tt
h
e
m
o
st
fr
o
m
th
is
p
ro
vi
si
o
n
.
H
o
w
ar
d
an
d
S
h
ea

296. re
r
(2
01
3)
D
es
cr
ip
ti
o
n
an
d
d
is
cu
ss
io
n
o
fv
ar
io
u
s
st
at
e
p
o
li
ci

297. es
an
d
p
ro
gr
am
s
to
re
d
u
ce
ch
u
rn
in
g
an
d
p
ro
m
o
te
co
n
ti
n
u

298. it
y
o
f
co
ve
ra
ge
/c
ar
e
T
h
er
e
ar
e
va
ri
o
u
s
ap
p
ro
ac
h
es
b
y
st
at

299. es
to
li
m
it
th
e
p
ro
gr
am
el
ig
ib
il
it
y
ch
an
ge
s
an
d
/o
r
th
e
im
p
ac

300. tt
h
o
se
ch
an
ge
s
h
av
e
o
n
in
d
iv
id
u
al
co
n
su
m
er
s.
Ja
co
b
s
an
d

301. C
al
la
gh
an
(2
01
3)
*
Q
u
al
it
at
iv
e
an
d
q
u
an
ti
ta
ti
ve
an
al
ys
is
to

302. ex
p
la
in
th
e
va
ri
at
io
n
s
in
re
la
ti
ve
st
at
e
p
ro
gr
es
s
in
im
p
le
m
en

303. ti
n
g
M
ed
ic
ai
d
ex
p
an
si
o
n
E
x
am
in
e
h
o
w
ec
o
n
o
m
ic
co
n
d

304. it
io
n
s,
p
as
tp
o
li
ci
es
,p
o
li
ti
cs
,a
n
d
ad
m
in
is
tr
at
iv
e
ca
p
ac
it
y
in

305. fl
u
en
ce
st
at
es
’
M
ed
ic
ai
d
ex
p
an
si
o
n
d
ec
is
io
n
.
C
on
ti
nu
ed

306. The ACA’s Key Provisions: A Systematic Review 1745
T
ab
le
2.
C
on
ti
nu
ed
R
es
ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds
B
ri
ef

307. D
es
cr
ip
ti
on
K
F
F
an
d
C
F
(2
01
5)
*
K
F
F
/C
F
2
01
5
N
at
io
n
al
S
u

308. rv
ey
o
fP
ri
m
ar
y
C
ar
e
P
ro
vi
d
er
s;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
th

309. e
im
p
ac
to
ft
h
e
A
C
A
o
n
p
at
ie
n
t
p
o
p
u
la
ti
o
n
,p
ro
vi
d
er
s’

310. p
ra
ct
ic
e
ca
p
ac
it
y,
an
d
th
ei
r
o
p
in
io
n
s
ab
o
u
tt
h
e
A
C
A
’s
im
p

311. ac
to
n
m
ed
ic
al
p
ra
ct
ic
e
M
aj
o
ri
ty
o
fp
ri
m
ar
y
ca
re
p
ro
vi
d
er

312. s
su
rv
ey
ed
sa
w
in
cr
ea
se
in
u
n
in
su
re
d
o
r
M
ed
ic
ai
d
p
at
ie
n
ts
(i
n

313. ex
p
an
si
on
st
at
es
)w
it
h
ou
tr
ed
uc
in
g
qu
al
it
y
o
f
ca
re
.
K
ar
p

314. m
an
,W
ei
ss
,
an
d
L
o
n
g
(2
01
5)
*
U
rb
an
In
st
it
u
te
H
ea
lt
h
R
ef
o
rm

315. M
o
n
it
o
ri
n
g
S
u
rv
ey
;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
T
h
e
p
ro
p
o
rt

316. io
n
o
fm
id
d
le
-a
n
d
h
ig
h
-i
n
co
m
e
ad
u
lt
s
re
p
o
rt
in
g
ac
ce
ss
p
ro

317. b
le
m
s
d
ec
re
as
ed
in
2
01
4
co
m
p
ar
ed
to
2
01
3.
D
is
p
ar
it
ie
s
p
er
si
st
fo

318. r
ce
rt
ai
n
ag
e,
in
co
m
e,
an
d
et
h
n
ic
gr
o
u
p
s,
an
d
4
0%
o
fa
d
ul
ts
re

319. po
rt
ed
va
ri
ou
s
p
ro
vi
d
er
ac
ce
ss
p
ro
b
le
m
s.
K
au
fm
an
et
al
.(
2

320. 01
5)
*
E
n
co
u
n
te
r
d
at
a
fr
o
m
Q
u
es
tD
ia
gn
o
st
ic
s;
d
es
cr
ip
ti
ve

321. st
at
is
ti
cs
o
n
th
e
n
u
m
b
er
o
fn
ew
ly
id
en
ti
fi
ed
d
ia
b
et
es
p

322. at
ie
n
ts
in
2
01
3
ve
rs
u
s
2
01
4
N
u
m
b
er
o
fM
ed
ic
ai
d
p
at
ie
n
ts

323. w
it
h
n
ew
d
ia
b
et
es
d
ia
gn
o
se
s
in
cr
ea
se
d
,
p
ar
ti
cu
la
rl
y
in
M

324. ed
ic
ai
d
ex
p
an
si
o
n
st
at
es
.
K
ee
h
an
et
al
.
(2
01
5)
*
D
at
a
fr

325. o
m
va
ri
o
u
s
so
u
rc
es
in
cl
u
d
in
g
C
M
S
,B
u
re
au
o
f
E
co
n
o
m

326. ic
A
n
al
ys
is
,U
.S
.C
en
su
s;
p
ro
je
ct
io
n
s
b
as
ed
o
n
ac
tu
ar
ia
la
n
d
ec

327. o
n
o
m
et
ri
c
m
o
d
el
in
g
m
et
h
o
d
s
P
ro
vi
d
e
va
ri
o
u
s
p
ro
je
ct
io
n

328. s
fo
r
n
at
io
n
al
h
ea
lt
h
ex
p
en
d
it
u
re
s
(b
y
sp
en
d
in
g
ca
te
go
ri

329. es
,p
er
en
ro
ll
ee
,b
y
sp
o
n
so
r
ty
p
e,
et
c.
)f
o
r
2
01
4–
2
0
2
4.
K
ir

330. zi
n
ge
r,
C
o
h
en
,a
n
d
G
in
d
i(
20
13
)*
N
H
IS
;d
es
cr
ip
ti
ve
st
at

331. is
ti
cs
o
n
th
e
tr
en
d
s
in
in
su
ra
n
ce
co
ve
ra
ge
an
d
so
u
rc
e
o
fc
o
ve

332. ra
ge
am
o
n
g
yo
u
n
g
ad
u
lt
s
A
ft
er
th
e
d
ep
en
d
en
tc
o
ve
ra
ge

333. p
ro
vi
si
o
n
o
ft
h
e
A
C
A
to
o
k
ef
fe
ct
,p
ri
va
te
h
ea
lt
h
in
su
ra
n
ce

334. co
ve
ra
ge
am
o
n
g
yo
u
n
g
ad
u
lt
s
ag
ed
19
–
2
5
in
cr
ea
se
d
re
la
ti
ve

