Progress Remains in Jeopardy

Since first evaluated in 2014, gains in health insurance coverage and improvement in health care access and affordability have continued through the first quarter of 2017. These gains are particularly striking among low- and moderate-income Americans living in states that expanded Medicaid. The latest data from the Urban Institute’s 2017 Health Reform Monitoring Survey show that between Q3 2013 and Q1 2017, uninsurance among adults with family incomes at or below 138% FPL decreased by 42.7% (p<0.01), while uninsurance among incomes of 139-399% FPL decreased by 49.4%. Nearly all of this reduction in uninsurance for low- and moderate-income adults was due to gains in Medicaid coverage.

Despite these gains, many were trapped in a “coverage gap” in the nineteen states that did not expand Medicaid. The rate of those who remained uninsured in the low-income group was almost 2.5 times higher in non-expansion states than in expansion states – 33.2% versus 13.9% (p<0.01). Thus, despite opportunities to further reduce uninsurance in the states that expanded Medicaid, the potential is much greater in the states that did not.

Policymakers will be tasked with deciding whether they want to build on the gains documented here or put them at risk. With repealing and replacing the ACA still under consideration, many people will be at substantial risk if the health and financial consequences for those projected to lose coverage are not carefully considered. Even if the ACA remains in place, strategies indicated by the current administration such as refusing to pay for cost-sharing reductions for low-income adults, failing to enforce the individual mandate, and eliminating support for outreach efforts, may undermine the ACA Marketplace.

Opportunities exists for a more equitable and efficient health care system if politicians choose to focus on addressing the ACA’s current problems, such as improving inadequate financial assistance, better educating consumers about the program, and reducing the high level of premium before subsidies, instead of continually focusing on repeal. Though challenging, the potential to improve upon our health care system remains possible.

This Policy Prescriptions® review is written by Jennifer N. Kistama, ML, MSN, RN. 

Abstract

The significant gains in health insurance coverage and improvements in health care access and affordability that followed the implementation of the key coverage provisions of the Affordable Care Act in 2014 have persisted into 2017. Adults in all parts of the country, of all ages, and across all income groups have benefited from a large and sustained increase in the percentage of the US population that has health insurance. The gains have been particularly striking among low- and moderate-income Americans living in states that expanded Medicaid. Our latest survey data from the Urban Institute’s 2017 Health Reform Monitoring Survey shows that only 10.2 percent of nonelderly adults are now uninsured—a decline of almost 41 percent from the period before implementation of the ACA. Nonetheless, repealing and replacing the ACA remained under consideration during the summer of 2017, along with more systematic changes to the financing of the Medicaid program. Many people will be at substantial risk if key components of the law are repealed or otherwise changed without carefully considering the health and financial consequences for those projected to lose coverage. Though the politics of health reform are challenging, opportunities exist to create a more equitable and efficient health care system.

PMID: 28879455

Long, S, et al. Health Affairs. 2017; 36(9): 1656-1662.