By: TAHP | Tuesday, October 10, 2023

Happy Anniversary! This fall marks the 10th anniversary of open-enrollment for the Affordable Care Act’s “individual market” at healthcare.gov, and it’s come along way.

Catch up: As a result of the ACA, Texans without job-based health insurance or other government programs like Medicare and Medicaid can shop in the individual market for themselves and their families to find insurance that fits their needs.

Why it matters: Coverage increases access, and the ACA’s individual market increased coverage.

• Texans with health insurance get preventive care and earlier disease diagnosis so they can get the care they need before problems worsen.
• Insurance coverage means covered Texans are twice as likely to have their mental health care needs met.
• Coverage helps Texans avoid unnecessary and expensive ER visits.

How it all started: Back before 2014, Texans struggled to access affordable, comprehensive coverage, particularly those with pre-existing medical conditions.

• Prior to the ACA, less than 600,000 Texans without employer-provided coverage bought insurance in the individual market.
• In 2023, more than 2.4 million Texans enrolled in a plan through healthcare.gov – a 400% increase in Texans getting coverage outside of an employer.

Enter the Affordable Care Act (ACA), which sought to solve that problem with a three-pronged approach:

• First, the ACA created a community rating and guaranteed coverage, meaning you can’t be charged more or denied based on your health.
• Next, the law set up new markets for health coverage where strict rules dictate insurance plan designed, covered benefits, and how insurers must spend premium dollars.
• The final element was subsidies to help pay for this new comprehensive coverage, those are called advanced premium tax credits (APTCs).

Go deeper: Insurance sold at healthcare.gov has to meet requirements that didn’t exist before the ACA.

• All plans must include “essential health benefits” which include comprehensive coverage for all categories of care, from mental health to hospitalization and preventive services.
• Insurance plans are sold at standardized “metal levels” so you can pick how much coverage you need, based on what works for you.
• Texans with family incomes up to double the poverty level also get help covering out-of-pocket costs like copays and deductibles.
• Some states have taken the option to set up their own “exchange” in place of healthcare.gov, but all of these same rules apply. Texas and 32 other states use healthcare.gov.
• Consumers have extensive protections against coverage caps, denials, and cancellations under the law.

The bottom line: Nearly two and a half million Texans are now enrolled under the ACA’s healthcare.gov marketplace, making the old days of pre-existing condition denials, affordability woes, and coverage gaps a distant memory.

Want to learn more? You can attend the Texas State of Enrollment Conference this week, hosted by the Texas Association of Community Health Centers, where you can learn more about signing up more people for health insurance coverage when open enrollment starts on November 1.