Kansas State University


Issues in Health Reform

How is the ACA faring according to enrollment criteria or what do the enrollment numbers mean?

If one uses as a standard the Forbes article analyzing recently released Census Bureau data ACA is performing at 71% of expected enrollment and is therefore a failure. True that the Census data used in that article in all new reports are likely more accurate than earlier reports based on smaller samples that had shown more hopeful progress. Still, I find it odd, to say the least, to call a drop in the rates of uninsured of about 8% overall to be a failure. The ASPE DHHS national data report now shows 17.6 million uninsured gaining health insurance coverage through the Health Insurance Marketplaces, Medicaid, and also including individual private market coverage.

The ASPE report also notes that the decreases in the uninsured has differentially affected racial and ethnic groups. The largest decline was among African Americans where the uninsurance rate was halved from 22.4% to 12.1%, 2.6 million people gaining insurance.  Hispanics had farther to go. They started at 41.8% uninsured and are now at 30.3%. That is still a high rate of uninsured that is complicated by matters of documentation but a significant drop nonetheless and affecting 4 million real lives. Whites had, and continue to have, the lowest rates of uninsurance among those three groups. They started at 14.3% and have declined to 8.3%, impacting 7.4 million lives.

Those are significant numbers of Americans now being insured and having much more balanced access to health insurance. No one can be denied a policy because they are sick. No one’s policy can be cancelled because they are sick. There are no longer annual nor lifetime maximums on the amount paid out for covered services. In a nutshell, not only are all of the new folks insured and protected, but most who are insured through employer plans also now share those same protections (there are exceptions for self-funded plans and for the small percentage still grandfathered in under old regulations). Further, this ability to access insurance through a place other than a place of employment has opened up opportunities for those who want to leave their current places of employment. In the past many were stuck in jobs solely for the purpose of keeping health insurance because they would have been denied coverage elsewhere because of pre-existing conditions.

So why is there less enrollment than anticipated? There are two barriers to fuller enrollment that the Forbes article does not acknowledge. The first barrier more critical to less than anticipated enrollment is the reality that 19 states have still not expanded Medicaid, the public insurance program through which it was anticipated many of the newly insured were to become insured. The ASPE Data Point Report shows that expansion states have dropped to lower rates of uninsurance (from 18.2% to 10.1%) compared to non-expansion states (from 23.4% to 16.1%), though it is telling that the non-expansion states had farther to go, indicating perhaps a less friendly environment for employment based opportunities for insurance and a host of other contextual issues that drive health disparities in those states at the start.

The second reason is that most of the states that are relying on the federal government to run their insurance exchanges had less enthusiasm for the law and perhaps created less supportive environments to ensure that all eligible individuals knew of their new insurance options. One cannot blatantly ignore the political realities that have created fear around the law and discouraged eligible families to consider their options. It is therefore understandable that initial anticipated goals have not yet been reached and it remains an uphill battle in many states to get to expected enrollment numbers.

Agreed that it would have been best not to have overestimated the potential of the ACA to decrease the number of uninsured, especially in such a hostile political environment. Still, you can decide if a drop from over 20% to under 13% uninsured makes the ACA a success or a failure. And then we can determine what needs to be done to make sure that more Americans can gain insurance.

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