Affordable Care Act Enrollment: Analysis of Variation in Nationwide Implementation and Implications for Health Equity

Abstract

Signed into law by President Barack Obama on March 23, 2010, the Patient Protection and Affordable Care Act, known as the Affordable Care Act (ACA) promised to radically alter the healthcare landscape of America. Through its numerous policies, the goal of the act was to improve healthcare accessibility and affordability, reforms that are crucial for a country striving to create equity in public health. The new insurance “marketplaces” were opened to the American public in October 2013, and there have been two enrollment periods to date. Enrollment numbers per state have varied widely, with some states, such as Maine, enrolling 60% of qualified individuals, and others, like Minnesota, enrolling only 22% of qualified individuals. (Kaiser Family Foundation 2015, “Marketplace Enrollment As a Share of the Potential Marketplace Population”). Why have some states been far more successful at expanding coverage than others? Answering this question is crucial if we wish to understand the factors that provide the most access to coverage. To explain this variation, we investigate the impact of a broad range of demographic and political factors, and discuss the efficacy of enrollment campaigns and advertising. This allows us to determine an understanding of the current successes and failures of ACA enrollment, an analysis that will be enlightening to policymakers who aim to expand ACA enrollment in the future.