Affordable Care Act Impacted Patient Experience, Not Utilization, Cost

The implementation of the Affordable Care Act coincided with some improvements in patient experience and access to care for low-income enrollees, but did not significantly impact their care utilization or costs of care, according to a study published in JAMA Network Open.

“The association of coverage expansion under the ACA with quality of care remains largely unexamined, although 2 initial studies have identified an association between Medicaid expansion and patient-reported access to and experiences with chronic care,” the study explained. 

“A more complete and national understanding of the longer-term association between the implementation of the ACA and quality and experience of care in the US could better inform current and future policy decisions.”

The researchers studied over 123,100 individuals in order to assess the quality of care that they received through Affordable Care Act coverage, using data from the Medical Expenditure Panel Survey from 2011 to 2013 and 2014 to 2016 to compare the cost and quality of care pre- and post-implementation of the Affordable Care Act.

The most significant result was that low-income individuals—whose incomes totaled less than 400 percent of the federal poverty level—saw more high-value care after the law was enacted than higher-income individuals did. Specifically, high-value care encompassed diagnostic and preventive testing.

Before the implementation of the Affordable Care Act, 70 percent of low-income individuals reported receiving diagnostic and preventive testing. After the law went into effect, 72 percent of low-income individuals reported receiving diagnostic and preventive testing. 

In contrast, 84 percent of higher-income individuals received diagnostic preventive testing before the Affordable Care Act went into effect and this number did not change after the law was instated.

Low-quality care did not change significantly for any income bracket after the Affordable Care Act’s implementation.

The study also compared improvements in enrollees’ “global ratings of healthcare.” This measure addressed patient experience, access to care, and communication.

Lower-income enrollees experienced a shift in their global healthcare ratings. Before the Affordable Care Act went into effect, 69 percent of lower-income individuals experienced an improvement in the global healthcare rating, but after the law’s implementation 73 percent of lower-income individuals saw improvement.

Higher-income individuals saw a smaller increase in improvement in comparison, rising from 79 percent experiencing an improvement in global healthcare rating to 81 percent.

Physician communication improved for both low-income and high-income respondents as did access to care.

Care utilization measures, such as preventive care visits and prescriptions filled, did not change significantly for low- or high-income respondents. High-income respondents reported a decrease in primary care visits, from 80 percent receiving primary care services before the Affordable Care Act was implemented to 77 percent after the law went into effect.

While the total cost of care remained level, lower-income enrollees witnessed a lower out-of-pocket healthcare spending after the Affordable Care Act, while their economic counterparts saw a boost in out-of-pocket healthcare spending.

The researchers emphasized that the study found a correlation, but that did not necessarily mean that the Affordable Care Act was the driving force or cause behind these trend changes. The study also left out outpatient care statistics and did not account for differences by state.

As the Affordable Care Act enters its twelfth year since implementation, the researchers found cause for celebration and areas for improvement.

“Implementation of the ACA was associated with improved patient experience and access and decreased out-of-pocket expenditures for lower income individuals, but little or no change in quality, utilization, and the total cost of care,” the researchers concluded. 

“Our work suggests that the insurance coverage changes achieved under the ACA are but the first of likely many steps that will be required to improve the US health care system.”

Separate studies have also found strong patient satisfaction among Affordable Care Act enrollees. The Affordable Care Act marketplace has been reshaped as insurers re-enter.