- More U.S. adults are underinsured now than when the Affordable Care Act was implemented in 2010, and the greatest change has been in people with employer-based insurance, according to a new report from The Commonwealth Fund.
- The rate of people with no insurance has dropped since 2010 and was mostly unchanged from 2016 to 2018, despite numerous attempts from the Trump administration to undermine the health law. Coverage gaps also decreased in length from 2010 to 2018, according to the biennial survey.
- Long-term uninsurance rates have also dropped, from 72% of people going without coverage for more than two years in 2010 to 54% in 2018. The percentage of people without insurance for six months or less, however, nearly doubled to about 20%.
The ACA succeeded in one of its core goals — getting more Americans health insurance coverage. Lack of adequate coverage clearly remains a concern, however.
Patients who are underinsured say they sometimes forgo care because of the costs. The Commonwealth Fund survey found that 35% of respondents said they either didn't visit a doctor despite a medical problem, didn't fill a prescription, skipped recommended treatment or did not get needed specialist care because of cost worries.
The report defines "underinsured" as adults insured all year but also faced steep out-of-pocket costs and deductibles compared to their income. In 2018, the number of people who were insured all year, but underinsured, was 43.8 million (22.6%), up from 16 million (16%) in 2010.
Coverage gaps mean people are less likely to get preventive care, including cancer screenings, the report found.
The authors suggest a number of policy recommendations to improve coverage for American adults, including expanding Medicaid in more states (without restrictions like work requirements), limiting plans not compliant with the ACA, extending the marketplace open enrollment period and passing legislation to protect patients from surprise bills.
Most of these ideas, however, are not embraced by the Trump administration.
Report authors also recommend reinstating cost-sharing reduction subsidies for payers, instituting reinsurance programs and increasing the ACA's minimum level of coverage.
Newly empowered House Democrats could push some of these policies as they look to roll back restrictions the GOP mounted on the ACA and potentially strengthen some of its provisions. They have already held or planned several hearings on topics like protections for people with pre-existing conditions — though they still face a Republican-controlled Senate and executive branch.
Meanwhile, a Texas judge's decision late last year that the ACA is unconstitutional without its individual mandate penalty looms. The ruling has been stayed and appealed, and the case will likely drag on throughout the year.