335. to
a
co
m
p
ar
is
o
n
gr
o
u
p
,w
h
il
e
co
ve
ra
ge
in
th
ei
r
o
w
n
n
am
e
h

336. as
d
ec
re
as
ed
.
K
o
ta
ga
le
t
al
.
(2
01
4)
*
B
R
F
S
S
,N
H
IS
;D
D
w

337. it
h
h
ea
lt
h
st
at
u
s,
p
re
se
n
ce
o
fa
u
su
al
so
u
rc
e
o
fc
ar
e
an
d
ab

338. il
it
y
to
af
fo
rd
m
ed
ic
at
io
n
s,
d
en
ta
lc
ar
e,
o
r
p
h
ys
ic
ia
n
vi
si
ts

339. as
o
u
tc
o
m
e
m
ea
su
re
s
F
in
d
in
cr
ea
se
in
co
ve
ra
ge
fo
r
yo
u
n
g
ad

340. u
lt
s
o
f1
9–
2
5
ye
ar
s
o
ld
re
la
ti
ve
to
a
co
m
p
ar
is
o
n
gr
o
u
p
,b

341. u
tm
o
re
li
m
it
ed
ch
an
ge
s
in
ac
ce
ss
to
ca
re
an
d
h
ea
lt
h
st
at
u

342. s.
K
o
w
al
sk
i(
2
01
4)
*
N
at
io
n
al
A
ss
o
ci
at
io
n
o
fI
n
su
ra
n
ce
C
o
m

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is
si
o
n
er
s
d
at
a;
st
at
e-
sp
ec
ifi
c
se
as
o
n
al
ly
ad
ju
st
ed
tr
en
d
re
gr

344. es
si
o
n
s
o
fh
ea
lt
h
in
su
ra
n
ce
co
ve
ra
ge
,p
re
m
iu
m
s,
an
d
co
st
s

345. S
u
gg
es
ts
th
at
st
at
e
p
o
li
ci
es
to
w
ar
d
th
e
A
C
A
h
av
e
d
if
fe
re
n
ti
al
ef

346. fe
ct
s
o
n
w
el
fa
re
o
fm
ar
ke
tp
ar
ti
ci
p
an
ts
.
L
au
et
al
.(
2
01
4)

347. *
M
E
P
S
;p
re
-p
o
st
d
es
ig
n
u
si
n
g
m
u
lt
iv
ar
ia
te
re
gr
es
si
o
n
an
al

348. ys
is
o
fh
ea
lt
h
ca
re
u
se
in
cl
u
d
in
g
ro
u
ti
n
e
ex
am
in
at
io
n
in
th

349. e
p
as
t
ye
ar
,b
lo
o
d
p
re
ss
u
re
/c
h
o
le
st
er
o
ls
cr
ee
n
in
gs
,i
n
fl
u
en

350. za
va
cc
in
at
io
n
,a
n
d
an
n
u
al
d
en
ta
lv
is
it
A
C
A
’s
d
ep
en
d
en
tc
o

351. ve
ra
ge
p
ro
vi
si
o
n
h
as
in
cr
ea
se
d
in
su
ra
n
ce
co
ve
ra
ge
an
d
th
e
u
se

352. o
fs
o
m
e
p
re
ve
n
ti
ve
se
rv
ic
es
am
o
n
g
yo
u
n
g
ad
u
lt
s.
L
ev
it
t,

353. C
o
x
,a
n
d
C
la
x
to
n
(2
01
5)
*
H
ea
lt
h
C
o
ve
ra
ge
P
o
rt
al
d
at
a
o
n

354. in
su
ra
n
ce
co
m
p
an
y
fi
li
n
gs
;
d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
m
ar
ke

355. tp
la
ce
en
ro
ll
m
en
ts
(b
y
st
at
e)
D
is
cu
ss
in
d
iv
id
u
al
m
ar
ke
tc
o
ve
ra
ge

356. in
2
01
4.
A
b
o
u
t8
5%
o
ft
h
o
se
w
it
h
m
ar
ke
tp
la
ce
p
la
n
s
w
er
e
el

357. ig
ib
le
fo
r
su
b
si
d
ie
s.
C
on
ti
nu
ed
1746 HSR: Health Services Research 51:5 (October 2016)
T
ab
le
2.
C
on
ti
nu
ed
R
es

358. ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds
B
ri
ef
D
es
cr
ip
ti
on
L
ip
to
n
an
d
D
ec
ke
r

359. (2
01
5)
*
N
H
IS
;D
D
w
it
h
li
ke
li
h
o
o
d
o
fH
P
V
va
cc
in
e
in
it
ia
ti
o
n

360. ,
co
m
p
le
ti
o
n
an
d
aw
ar
en
es
s
as
o
u
tc
o
m
e
m
ea
su
re
s
A
C
A

361. ’s
d
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
an
in
cr
ea
se

362. in
H
P
V
va
cc
in
at
io
n
ra
te
s
fo
r
yo
u
n
g
ad
u
lt
s
re
la
ti
ve
to
co
m
p
ar

363. is
o
n
gr
o
u
p
.
M
ar
ti
n
ez
,W
ar
d
,
an
d
A
d
am
s
(2
01
5)
*
N
H
IS
;d

364. es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
ch
an
ge
s
in
h
ea
lt
h
in
su
ra
n
ce
co
ve
ra
ge

365. an
d
se
le
ct
ed
m
ea
su
re
s
o
fh
ea
lt
h
ca
re
ac
ce
ss
an
d
u
ti
li
za
ti
o
n

366. D
o
cu
m
en
td
is
p
ar
it
ie
s
in
ac
ce
ss
to
ca
re
,c
o
ve
ra
ge
,a
n
d
h
ea
lt
h
ca
re

367. u
ti
li
za
ti
o
n
.
M
cC
u
e
an
d
H
al
l(
2
01
3)
In
su
re
r
d
at
a
fr
o
m

368. th
e
D
ep
ar
tm
en
to
fH
ea
lt
h
an
d
H
u
m
an
Se
rv
ic
es
;d
es
cr
ip
ti
ve
st

369. at
is
ti
cs
o
n
p
re
m
iu
m
in
cr
ea
se
s
fo
r
in
d
iv
id
u
al
an
d
sm
al
l-
gr
o

370. u
p
p
la
n
s
as
w
el
la
s
th
e
co
n
tr
ib
u
ti
n
g
fa
ct
o
rs
in
cl
u
d
in
g
th
e
A

371. C
A
In
su
re
rs
at
tr
ib
u
te
d
th
re
e-
q
u
ar
te
rs
o
r
m
o
re
o
ft
h
e
la
rg
er
ra

372. te
in
cr
ea
se
s
to
fa
ct
o
rs
su
ch
as
tr
en
d
s
in
m
ed
ic
al
ex
p
en
se
s.
T

373. h
ey
at
tr
ib
u
te
d
o
n
ly
a
ve
ry
sm
al
lp
o
rt
io
n
o
ft
h
es
e
ch
an
ge
s
to

374. th
e
A
C
A
.
M
cC
u
e
an
d
H
al
l(
2
01
5)
*
In
su
re
r
d
at
a
fr
o
m
th
e

375. D
ep
ar
tm
en
to
fH
ea
lt
h
an
d
H
u
m
an
Se
rv
ic
es
;d
es
cr
ip
ti
ve
st
at
is

376. ti
cs
o
n
p
re
m
iu
m
in
cr
ea
se
s
fo
r
in
d
iv
id
u
al
an
d
sm
al
l-
gr
o
u
p

