By Sara R. Collins, Munira Z. Gunja, Michelle M. Doty and Herman K. Bhupal
The Commonwealth Fund, May 1, 2018
The marked gains in health insurance coverage made since the passage of the Affordable Care Act (ACA) in 2010 are beginning to reverse, according to new findings from the latest Commonwealth Fund ACA Tracking Survey. The coverage declines are likely the result of two major factors: 1) lack of federal legislative actions to improve specific weaknesses in the ACA and 2) actions by the current administration that have exacerbated those weaknesses. These include the administration’s deep cuts in advertising and outreach during the marketplace open-enrollment periods, a shorter open enrollment period, and other actions that collectively may have left people with a general sense of confusion about the status of the law. Signs point to further erosion of insurance coverage in 2019: the repeal of the individual mandate penalty included in the 2017 tax law, recent actions to increase the availability of insurance policies that don’t comply with ACA minimum benefit standards, and support for Medicaid work requirements.
* About 4 million working-age people have lost insurance coverage since 2016
* The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018
* The uninsured rate among working-age adults increased to 15.5 percent
* The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent
* The uninsured rate increased among adults age 35 and older
* The uninsured rate among adults who identify as Republicans is higher compared to 2016
* The uninsured rate remains highest in southern states
* Five percent of insured adults plan to drop insurance because of the individual mandate repeal
From the Policy Implications
In the absence of bipartisan support for federal action, legislative activity has shifted to the states.
More broadly, leaving policy innovation to states will ultimately lead to a patchwork quilt of coverage and access to health care across the country, a dynamic that will fuel inequity in overall health, productivity, and well-being. At some point, Congress will likely face pressure to step in to level the playing field.
By Don McCanne, M.D.
Although building on our current fragmented health care financing system is the most expensive model of reform, it was understood from the beginning that the Affordable Care Act would fall far short of our goals of universality, comprehensiveness, and affordability. If there is any surprise here, it is how quickly some of the gains could be reversed without the formality of enacting repeal and replace legislation. Not only is ACA a fundamentally flawed model, it is subject to damage through the political whims of ideologues.
Some of the proposed policy options to improve coverage include more advertising of exchange plans, reinsurance to reduce risk of insurer losses, more premium and cost sharing subsidies, and even a public option such as a Medicare buy-in. The problem is that these leave in place the high costs and administrative waste and other deficiencies that characterize our system while failing to protect against political chicanery.
If we had in place a well designed single payer national health program – an improved Medicare for all – everyone would have access to their choice of health care professionals and institutions, and care would be prepaid automatically through progressive taxes and thus affordable for everyone. It would be the privilege once granted that became an irrevocable right, if there were any doubts before.
The Commonwealth Fund would have plenty of other features of our health care system to study, but no longer would they have to keep count of how many go without any health care coverage at all, or how many face financial hardship because they are underinsured. Everyone would be included and nobody would be deprived of care because it was not affordable. So the question is, why do we continue to tolerate the injustices of our highly dysfunctional financing system when we don’t have to?
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