Though the Affordable Health Care was passed and signed without really knowing what it was, a few things were certain; you could keep your doctor, it would be cheaper due to competition for new customers, and socio-economic disparities would be eliminated.

None of those have turned out to be true. While there are fewer uninsured Americans, that is due to penalties and forcing the companies of parents to pay for adult children until they are 26. Insurance companies are abandoning the programs because they are still losing billions; they are forced to pick an insurance cost while not considering the health of the applicant, and thus there are no actuarial tables. And poor people have little choice. Many regions have one provider, no one is competing to be in a business where the costs are hidden but the revenue is fixed.

A paper in Health Services Research was based on a structured and systematic review of 100 analyses since 2010 and found: 

• In the first five years of the ACA, 11.7 million individuals purchased new plans from the marketplace, 10.8 million more now have Medicaid coverage, and 3 million young adults are on their parents' policies. How many of those would have bought insurance anyway was not considere

• Expanded coverage has led to better access to a physician among all income groups. Although the proportion without a regular source of care decreased from 29.8 percent in 2013 to 26 percent in 2014, almost 40 percent of respondents still had at least one access problem.

• 1-3 million uninsured young adults were forced into coverage under the ACA - how many would have bought insurance regardless of the ACA was not factored in. The gains were especially pronounced in young single people, who were generally healthy and so may not have purchased health insurance early in their earnings years otherwise.

•  Disparities persist by race, ethnicity, and income. 

• The amount of uncompensated care for young adults decreased as a greater proportion of health care utilization is being covered by private insurance.

• Disparities in health care access persist for different racial/ethnic and income groups. The uninsured are still more likely to be young, low-income, and Hispanic.

Use of Marketplace Subsidies

• Plans purchased in the marketplace accounted for 43 percent of all individually purchased plans in 2014, and 85 percent of those enrolling in marketplace plans qualified for tax credits.

• In 2014, tax credits reduced marketplace premiums by an average of 76 percent. As incomes rise and subsidies decline, however, premiums may increase sharply, making it increasingly difficult for those at the subsidy threshold to afford health insurance.

• Due to the ACA's "family glitch," whereby a low-income employee can't afford family coverage through his/her employer and doesn't qualify for subsidies through the exchanges, a significant number of low- to moderate-income individuals--2-4 million according to various estimates--may be denied financial assistance.

Participation and Competition in Exchanges

• Among the incumbent insurers in 2012, 10 percent participated in the marketplace in 2014. As the ACA matures, participation may increase further--25 percent more insurance companies joined the marketplace in 2015 than in 2014.

• In 2014, almost all state exchanges had multiple issuers, most included a mix of large and small companies, and more populous states usually had a wider selection of plans.
  Medicaid Expansion

• An estimated 3.7 million adults in non-expansion states are in the "coverage gap," with low-income blacks disproportionately affected. This means they earn too much to qualify for Medicaid, but not enough to be eligible for premium tax credits in the marketplace.

Budgetary Effects of the ACA

• Overall, studies presented evidence that expanding Medicaid was financially prudent for most states, but only because Federal contributions cover all expansion costs during the first three years, which will benefit providers and generate economic activity. Now that state budgets are required to fund more of the expansion, they are finding that payments for uncompensated care are not offsetting the budget cost. 

•   Due to its major role in Medicaid expansion and the establishment of health insurance exchanges, the federal government will likely end up financing a much larger proportion of health care than before the ACA. 

• The Congressional Budget Office (CBO) estimated that federal deficits will grow by $137 billion from 2016 to 2025 if the ACA were repealed, but that was before this year, when the realization that the ACA is not anywhere near its targets. There is a lot of real money being spent and pretend money lost is looking less and less likely.

"Our paper provides the public with a non-partisan, scientific perspective on the initial impact of the Affordable Care Act," said Michael T. French, professor of health sector management and policy, and sociology at the University of Miami School of Business Administration, a co-author of the paper. "With new research studies on the ACA being published every month, another comprehensive status report will be necessary in the near future."

"The scientific research so far suggests that ACA's progress is encouraging, especially in terms of expanding coverage," said co-author Gulcin Gumus, associate professor of Management Programs - Health Administration at the Florida Atlantic University College of Business.