377. p
la
n
s
as
w
el
la
s
th
e
co
n
tr
ib
u
ti
n
g
fa
ct
o
rs
in
cl
u
d
in
g
th
e
A
C
A

378. In
su
re
rs
at
tr
ib
u
te
d
th
e
gr
ea
tp
o
rt
io
n
o
fl
ar
ge
r
ra
te
in
cr
ea
se
s
to
fa

379. ct
o
rs
su
ch
as
tr
en
d
s
in
m
ed
ic
al
ex
p
en
se
s,
an
d
m
o
st
o
ft
h

380. em
d
id
n
o
ta
tt
ri
b
u
te
th
es
e
ch
an
ge
s
to
th
e
A
C
A
.
M
cM
o
rr

381. o
w
et
al
.(
2
01
5)
*
N
H
IS
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
th
e
tr
en
d

382. s
in
in
su
ra
n
ce
co
ve
ra
ge
an
d
so
u
rc
e
o
fc
o
ve
ra
ge
am
o
n
g
yo
u
n
g

383. ad
u
lt
s
T
h
e
d
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
re
d
u
ce
d
u
n
in

384. su
ra
n
ce
m
ai
n
ly
am
o
n
g
h
ig
h
-i
n
co
m
e
yo
u
n
g
ad
u
lt
s,
w
h
il

385. e
th
e
la
te
r
A
C
A
p
ro
vi
si
o
n
s
re
d
u
ce
d
u
n
in
su
ra
n
ce
m
ai
n
ly
am

386. o
n
g
lo
w
-a
n
d
m
o
d
er
at
e-
in
co
m
e
yo
u
n
g
ad
u
lt
s,
p
ar
ti
cu
la
rl
y

387. in
M
ed
ic
ai
d
ex
p
an
si
o
n
st
at
es
.
M
u
lc
ah
y
et
al
.(
2
01
3)
*

388. IM
S
H
ea
lt
h
C
h
ar
ge
D
at
a
M
as
te
r
d
at
ab
as
e;
D
D
w
it
h
n
o
n
d
is
cr

389. et
io
n
ar
y
E
D
vi
si
ts
(b
y
ty
p
e
o
fi
n
su
ra
n
ce
co
ve
ra
ge
an
d
re
as
o
n
fo
r

390. vi
si
t)
as
th
e
o
u
tc
o
m
e
m
ea
su
re
A
C
A
’s
d
ep
en
d
en
tc
o
ve
ra
ge
p

391. ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
an
in
cr
ea
se
in
th
e
p
ri
va
te
ly
co
ve
re
d

392. p
ro
p
o
rt
io
n
o
fy
o
u
n
g
ad
u
lt
E
D
vi
si
ts
(a
n
d
a
d
ec
re
as
e
in
u
n

393. in
su
re
d
yo
u
n
g
ad
u
lt
E
D
vi
si
ts
)r
el
at
iv
e
to
co
m
p
ar
is
o
n
gr
o
u
p

394. .
O
’H
ar
a
an
d
B
ra
u
lt
(2
01
3)
*
A
C
S
;D
D
w
it
h
u
n
in
su
ra
n
ce

395. an
d
p
ri
va
te
h
ea
lt
h
in
su
ra
n
ce
co
ve
ra
ge
ra
te
s
as
th
e
o
u
tc
o
m
e
m
ea

396. su
re
s
E
st
im
at
e
in
su
ra
n
ce
ra
te
s
b
y
st
at
e,
ge
n
d
er
,r
ac
e,
et
h
n
ic
it

397. y,
E
n
gl
is
h
sp
ea
ki
n
g,
an
d
ci
ti
ze
n
sh
ip
st
at
u
s.
D
is
p
ar
it
ie
s
b
y
ge

398. n
d
er
n
ar
ro
w
ed
,b
u
t
th
o
se
b
y
ra
ce
an
d
et
h
n
ic
it
y
p
er
si
st
.

399. O
ls
o
n
(2
01
5)
C
as
e
st
u
d
y
o
fP
en
n
sy
lv
an
ia
in
te
rm
s
o
fi
ts
ex

400. is
ti
n
g
M
ed
ic
ai
d
p
ro
gr
am
an
d
h
o
w
it
h
as
b
ee
n
af
fe
ct
ed
b
y

401. th
e
A
C
A
E
x
am
in
e
fi
n
an
ci
al
an
d
o
th
er
co
n
si
d
er
at
io
n
s
in

402. p
o
li
cy
m
ak
er
s’
M
ed
ic
ai
d
ex
p
an
si
o
n
d
ec
is
io
n
.
P
o
ls
ky
et

403. al
.
(2
01
4)
*
D
at
a
o
n
al
lp
la
n
s
o
ff
er
ed
in
th
e
m
ar
ke
tp
la
ce
s
fr
o

404. m
th
e
H
ea
lt
h
In
su
ra
n
ce
E
x
ch
an
ge
s
(H
IX
)2
.0
d
at
as
et
;d
es
cr

405. ip
ti
ve
st
at
is
ti
cs
o
n
si
lv
er
p
la
n
s
C
om
p
ar
e
in
su
re
r
co
m
p
et
it

406. io
n
,p
la
n
ch
ar
ac
te
ri
st
ic
s,
an
d
p
re
m
iu
m
s
in
h
ea
lt
h
in
su
ra
n
ce
ex

407. ch
an
ge
s
fo
r
ru
ra
la
n
d
u
rb
an
ar
ea
s.
P
o
ls
ky
et
al
.
(2
01
5)
*
S
im

408. u
la
te
d
p
at
ie
n
ts
tu
d
y
o
fp
ri
m
ar
y
ca
re
p
ra
ct
ic
es
in
10
st
at
es
;

409. d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
th
e
av
ai
la
b
il
it
y
o
fa
p
p
o
in
tm
en
ts
an

410. d
w
ai
ti
n
g
ti
m
es
fo
r
ap
p
o
in
tm
en
ts
fo
r
n
ew
p
at
ie
n
ts
b
y
st
at

411. e
an
d
in
su
ra
n
ce
ty
p
e
A
va
il
ab
il
it
y
o
fp
ri
m
ar
y
ca
re
ap
p
o
in

412. tm
en
ts
fo
r
M
ed
ic
ai
d
p
at
ie
n
ts
in
cr
ea
se
d
fo
ll
o
w
in
g
an
in
cr
ea
se

413. in
M
ed
ic
ai
d
re
im
b
u
rs
em
en
ts
w
h
il
e
n
o
ch
an
ge
s
w
er
e
o
b
se
rv

414. ed
fo
r
th
e
p
ri
va
te
in
su
ra
n
ce
gr
o
u
p
.
C
on
ti
nu
ed
The ACA’s Key Provisions: A Systematic Review 1747
T
ab
le

415. 2.
C
on
ti
nu
ed
R
es
ea
rc
h
St
ud
y
D
at
a/
M
et
ho
ds
B
ri
ef
D
es
cr
ip
ti
on
R

