A Gallup survey published last month analyzes the impact of the Affordable Care Act (ACA). It shows that more people had health insurance in 2015 than in 2013, although the rate of change decreased precipitously in 2015. (Gallup: U.S. Uninsured Rate 11.9% in Fourth Quarter of 2015)
The uninsured rate has fallen dramatically, down to 12% from the awful, awful Bush Recession levels of 16%-plus that the United States experienced from 2009 through 2013, peaking at 18% in Q3-2013. However, the rate of decline stalled in 2015, as the year ended at the same level it began despite a temporary dip in the 2nd and 3rd quarters. Essentially all of ACA’s impact to date occurred in the last quarter of 2013 through the end of 2014, or 5 quarters total.
The 6% drop in uninsureds in the 2 years since ACA’s major provisions took effect (Gallup uses Q4-2013 to Q4-2015 for its analysis) affected every income level, age group (except 65+, who already had Medicare) and demographic cohort.
This is wonderful, wonderful news. President Obama and any Democrats in Congress that helped push through ACA should be very proud of what they accomplished.
But the job remains unfinished.
Especially troubling is the fact that 32.3 million remain uninsured despite ACA. (Kaiser Family Foundation: New Estimates of Eligibility for ACA Coverage among the Uninsured)
Change in Sources of Insurance Coverage
Disturbingly, coverage provided through employers dropped by 1%. That may not seem like much, but keep in mind that overall employment increased by 3.4 million workers during this time frame. Thus, the claim that some employers would drop employee coverage proved true, although nowhere near the rate doom-n-gloomers predicted.
Coverage through Medicaid accounted for 2% of the decrease in uninsureds. This is one of the key features of ACA, which increased the Medicaid income limit. Sadly, Republican governors in 19 states opted out of ACA, thus reducing the number of people who would otherwise qualify. Blame rests squarely on the Supreme Court, which determined that Medicaid expansion is optional.
The largest segment of the decrease in uninsureds is people buying their own health insurance policy, either fully out-of-pocket or with some level of support from Federal subsidies. This accounted for 4%, or 2/3rds of the total drop and proves that the mandate does change individual behavior and government subsidies do work.
Unfortunately, though, we appear to have reached Peak ACA. As mentioned earlier, there was essentially no change in 2015 and the bulk of the change occurred in 2013 — 2014.
What About the 32 Million Uninsured?
According to Kaiser, about 15.9 million or ½ of the uninsured are eligible for financial assistance either through Medicaid or subsidized Marketplace coverage. More than 3 million of the eligible uninsured are children that would qualify for Medicaid or CHIP. Another 5.8 million are Medicaid eligible adults and about 7 million are eligible for tax credits at some level.
However, even if every eligible person obtained health insurance, there would still be over 16 million without it. Some of them are undocumented immigrants and others are ineligible for income or other reasons.
Why don’t more people obtain health insurance? According to Kaiser Family Foundation,
Data from other sources indicates that misperceptions about cost, lack of awareness of financial assistance, and confusion about eligibility rules were barriers to some eligible uninsured gaining coverage. Others report that they found coverage to be too expensive, even with the availability of financial assistance.
Nearly a quarter of the remaining uninsured population is outside the reach of the ACA due to either their immigration status or their state’s decision not to expand Medicaid.
As of 2016, there are still substantial opportunities to increase coverage by reaching those who are eligible for help under the ACA. However, the breakdown of who the remaining uninsured are suggests that many may be difficult to reach and will still remain uninsured.
(Kaiser — from link given earlier)
I can’t speak for other, but in my case, I remain uninsured because I was rejected for Medicaid. My income is too high (Ha!) and even with subsidies, I can’t afford a Marketplace policy. Insurers can charge 60 year olds like me premiums that are 300% higher than those younger people are charged.
Fortunately, I’ll be able to enroll in Medicare 5 years from now, and that will certainly be a red letter day for me. Unfortunately, it will not be a red letter day for most of the other 32 million uninsureds unless they happen to be decrepit old lucky-duckies like me.
What should we do? Well, Bernie is right. Medicare For All is the right way to proceed. I don’t know that his full plan with all its bells and whistles is reachable (No reason not to try, though. You don’t start negotiating from the middle of the table and end up sitting in your opponent’s lap.), but extending traditional Medicare A and B to people under 65 certainly is doable, and careful implementation ensures minimal disruption to our current healthcare system.
[ Other than a diminution of insurance and pharmaceutical company profit margins. For some reason, that doesn’t bring tears to my eye. Perhaps I’m callous. ]
Since traditional Medicare has coverage gaps, Federal programs like CHIP and Medicaid remain untouched. Portions of ACA are still viable and necessary. Private Medigap insurance is still needed. Private insurers compete to offer Medigap and Medicare Advantage plans with alternative coverage options, and they can offer plans that fill in the donut hole and provide dental, hearing and vision, none of which are covered in traditional Medicare.
Tweaking ACA is not enough. Even under the best of circumstances, a large swath of American remain uninsured. And that is a sad state of affairs for the richest and mightiest nation on the face of the Earth.
We can do better.