Affordable Care Act more successful in some states than others

As the Trump administration and Congress take steps to repeal the Affordable Care Act, casting its future into uncertainty, many are questioning if the ACA is truly the disaster that President Trump has made it out to be. According to new research released Thursday by the Center for Health Policy at the Brookings Institution, the ACA's effectiveness has varied on a state-by-state basis.

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The study focused on ACA marketplace competition in five states — California, Florida, Michigan, North Carolina, and Texas — and found that successful implementation depended largely on how states handled it. For instance, while the ACA is responsible for covering roughly 20 million uninsured Americans, California and Michigan had more success implementing the ACA than Florida, North Carolina, and Texas. The Center for Health Policy at Brookings partnered with the ACA Network, and interviewed health insurers, state insurance regulators, insurance brokers, agents, and navigators about the first three years of the insurance marketplaces, from 2013-2016.

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States' attitudes towards the ACA made major differences in the marketplaces. From the beginning, political leaders in Florida and Texas were strongly opposed to the ACA, and both of these states passed laws that made the marketplaces difficult to succeed. For example, both passed laws that made it harder to become a navigator — or a person who acts as a guide to inform people about the ACA and their insurance options — and that proved to play an essential role in some communities. These states also declined to review premiums in the first two years of the exchanges.

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California and Michigan, on the other hand, were more supportive, and made efforts to implement new laws that bolstered the ACA. In California, the state with the most successful marketplace of the five, the state-based exchanged enrolled around 14 million people, and the uninsured population went from 17.1 percent to 8.1 percent in the first open enrollment period in 2013.

"Policymakers and market participants need to appreciate the nuances of different local settings if programs are to be successful," the researchers wrote.

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Success also varied significantly between different cities within each state. In order to remain competitive and offer an effective plan, insurers need to have a network of enough local hospitals, physicians, pharmacies. If there are fewer hospitals and doctors in a given county, insurers won't be able to offer a competitive plan. In California, for instance, San Francisco varied greatly from Los Angeles because it has significantly fewer health systems and insurers, and therefore faced higher prices and charged higher premiums.

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Ultimately, researchers found that health care markets are individual, and what works in North Carolina won't necessarily work in California or Texas.

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