416. as
m
u
ss
en
et
al
.(
2
01
4)
*
C
F
A
C
A
T
ra
ck
in
g
S
u
rv
ey
;d
es
cr
ip
ti
ve

417. st
at
is
ti
cs
o
n
p
re
m
iu
m
s,
o
u
t-
o
f-
p
o
ck
et
co
st
s,
p
eo
p
le
’s
ab
il

418. it
y
to
co
m
p
ar
e
p
la
n
s
an
d
th
ei
r
ex
p
er
ie
n
ce
s
in
te
rm
s
o
ffi

419. n
d
in
g
o
u
ta
b
o
u
tt
h
ei
r
el
ig
ib
il
it
y
fo
r
fi
n
an
ci
al
as
si
st
an
ce
o

420. r
M
ed
ic
ai
d
M
os
ta
d
u
lt
s
w
it
h
m
ar
ke
tp
la
ce
co
ve
ra
ge
ar
e
sa
ti
sfi
ed

421. w
it
h
th
ei
r
p
la
n
s.
T
h
o
se
w
it
h
lo
w
o
r
m
o
d
er
at
e
in
co
m
es
re

422. p
o
rt
h
av
in
g
p
re
m
iu
m
s
an
d
d
ed
u
ct
ib
le
s
si
m
il
ar
to
th
o
se
w
it

423. h
E
S
I.
R
as
m
u
ss
en
et
al
.(
2
01
5)
C
F
B
ie
n
n
ia
lH
ea
lt
h
In
su
ra
n
ce

424. S
u
rv
ey
;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
h
ea
lt
h
in
su
ra
n
ce
co
ve
ra
ge
,c

425. o
st
-r
el
at
ed
p
ro
b
le
m
s
ge
tt
in
g
n
ee
d
ed
ca
re
,a
n
d
m
ed
ic
al
d
eb

426. ti
n
C
al
if
o
rn
ia
,F
lo
ri
d
a,
N
ew
Y
o
rk
,a
n
d
Te
x
as
C
al
if
o
rn
ia
an
d

427. N
ew
Y
o
rk
h
av
e
th
ei
r
o
w
n
ex
ch
an
ge
s
an
d
ex
p
an
d
ed
M
ed

428. ic
ai
d
.U
n
in
su
re
d
ra
te
s
in
th
es
e
st
at
es
ar
e
lo
w
er
an
d
af
fo
rd
ab

429. il
it
y
is
b
et
te
r
th
an
in
F
lo
ri
d
a
an
d
T
ex
as
,w
h
ic
h
re
ly
o
n
th
e

430. fe
d
er
al
ex
ch
an
ge
an
d
d
id
n
o
te
x
p
an
d
M
ed
ic
ai
d
.
R
os
en

431. b
au
m
et
al
.(
2
01
4)
*
R
ev
ie
w
p
la
n
-t
o
-p
la
n
tr
an
si
ti
o
n
p
o
li
ci

432. es
im
p
le
m
en
te
d
in
16
st
at
es
an
d
W
as
h
in
gt
o
n
,D
C
,t
o
m
it
ig
at
e

433. th
e
ef
fe
ct
s
o
f
ch
u
rn
in
g
an
d
to
en
su
re
co
n
ti
n
u
it
y
o
fc
ar
e.
T

434. h
er
e
ar
e
va
ri
o
u
s
st
ra
te
gi
es
to
m
it
ig
at
e
th
e
ef
fe
ct
s
o
fc
h
u
rn
in
g
ac

435. ro
ss
M
ed
ic
ai
d
,C
H
IP
,a
n
d
p
u
b
li
cl
y
su
b
si
d
iz
ed
p
ri
va
te
co
ve
ra

436. ge
,b
u
tt
h
ey
ar
e
ra
th
er
co
m
p
le
x
an
d
m
ay
ta
ke
ti
m
e
to
im
p

437. le
m
en
ta
n
d
to
yi
el
d
th
e
d
es
ir
ed
re
su
lt
s.
S
al
o
n
er
an
d
L
e

438. C
o
o
k
(2
01
4)
*
N
at
io
n
al
S
u
rv
ey
o
fD
ru
g
U
se
an
d
H
ea
lt
h
;D
D

439. w
it
h
se
le
ct
ed
m
ea
su
re
s
o
fm
en
ta
lh
ea
lt
h
an
d
su
b
st
an
ce
ab
u
se

440. tr
ea
tm
en
ta
s
o
u
tc
o
m
es
A
C
A
’s
d
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi

441. si
o
n
is
as
so
ci
at
ed
w
it
h
in
cr
ea
se
d
u
se
o
f
m
en
ta
lh
ea
lt
h
tr
ea
tm

442. en
ta
m
o
n
g
yo
u
n
g
ad
u
lt
s
re
la
ti
ve
to
co
m
p
ar
is
o
n
gr
o
u
p
.N

443. o
si
gn
ifi
ca
n
tc
h
an
ge
s
w
er
e
o
b
se
rv
ed
in
su
b
st
an
ce
u
se
tr
ea
tm

444. en
t.
Sc
h
o
en
,R
ad
le
y,
an
d
C
o
ll
in
s
(2
01
5)
*
M
E
P
S
,C
P
S

445. ;d
es
cr
ip
ti
ve
st
at
is
ti
cs
o
n
E
S
I
p
la
n
tr
en
d
s
re
ga
rd
in
g
th
ei
r

446. p
re
m
iu
m
s,
af
fo
rd
ab
il
it
y,
w
o
rk
er
co
n
tr
ib
u
ti
o
n
s,
an
d
o
u
t-
o
f-

447. p
o
ck
et
co
st
s
R
ep
o
rt
th
at
th
e
co
st
o
fE
S
I
p
re
m
iu
m
s
ro
se
fa
st
er

448. th
an
m
ed
ia
n
in
co
m
es
d
u
ri
n
g
2
00
3–
2
01
3.
A
sl
o
w
d
o
w
n
in

449. th
e
gr
o
w
th
ra
te
o
fp
re
m
iu
m
s
w
as
o
b
se
rv
ed
o
ve
r
th
e
la
st
3
ye
ar

450. s
fo
ll
o
w
in
g
th
e
A
C
A
im
p
le
m
en
ta
ti
o
n
.
Sc
o
tt
et
al
.(
2
01
5)
*

451. N
at
io
n
al
T
ra
u
m
a
D
at
a
B
an
k;
D
D
w
it
h
u
n
in
su
ra
n
ce
st
at
u
s
an

452. d
cl
in
ic
al
o
u
tc
o
m
es
fo
r
tr
au
m
a
p
at
ie
n
ts
as
o
u
tc
o
m
e
m
ea
su

453. re
s
D
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
a
si
gn

454. ifi
ca
n
td
ec
re
as
e
in
th
e
ra
te
o
fu
n
in
su
re
d
tr
au
m
a
p
at
ie
n
ts
ag
es

455. 19
–
2
5,
b
u
tt
h
er
e
ar
e
n
o
si
gn
ifi
ca
n
tc
h
an
ge
s
in
cl
in
ic
al
tr
au

456. m
a
o
u
tc
o
m
es
.
S
h
an
e
an
d
A
yy
ag
ar
i(
2
01
4)
*
M
E
P
S
;D
D

457. w
it
h
in
su
ra
n
ce
co
ve
ra
ge
b
y
ra
ce
,i
n
co
m
e,
m
ar
it
al
st
at
u
s,
an
d
p

