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Since the advent of the Affordable Care Act in 2009 over 20 million previously uninsured people have gained health insurance coverage. This has had a number of positive impacts on access to care and health outcomes which I’ve covered in previous blogs. But as we all know, there have also been challenges. The Supreme Court ruling, which made expansion of Medicaid optional for states, the compromises on benefits coverage that were required to get the plan passed in the first place, and the elimination of a public option (e.g. Medicare buy in for people 55 and older) by the US Senate diminished the impact of the law. Congress’ removal of the individual mandate last year and the current administration’s dramatic reductions in outreach funding and time access to enrollment have further undermined the ACA.

And now a Commonwealth Fund survey reveals some disturbing trends. While the uninsured rate has declined from 20% in 2010 to 12% for the past 3 years (and it is unfortunate we could not make more progress on that) the rate of underinsured has risen from 16% to 23% during the same time period). And more surprisingly, the most rapid rate of increase in the underinsured is among those with employer based insurance, not those who purchase their insurance as individuals. This is a reflection of ever increasing deductibles and co-pays as health care cost increases outpace wages, driven largely by pharmaceutical costs and the ongoing waste in healthcare spending ($1 trillion of the $3 trillion spent on healthcare each year).

Most of us have experienced this phenomenon on a very personal level as year after year our personal costs for health insurance coverage increase while there is simultaneous pressure on benefit design to try to create cost reductions. The authors of the survey suggest several strategies to reverse this trend and they include:
• Improve the basic required coverage under the ACA to require coverage of more of the costs of care and of medications.
• Increase Medicaid expansion.
• Support growth of reinsurance markets.
• Restore outreach and enrollment funding.
• Reinstate funding to reduce cost sharing (which ahs been cancelled by the Trump administration).
• Eliminate “junk plans”, the short term plans with very limited benefits that were expanded by congress last year.
• Make health insurance premiums tax deductible.

There are other strategies that ought to be considered as well. Medicare buy in for people aged 55 and over was seriously considered in 2009 and ought to be re-evaluated. States may also undertake innovations like allowing buy in to Medicaid. We ought to be able to do better and we can if we put people first in public policy.

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