A Brief History

The Affordable Care Act (ACA) was signed into law on March 23, 2010. It was enacted to increase the availability and affordability of health insurance. It introduced the concept of insurance exchanges that take the form of websites where the private plans allowed on sale within them will be regulated and comparable.

Consumers can login to a website to compare the various health insurance plans and select from the options available. Once they select the plan they want, they can complete a form to determine their eligibility for federal subsidies, and then purchase the insurance of their choice from the options available. This can be done only during limited open enrollment periods. The plans offered on the exchanges will be the same types of plans offered currently in the market, but they will be more comparable and available to individuals than they were previously.

The second part of the law requires insurance companies to cover all applicants with new minimum standards and offer the same rates regardless of preexisting conditions or gender. Premiums must now be based on age and geographic location. It also has strict regulations that certain employers must offer some portion of health insurance to their employees, and on how much employers can reimburse of the health insurance coverage they offer. If the employers do not offer coverage, employees can get subsidies for their insurance in certain circumstances, but the employer will be fined on their company income tax return.

These regulations generally help the premiums for the older, less healthy employee, although it is to the detriment of the younger, healthier individual. To discourage individuals from declining coverage, the government has set up a schedule of penalties for not having health insurance. These penalties will be levied through an excise tax paid with an individual's income tax return.

In addition, a much larger number of individuals qualify for Medicaid coverage under the ACA. There are many other elements to the ACA, which can be viewed at the US Department of Health and Human Services website.

Patients

This law took effect with the open enrollment period in autumn 2013. What we know thus far:

• The Commonwealth Fund reported in July 2014 that an additional 9.5 million people aged 19-64 years had obtained health insurance—roughly 5% of the working-age population. ^[1]

• Gallup reported in April 2015 that the uninsured rate among adults aged 18 years or older fell from 18.0% in the third quarter of 2013 to 11.9% by the first quarter of 2015. ^[2]

• The RAND Corporation reported that by August 2015, "Enrollment in employer-sponsored insurance plans increased by 10.4 million and Medicaid enrollment increased by 9.5 million, although some individuals did lose coverage during this period. The authors also found that 28.2 million (14.2%) of adults age 18-64 experienced a change in the source of their insurance between February and August 2015. The number gaining or losing any particular type of insurance is small, and our sample is not large enough to measure these changes with precision. However, changes occur across all sources of insurance. While the impacts of gaining or losing insurance are most obvious, those who switch from one type of insurance to another represent half of the people experiencing a transition. While they maintain coverage, this group may lose access to providers if their new insurance does not cover the same providers as their old insurance. ^[3]

• Health insurance exchanges are growing, with nearly 13 million enrolled as of January 31, 2016, when the most recent sign-up period ended. Subsidized coverage from these marketplaces and the expansion of Medicaid under Obamacare in 31 states and the District of Columbia are the main reasons why an estimated 20 million more people have health insurance this year than before the Affordable Care Act became law and the uninsured rate declined to a historic low. ^[4]

Looking at this information, we see that clearly, more individuals are covered by health insurance than previously. Although large company policies were still the norm as of 2016, many employees have been losing their more robust corporate-sponsored policies and have been changing insurance—and, ultimately, their physicians. This is because the increase in benefits mandated to be included in health insurance has resulted in an increase in premiums, and because preexisting conditions are no longer excluded from coverage.

With the insurance system introduced under the ACA, employers have generally not stopped their company-sponsored insurance plans, but they have significantly increased the amount of the premium paid for by their workers. According to a survey conducted by the Kaiser Family Foundation, total premiums have increased from 2005 to 2015 by 61%, and during the same period, workers' contributions increased by 83%. In addition, the percentage of workers paying deductibles of $1000 or more increased from 10% in 2006 to 46% in 2015. ^[5]

Physicians

Physicians are not seeing a significant increase in the number of patients with insurance, because most of their patients already had some type of insurance. Most physicians saw a very small number of patients who had no insurance, because most noninsured patients went to a hospital emergency department or clinics for treatment rather to a physician. Many patients are still going to the emergency department for treatment.

According to an analysis done by Forbes, in the states that took the Medicaid expansion, Medicaid visits increased, and in the states that did not take the Medicaid expansion, the number of Medicaid visits remained flat. The problem arises in the states where the number of Medicaid visits increased and the number of visits from commercially insured patients fell. Because the collections from Medicaid programs across the country are significantly lower than the collections from Medicare or commercial insurance plans, a shift of commercial insurance patients to Medicaid insurance patients will lead to lower collections by the physicians for a similar volume of services. In the states that did not take the Medicaid expansion, there was an increase in patients in all categories and the ratio of Medicaid patients to all other patients rose only slightly.

Surveys of physician income over this period show that physician income has remained flat and not dropped significantly. Although average revenue per patient has gone down in the states where the number of Medicaid visits increased, physicians seem to be making up the shortfall by either increasing the number of patient visits per month or by expanding covered tests or cash procedures.