458. o
li
cy
h
o
ld
er
st
at
u
s
as
th
e
o
u
tc
o
m
e
m
ea
su
re
s
W
h
il
e
th
e
d

459. ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
in
cr
ea
se
d
in
su
ra
n
ce
co
ve
ra
ge
am
o

460. n
g
al
lr
ac
ia
la
n
d
et
h
n
ic
gr
o
u
p
s,
it
d
id
n
o
tr
ed
u
ce
o
ve
ra
ll
d
is

461. p
ar
it
ie
s.
D
is
p
ar
it
ie
s
m
ay
h
av
e
w
id
en
ed
am
o
n
g
lo
w
-i
n
co
m
e

462. in
d
iv
id
u
al
s.
S
ko
p
ec
an
d
K
ro
n
ic
k
(2
01
3)
*
V
ar
io
u
s
so
u
rc
es

463. in
cl
u
d
in
g
M
E
P
S
an
d
m
ar
ke
tp
la
ce
in
su
ra
n
ce
p
re
m
iu
m
s
fr
o
m

464. se
le
ct
ed
st
at
es
;d
es
cr
ip
ti
ve
co
m
p
ar
is
o
n
s
o
f
th
e
p
re
m
iu
m
s

465. in
th
e
in
d
iv
id
u
al
an
d
sm
al
l-
gr
o
u
p
m
ar
ke
ts
to
ea
rl
ie
r
C
B
O
es

466. ti
m
at
es
P
re
m
iu
m
s
fo
r
si
lv
er
p
la
n
s
in
2
01
4
ar
e
lo
w
er
th
an
C

467. B
O
es
ti
m
at
es
an
d
ap
p
ea
r
to
b
e
af
fo
rd
ab
le
fo
r
th
e
m
o
st
p
ar
t.

468. So
m
m
er
s
an
d
K
ro
n
ic
k
(2
01
2)
*
C
P
S
;D
D
w
it
h
in
su
ra
n
ce
co
ve

469. ra
ge
an
d
ty
p
e
as
w
el
la
s
p
o
li
cy
h
o
ld
er
st
at
u
s
as
o
u
tc
o
m
es

470. D
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
le
d
to
in
cr
ea
se
s
in
in
su
ra
n
ce

471. co
ve
ra
ge
fo
r
yo
u
n
g
ad
u
lt
s,
es
p
ec
ia
ll
y
am
o
n
g
m
in
o
ri
ti
es
.

472. C
on
ti
nu
ed
1748 HSR: Health Services Research 51:5 (October 2016)
T
ab
le
2.
C
on
ti
nu
ed
R
es
ea
rc
h
St
ud
y
D
at
a/

473. M
et
ho
ds
B
ri
ef
D
es
cr
ip
ti
on
So
m
m
er
s
et
al
.(
2
01
3)
*
N
H
IS
,C
P
S

474. ;D
D
w
it
h
in
su
ra
n
ce
co
ve
ra
ge
an
d
ac
ce
ss
to
ca
re
as
o
u
tc
o
m
e
m
ea

475. su
re
s
D
ep
en
d
en
tc
o
ve
ra
ge
p
ro
vi
si
o
n
is
as
so
ci
at
ed
w
it
h
si
gn

476. ifi
ca
n
ti
n
cr
ea
se
s
in
p
ri
va
te
h
ea
lt
h
in
su
ra
n
ce
an
d
ac
ce
ss
to
ca
re
fo

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478. K
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481. su
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485. C
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486. ra
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487. 17
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488. et
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489. iv
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490. ge
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491. o
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492. io
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fo
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494. *
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495. sa
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496. D
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it
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498. e
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499. ,a
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500. ta
lb
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502. ea
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ve
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503. il
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d
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504. n
d
af
fo
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u
n
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la
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505. o
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la
ce
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d
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m
m
er
s
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01
5)
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506. ra
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f-
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p
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507. as
o
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m
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si
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508. ci
at
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h
b
et
te
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se
lf
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d
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509. ca
re
am
o
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u
n
g
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510. W
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ra
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l5

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512. eq
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513. ts
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514. d
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le
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515. ar
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ss
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th
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516. ,A
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522. ea
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524. rv
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525. co
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p
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.
The ACA’s Key Provisions: A Systematic Review 1749
RESULTS
Dependent Coverage Provision
Under the so-called young adult mandate, individuals between
the ages of 19–
25 years are allowed to remain on their parents’ health
insurance plans. Since
this mandate took effect in 2010, many researchers have already
examined the
impact of the law on this population. Most of this literature uses

526. a quasi-experi-
mental difference-in-differences approach to compare young
adults aged
19–25 to slightly older individuals before and after 2010.
Although magni-
tudes vary, all studies show a rapid increase in insurance
coverage among
young adults after this provision took effect (Cantor et al. 2012;
Sommers and
Kronick 2012; Akosa Antwi, Moriya, and Simon 2013;
Kirzinger, Cohen, and
Gindi 2013; O’Hara and Brault 2013; Chua and Sommers 2014;
Kotagal et al.
2014). Collins et al. (2013a) reported that in 2013 an estimated
15 million
young adults were on a parent’s policy in the past 12 months, an
increase of
1.3 million since 2011. Approximately half of these were full-
time students
(Collins et al. 2013a). These estimates are in line with other
studies suggesting
that 1–3 million uninsured young adults gained coverage under
the ACA
(Akosa Antwi, Moriya, and Simon 2013; O’Hara and Brault
2013; Blumen-
thal, Abrams, and Nuzum 2015; McMorrow et al. 2015).
The gains in coverage are especially pronounced for men,
unmarried
individuals, and nonstudents (Sommers et al. 2013). Consistent
with
adverse selection, young adults in worse health acquired
coverage sooner
and with greater frequency than others (Sommers et al. 2013).
This man-
date primarily benefitted those with relatively high incomes,

527. while Medi-
caid expansion and marketplace reforms implemented in 2014
targeted
lower income young adults (McMorrow et al. 2015). Overall,
the rate of
uninsured young adults decreased from 30 percent in 2009 to 19
percent
in 2014, which translates to about 6 million of them remaining
uninsured
in 2014 (McMorrow et al. 2015). Disparities persist by race,
ethnicity, and
income (O’Hara and Brault 2013; Shane and Ayyagari 2014).
Most studies
report that gains in insurance coverage are associated with
better access to
health care for young adults (Sommers et al. 2013; Wallace and
Sommers
2015), especially among men and college graduates
(Barbaresco, Courte-
manche, and Qi 2015). Others find that the ACA is associated
with
improvements in self-reported health status among young adults
(Carlson
et al. 2014; Chua and Sommers 2014; Barbaresco,
Courtemanche, and Qi
2015; Wallace and Sommers 2015).
1750 HSR: Health Services Research 51:5 (October 2016)
Studies have examined the effect of expanded dependent
coverage on
the utilization of emergency department (ED) care (Mulcahy et
al. 2013;
Hernandez-Boussard et al. 2014; Akosa Antwi et al. 2015),

