Much of the attention on the Affordable Care Act has focused on government-run insurance exchanges, but the law has had big impacts on other parts of health-care delivery.

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With the second round of Obamacare insurance sign-ups now closed, state officials expect to beat their numbers from last year only slightly when the final count is in, with more than 165,000 people enrolled through the Washington Healthplanfinder exchange.

But while the government-run health-insurance exchanges have attracted significant attention, the goals of the Affordable Care Act (ACA) are much broader. It seeks to put health insurance within reach of most every American, bring down medical costs and provide better care to more satisfied patients.

Those reforms are playing out in rural clinics and high-tech hospitals in every corner of Washington. Here are some of the most pronounced changes in coverage and care since Obamacare became law five years ago.

The Medicaid surge: The number of people covered by Medicaid has spiked 44 percent since Washington officials made it easier to participate in the free health-care program beginning last year. Roughly 2 million of Washington’s adults and children are covered by Medicaid, which is available to people earning up to 138 percent of the federal poverty level (nearly $16,000 for an individual).

The spike in Medicaid enrollment has helped lower the fraction of uninsured state residents to approximately 9 percent, according to data from last year. A 2014 Gallup poll ranked Washington fourth nationally for reducing the fraction of residents who are uninsured.

But the large number of Medicaid enrollees has meant fewer people bought insurance through Washington’s exchange, creating serious budget challenges for the agency, whose funding comes in large part from taxes and fees applied to each plan it sells.

And while it appears that Medicaid patients so far are getting timely access to doctor’s appointments, despite their growing numbers, that could change.

To encourage physicians to treat more Medicaid patients, the ACA for two years boosted the government’s reimbursement rate by 70 to 90 percent. That increase ended with the new year, though doctors and other providers may not have noticed as they continue to receive the higher rate on 2014 claims still being processed.

“I haven’t heard a lot from the provider community, perhaps because they aren’t seeing the difference yet,” said MaryAnne Lindeblad, the state’s Medicaid director. “It’s hard at this point to assess the effect of the rollback.”

Better, cheaper care: Imagine a health-care system that provides patients with Nordstrom-quality service and attention to their every need. Or an Amazon.com experience that welcomes patients by name, tracks their pertinent information in one convenient place and makes it easy for them to find what they need.

That’s the system Dr. Joe Gifford is striving for in his role of chief executive of Providence-Swedish Health Alliance, an accountable care organization (ACO).

ACOs are an increasingly popular strategy for providing care designed to make patients healthier at a lower cost and with a better customer experience. It accomplishes this, at least in theory, by financially rewarding or penalizing doctors, clinics and hospitals based on measures of patient health and satisfaction.

The providers in ACOs achieve these goals by better coordinating their treatment of patients and with smarter follow-ups to manage chronic illnesses. Many of these changes are taking place behind the scenes and include technology upgrades for tracking patients and their health, but Gifford said some fixes should be readily apparent to patients.

“If it isn’t visible, we aren’t doing our job,” Gifford said.

In Western Washington, the Providence-Swedish ACO is covering 200,000 people enrolled in Medicare and Medicare Advantage, plus current and former Boeing employees. Providence has additional ACO and ACO-like arrangements elsewhere.

The Boeing deal was announced in June and while Gifford couldn’t share the number of employees participating, he did say that “the enrollment exceeded all targets.”

There are at least 16 ACO and ACO-like groups treating Medicare and privately insured patients in Washington. In the fall, the state plans to add an ACO-like plan to the insurance lineup available to roughly 190,000 public employees.

“We need to start shifting how we pay, and pay for value [in health care],” said Lou McDermott, division director of the Public Employees Benefits Board program. “I’m very optimistic that this is going to bear some fruit.”

No denial of coverage: The ACA prohibits insurance companies from charging people higher prices or denying them coverage based on their health. A 2012 federal government study estimated that approximately one-third of American adults have a pre-existing condition, depending on which ailments are considered.

This ACA provision has led people with a history of health troubles to find affordable coverage. It also has allowed many workers to explore new careers instead of sticking with jobs they don’t like because they couldn’t risk losing the health benefits of those jobs.

“When the Affordable Care Act happened, I applied online and now I have awesome insurance,” said Heather Verhey, a peach farmer from Royal City in Grant County.

Eight years ago, Verhey was diagnosed with and treated for breast cancer. She underwent chemotherapy and radiation, treatments that could cost $40,000 for a single chemo session. Verhey had insurance at the time, but her deductible was high and it was a struggle to pay her bills. The treatments worked and Verhey, now 47, hasn’t had any recurrence of the disease.

But working on her family’s farm in a job without benefits, Verhey couldn’t afford the sky-high premiums she was quoted after cancer and before the ACA.

“I feel so fortunate, after all that time of so much stress with the [cancer] diagnosis itself and the money and the bills that you get. You feel like you’re fighting for your life, and you get these crazy bills, and you have to take time off work because you get sick,” said Verhey, whose current income qualifies her for Medicaid. “People deserve to get treatment when they’re sick.”

Trickier taxes, surprise penalties: For health-care reform to work, most people need to be covered — not just those who are likely to get sick. So the ACA includes a mandate requiring coverage, and it penalizes those who go without.

That requirement, as well as the creation of tax subsidies for those buying insurance through the state’s exchange, has created additional paperwork and new complications for filing federal taxes.

The tax subsidies, which help lower monthly premiums, are based on how much a person predicts he or she will earn over a year. People who make more than they expected must pay back part of their subsidy, while those earning less get a larger refund when filing their 2014 returns. Kaiser Family Foundation estimated that half of the people getting subsidies would owe $794 on average, while slightly fewer than half would get refunds of about $773.

Even with the changes, tax season generally went smoothly, said David Liesse, vice president of education with Washington State Tax Consultants, a professional trade group.

Some of Liesse’s clients, however, were caught off-guard by the penalty.

“Those who have had to pay, didn’t really know what was coming,” he said. “They knew about the requirement, which surprised me, but they didn’t know the details of it. Some had heard about the $95, but weren’t sure of it.”

For 2014 taxes, most people who were uninsured owed a penalty of either $95 per adult or 1 percent of their adjusted household income. That amount goes up this year to $325 per adult and 2 percent of income for being uninsured.

“Most of them,” Liesse said, “are looking to get insurance.”