528. preventive ser-
vices (Lau et al. 2014; Barbaresco, Courtemanche, and Qi 2015;
Lipton and
Decker 2015), dental care (Vujicic, Yarbrough, and Nasseh
2014), and mental
health treatment (Saloner and Le Cook 2014; Golberstein et al.
2015). Akosa
Antwi, Moriya, and Simon (2015) found that inpatient hospital
visits increased
3.5 percent and mental health visits increased 9 percent among
young adults,
without significant differences in hospital length of stay or
charges. ED visits
actually decreased among young adults (Hernandez-Boussard et
al. 2014;
Akosa Antwi et al. 2015).
Besides the changes in insurance coverage and health care
utilization
among this group, the proportion of young adults reporting high
out-of-pocket
spending for health care decreased significantly following
passage of the ACA
(Busch, Golberstein, and Meara 2014; Chua and Sommers
2014). Compared
to individual plans, premiums for plans covering children have
increased
2.5–2.8 percent more due to the dependent coverage provision,
but employ-
ers absorbed much of this increase (Depew and Bailey 2015).
The amount of
uncompensated care for young adults decreased as a greater
proportion of
ED, trauma center, and psychiatric inpatient utilization being
covered by pri-
vate insurance (Mulcahy et al. 2013; Akosa Antwi, Moriya, and

529. Simon 2015;
Golberstein et al. 2015; Scott et al. 2015).
Overall Health Insurance Coverage, Access, and Affordability
Preliminary data suggest that the law has substantially
decreased the number
of uninsured Americans (Sommers et al. 2014a, 2015; Cohen
and Martinez
2015; Collins et al. 2015a,b). Figure 1 shows recent trends and
projections
for various sources of health insurance coverage and
uninsurance rates (Kee-
han et al. 2015). The rate of uninsured adults decreased from 20
percent in
2013 to 15 percent in 2014 (Doty, Rasmussen, and Collins
2014), with further
declines expected in coming years (Keehan et al. 2015).
According to Blu-
menthal, Abrams, and Nuzum (2015), an estimated 7–16 million
uninsured
people acquired coverage since 2010, with young adults, low-
income indi-
viduals, and minorities experiencing large gains. Similarly, the
CBO (2015a)
estimates that 17 million more people would have been
uninsured in 2015
without the ACA. In the first 5 years of the ACA, 11.7 million
purchased
new plans from the marketplace, 10.8 million more have
Medicaid coverage,
and 3 million young adults are on their parents’ policies
(Blumenthal,
Abrams, and Nuzum 2015).
The ACA’s Key Provisions: A Systematic Review 1751

530. The majority of new enrollees are satisfied with their plans and
feel more
financially secure, although paying the premiums is still a
challenge for some
(Hamel et al. 2014; Collins et al. 2015b). The 2014
Commonwealth Fund
Biennial Health Insurance Survey was the first since 2003 to
show a decline in
the number of adults reporting problems affording needed
medical care
(Collins et al. 2015b). Sommers et al. (2015) found significant
improvements
in access to primary care services and medications, affordability
of care, and
self-reported health after the first 2 years of the ACA. Analyses
indicate that
expanded coverage has led to better access to a physician
(Sommers et al.
2014a; Collins et al. 2015b) among all income groups
(Karpman, Weiss, and
Long 2015). Although the proportion without a regular source
of care
decreased from 29.8 percent in 2013 to 26 percent in 2014,
almost 40 percent
of respondents still had at least one access problem (Karpman,
Weiss, and
Long 2015). Disparities in access measures persist for different
racial/ethnic
0.00
15.00

531. 30.00
45.00
60.00
75.00
2007 2012 2013 2014* 2015* 2018*
%
o
f
to
ta
l
p
o
p
u
la
ti
o
n
Year
Figure 1: Health Insurance Coverage in the United States before
and after
the ACA

532. Notes. *Indicates projections. Estimated percentages in a given
year do not sum to 100% due to
rounding and because individuals can have multiple sources of
health insurance coverage.
Source: Keehan et al. (2015).
1752 HSR: Health Services Research 51:5 (October 2016)
and income groups (Cohen and Martinez 2015; Karpman, Weiss,
and Long
2015; Martinez, Ward, and Adams 2015).
Over the 2016–2025 period, the CBO (2015b) projects that the
ACAwill
reduce the number of uninsured by 24–25 million people
relative to what
would have occurred otherwise. However, about 26–29 million
nonelderly
are still expected to lack coverage, including unauthorized
immigrants, those
who live in non-Medicaid expansion states, individuals affected
by the “family
glitch” (discussed below), and those who choose not to enroll in
Medicaid or
purchase insurance (CBO 2015b). The uninsured are more likely
to be young,
low-income, and Hispanic (Collins et al. 2015b).
Health Insurance Exchanges, Tax Credits, and the Individual
Mandate
Impact of Marketplace Design and Implementation. Political
factors along with

533. administrative capabilities influenced whether a state
established its own
exchange or relied on the federal marketplace (Haeder and
Weimer 2013;
Brandon and Carnes 2014). The type of exchange established
and malfunctions
in implementation can have significant implications for market
participants
(Kowalski 2014). According to Brandon and Carnes (2014),
commodification of
insurance plans (i.e., making them transparent and accessible to
consumers),
competition, and communication are three elements of
successful exchanges.
Blumenthal, Abrams, and Nuzum (2015) discussed several
problems that
occurred during ACA implementation including cancelation
notices for non-
compliant plans (which were later allowed to be renewed),
narrow provider
networks, and plans with very high deductibles. Furthermore,
the public had a
limited understanding and awareness of the ACA provisions
(Collins et al.
2013a; Barcellos et al. 2014; KFF and CF 2015). Some survey
results show that
premiums and deductibles for plans purchased through the
marketplace are
comparable to ESI for those with similar incomes (Rasmussen et
al. 2014).
Premiums for marketplace plans are generally lower in areas
that are more den-
sely populated and in states with state-based exchanges (Barker
et al. 2014a).

534. Use of Marketplace Subsidies. Levitt, Cox, and Claxton (2015)
estimate that
plans purchased in the marketplace accounted for 43 percent of
all individu-
ally purchased plans in 2014, and 85 percent of those enrolling
in marketplace
plans qualified for tax credits. A Government Accountability
Office (GAO
2015) analysis suggests that the premium tax credit has
contributed to higher
rates of insurance coverage—in contrast to the employer tax
credit, which had
The ACA’s Key Provisions: A Systematic Review 1753
a more limited impact. In 2014, tax credits reduced marketplace
premiums by
an average of 76 percent (GAO 2015). As incomes rise and
subsidies decline,
however, premiums may increase sharply, making it
increasingly difficult for
those at the subsidy threshold (300–400 percent of the FPL) to
afford health
insurance (Graetz et al. 2014).
Although almost anyone can purchase insurance through the
market-
place (undocumented immigrants is a key exception), those who
have access
to ESI may not be eligible for tax credits, even if they meet the
income
requirements (HHS, 2014).3 Employees are not eligible if they
and/or their
spouses are offered “affordable” ESI coverage. When assessing

535. affordability,
however, the provision is unclear whether to consider the cost
of individual
coverage for the employee alone or the cost of family coverage.
The Internal
Revenue Service interprets the statute on the basis of individual
coverage,
which is much cheaper than family coverage. Due to this so-
called fam-
ily glitch, a significant number of low- to moderate-income
individuals—2–
4 million according to various estimates—may be denied
financial assistance
(Brooks 2014).
Effect of the Individual Mandate. The individual mandate is
intended to attract
new enrollees, increase the number of insured, diversify risk
pools, and lower
premiums (Gruber 2011b). The CBO (2014) estimates that 4
million people
will be penalized for violating the individual mandate in 2016
and about
$4 billion will be collected in penalties. Sheils and Haught
(2011) predict that
nongroup premiums would increase by 12.6 percent and 7.8
million people
would not have coverage without this mandate.
Participation and Competition in the Exchanges. Several studies
focus on partici-
pation of (Abraham, Feldman, and Simon 2014; CMS 2014;
GAO 2014a) and
competition among (Cox et al. 2014; Swartz, Hall, and Jost
2015) insurers in
the exchanges. Among the incumbent insurers in 2012, 10

536. percent partici-
pated in the marketplace in 2014—depending on presence in the
region, size,
and whether the insurer had prior experience in the group
market (Abraham,
Feldman, and Simon 2014). As the ACA matures, participation
may increase
further—25 percent more insurance companies joined the
marketplace in
2015 than in 2014 (CMS 2014).
Competition in state-sponsored exchanges varies considerably
both
within and across states (Cox et al. 2014; GAO 2014a; Kowalski
2014; Polsky
1754 HSR: Health Services Research 51:5 (October 2016)
et al. 2014; Dickstein et al. 2015; Swartz, Hall, and Jost 2015).
Dickstein et al.
(2015) reported that states can alter competition and market
outcomes by how
they define their coverage regions. In 2014, almost all state
exchanges had
multiple issuers, most included a mix of large and small
companies, and more
populous states usually had a wider selection of plans (GAO
2014a). An aver-
age of 37.3 plans were available through exchanges in urban
counties com-
pared to 25.7 plans in rural counties (Barker et al. 2014b). As
the ACA
restricts the ability of insurance companies to alter their risk
pool, they com-

537. pete instead by offering different cost-sharing arrangements,
benefits, and pro-
vider networks (Swartz, Hall, and Jost 2015). Furthermore,
incentives may
remain to restrict or ration care for some higher cost patients
(McGuire et al.
2014). To protect consumers from the risks associated with
“narrow network
plans,” 27 states established quantitative standards for network
adequacy and
governmental oversight is expected to increase over time
(Giovannelli, Lucia,
and Corlette 2015).
Employer Mandate and the ESI System
One of the overarching questions about the ACA is how it will
impact ESI,
and whether the vast majority of workers will continue to obtain
health insur-
ance via their workplace. Recent studies indicate an absence of
major changes
in ESI since the ACA has gone into effect (Claxton et al. 2014a;
Blavin et al.
2015). In 2014, the proportion of employers offering ESI (55
percent) and the
average annual premium for individual coverage therein
($6,025) were simi-
lar to those in 2013 (Claxton et al. 2014a). Since 2003,
premiums, deductibles,
and employee contributions for ESI have gradually increased,
but at a slower
rate starting in 2010 (Collins et al. 2014a; Schoen, Radley, and
Collins 2015).
Note that these preliminary findings are based on partial
implementation of

538. the employer mandate. Thus, additional research is needed to
evaluate
whether these trends persist as the employer mandate and
associated penalties
go into full effect in 2016.
The Small Business Health Options Program (SHOP). As of
June 2014, 18 state-
based SHOP marketplaces enrolled 76,000 individuals from
12,000 small
employers, and premiums for SHOP plans were similar to those
for other
small-group plans (GAO 2014b). Gabel et al. (2013) surveyed
small firms and
found the majority favored several SHOP features. However,
participation in
SHOP is lower than expected due to a number of challenges
(GAO 2014b).
The ACA’s Key Provisions: A Systematic Review 1755
Some employers believe the small business tax credit, intended
as an incentive
to use SHOP, is too limited in its scope and requires a complex
application
process (Blumberg and Rifkin 2014; GAO 2014b). Initial
participation in
SHOP was also hampered by technical problems with the
website, lack of
awareness about the program, and limited involvement by
brokers (Blumberg
and Rifkin 2014; GAO 2014b). Moving forward, it is unclear
whether small
businesses will embrace this feature of the ACA, especially as

539. some employers
consider other options to provide coverage, such as private
insurance
exchanges or continued reliance on grandfathered, noncompliant
plans
(Blumberg and Rifkin 2014).
Medicaid Expansion
Although provisions for full Medicaid expansion did not take
effect until
2014, California, Connecticut, Minnesota, and Washington, DC
began early
enrollment in 2010. Sommers, Kenney, and Epstein (2014)
found a steady
increase in Medicaid enrollment in these states, with the highest
take-up
among those with health limitations. Potential Medicaid
beneficiaries are gen-
erally healthier than those who are already enrolled, but those
with chronic
conditions are less likely than existing enrollees to have the
disease(s) under
control (Decker et al. 2013). As of September 2015, 30 states
and Washington,
DC had implemented Medicaid expansion and 20 chose not to
participate
(KFF 2015). Expansion decision is heavily influenced by
political factors as
well as state economic conditions, administrative capabilities,
and prior poli-
cies toward low-income residents and the uninsured (Jacobs and
Callaghan
2013). An estimated 3.7 million adults in nonexpansion states
are in the “cov-
erage gap,” with low-income blacks disproportionately affected

540. (Artiga, Ste-
phens, and Damico 2015). This means they earn too much to
qualify for
Medicaid, but not enough to be eligible for premium tax credits
in the market-
place.
The availability of coverage affects access and health outcomes
of Medi-
caid beneficiaries (Artiga, Rudowitz, and Ranji 2015; Kaufman
et al. 2015;
Sommers et al. 2015). According to the 2014 Commonwealth
Fund Biennial
Health Insurance Survey (Collins et al. 2015b), 78 percent of
adults who have
used their newly gained Medicaid coverage to obtain care said
“they would
not have been able to access or afford this care before.” Another
study found
that new coverage led to increases in the number of diabetes
diagnoses for
Medicaid patients (Kaufman et al. 2015). Sommers et al. (2015)
found the pro-
portion of low-income adults with difficulties accessing a
physician and
1756 HSR: Health Services Research 51:5 (October 2016)
medication decreased more in Medicaid expansion states than in
nonexpan-
sion states.
Frequent eligibility changes or “churning” is an ongoing
concern in all

541. states as individuals’ incomes vary and they transition to and
from Medicaid,
the marketplace, possibly ESI, and no coverage (Rosenbaum et
al. 2014;
Sommers et al. 2014b). Low-income adults in nonexpansion
states are particu-
larly vulnerable to being uninsured (Collins et al. 2015b) or
incurring high
out-of-pocket costs in the marketplace (Hill 2015). Eventually,
states will need
to address churning, which has implications for tax credits,
continuity of care,
and health outcomes (Rosenbaum et al. 2014).
A group of studies have focused on providers’ experiences with
expand-
ing Medicaid (Angier et al. 2015; Cunningham, Garfield, and
Rudowitz 2015;
KFF and CF 2015). Ascension Health, the largest nonprofit
health system in
the United States, had more Medicaid discharges and revenues,
and lower cost
of care for the poor in expansion states. In other states,
however, they experi-
enced only a small increase in Medicaid discharges, a decrease
in Medicaid
revenue, and higher cost of care for the poor (Cunningham,
Garfield, and
Rudowitz 2015). Provider participation in public insurance
programs has been
an ongoing concern as some physicians are reluctant to accept
Medicaid bene-
ficiaries due to low reimbursement rates (Polsky et al. 2015).
Following a tem-
porary increase in Medicaid payments to providers during 2013–
2014, the

542. availability of primary care appointments increased for
Medicaid enrollees,
while wait times for new appointments remained the same
(Polsky et al.
2015). A survey of primary care providers shows that the
proportion accepting
new Medicaid patients in 2015 is similar to that in 2011–2012
(KFF and CF
2015). A majority of providers surveyed, however, saw an
increase in unin-
sured or Medicaid patients in expansion states without
negatively affecting the
quality of care (KFF and CF 2015).
Insurance Premiums, Health Care Expenditures, and
Government Budgets
Health Insurance Premiums. Premiums continue to increase
faster than median
family income, leading more individuals to opt for high–
deductible plans
(Collins et al. 2014a; Schoen, Radley, and Collins 2015). While
certain provi-
sions of the ACA are likely to increase premiums (e.g.,
expansion of depen-
dent coverage, extended benefits, ban on charging more for
preexisting
conditions), other features (e.g., restrictions on administrative
costs and profits
for insurance companies, risk-sharing programs, individual
mandate, compe-
tition in the marketplace) are expected to have the opposite
effect (Blumenthal
The ACA’s Key Provisions: A Systematic Review 1757

543. and Collins 2014; Collins et al. 2014a; Cox et al. 2015; Schoen,
Radley, and
Collins 2015). Overall, average premiums and spending by
private health
insurers in 2014 were lower than projected (Skopec and Kronick
2013). Aver-
age annual growth in premiums per enrollee for all private
health insurance
was 2.1 percent in 2013 and is projected to be 5.4 percent in
2014 and 2.8 per-
cent in 2015 (Keehan et al. 2015). Insurers requesting large rate
increases pri-
marily attributed the change to higher prices for services and
certain ACA
requirements such as new taxes (McCue and Hall 2015). Even if
premiums
continue to gradually increase, most individuals are expected to
receive
expanded insurance benefits, and out-of-pocket costs may
actually decline for
those who are eligible for tax credits (Hill 2012; Keehan et al.
2015).
Health Care Expenditures. In recent years, national health care
spending slo-
wed from the relatively high growth rates experienced during
the 1990s and
early 2000s, averaging 4.0 percent annually over the 2008–2013
period
(Chandra, Holmes, and Skinner 2013; Dranove, Garthwaite, and
Ody 2014;
Keehan et al. 2015). Nevertheless, the portion of GDP spent on
health care is
expected to increase from 17.4 percent in 2013 to 19.6 percent

544. in 2024 (Keehan
et al. 2015). Health care spending is projected to grow at an
average annual
rate of 5.8 percent over the period of 2014–2024, and much of
this increase
may be driven by the ACA’s coverage expansions as well as
higher prescrip-
tion drug spending, a stronger economy, and an aging
population (Keehan
et al. 2015).
The expansion of insurance coverage under the ACA is expected
to
increase utilization of primary care and other services (Dall et
al. 2013). The
ACA includes a number of different approaches that have the
potential to con-
trol rising health care expenditures, such as reducing medical
errors, creating
exchanges, taxing high cost insurance plans, and adjusting
provider reim-
bursements (Gruber 2011a). It is too soon, however, to fully
evaluate whether
or to what extent these cost control measures will impact prices
and utilization
(Chandra, Holmes, and Skinner 2013; Blumenthal, Abrams, and
Nuzum
2015). Blumenthal, Abrams, and Nuzum (2015) asserted that the
ACA may be
contributing to slower health care spending growth and, at a
minimum, has
not led to a rapid increase in spending.
Budgetary Effects of the ACA. As individuals with chronic
diseases enroll in
Medicaid and gain access to health services, overall health care

545. utilization and
1758 HSR: Health Services Research 51:5 (October 2016)
spending will likely increase, creating challenges for state
budgets. The latest
estimates indicate that Medicaid spending increased 12 percent
and enroll-
ment increased 12.9 percent in 2014 (Keehan et al. 2015).
Federal contribu-
tions cover all expansion costs during the first 3 years, which
will benefit
providers and generate economic activity (Holahan, Buettgens,
and Dorn
2013). State budgets may be more strained later on, when they
are required to
fund more of the expansion. Even so, decreases in
uncompensated care are
expected to offset some of spending increases associated with
Medicaid
expansion. Overall, studies present evidence that expanding
Medicaid is
financially prudent for most states (Holahan, Buettgens, and
Dorn 2013;
Bachrach, Boozang, and Glanz 2015).
Due to its major role in Medicaid expansion and the
establishment of
health insurance exchanges, the federal government will end up
financing a
larger proportion of health care than before the ACA (Keehan et
al. 2015).
The actual estimate depends on the number of states
participating in Medicaid

546. expansion and a number of other factors. Changes in ESI also
need to be
taken into account as reductions in ESI coverage could increase
federal tax
receipts. However, this revenue increase could be offset by
higher wages,
which generate tax revenues but also lead to higher social
security spending.
Overall, the CBO (2015a) estimates that federal deficits will
grow to $137 bil-
lion from 2016 to 2025 if the ACAwere repealed.
DISCUSSION AND OPPORTUNITIES FOR FUTURE
RESEARCH
Opportunities abound for researchers to study the most
sweeping health care
legislation in recent U.S. history. Results from this current
systematic review
highlight gaps in the existing literature and can serve as a
resource for
researchers considering where additional work is needed.
Studies so far
clearly show that the ACA has led to expansions in insurance
coverage and
improved access to care, especially among young adults, the
relatively poor,
less healthy populations, and minorities. With the exception of
the dependent
coverage provision, most investigations of the ACA so far are
descriptive in
nature, and rigorous study designs are needed to provide more
convincing
empirical evidence. In addition, further research is required to
demonstrate
the full impact of the ACA on health care prices, utilization,

547. and perhaps most
important, health outcomes.
The ACA’s Key Provisions: A Systematic Review 1759
The findings so far clearly establish areas for future
investigation. For
example, given that young adults have different health
behaviors and health
care needs than older adults, it is unknown whether the results
for young
adults are generalizable to the rest of the nonelderly population.
Our review
also identified a number of studies related to delivery reforms,
workforce
issues, and insurance company regulations, but due to the
preliminary stage of
these inquiries, we chose to exclude them from our analysis.
Augmenting and improving the existing studies will provide a
deeper
understanding of insurance expansions such as the composition
of risk pools,
the type of health care (e.g., acute, chronic, preventive,
emergency, hospital,
diagnostic services) some of the newly insured receive, and the
quality of care
therein. Going forward, out-of-pocket costs associated with the
new plans pur-
chased in marketplaces will need to be tracked. How will
narrow provider net-
works affect consumer satisfaction and outcomes? In the
aggregate, health
care expenditures have moderated recently, but is this a