Universal health care remains an unfulfilled dream for the United States. But in some parts of the country, the dream has moved closer to reality in the 13 years since the Affordable Care Act was passed.
Overall, the number of uninsured Americans has fallen from 46.5 million in 2010, when President Barack Obama signed his signature health care law, to about 26 million today. The U.S. health care system remains deeply flawed, with more than 8 percent of the population uninsured, far more than comparable countries. Many people who technically have health insurance still struggle to cover their share of medical expenses. Nevertheless, more people have some form of financial protection against health care costs than at any previous time in American history.
The country is moving towards universal coverage. If everyone eligible for either the ACA’s financial assistance or its Medicaid expansion successfully enrolled in the program, we’d get even closer: More than half of the uninsured are technically eligible for government health care subsidies.
Especially in recent years, states have been the most aggressive in reducing the number of uninsured, using the tools provided by the ACA.
Today, 10 states have less than 5 percent uninsured coverage, not quite universal coverage but getting close. Other states may hover around the national average, but it still represents a dramatic improvement over the pre-ACA reality: In New Mexico, for example, 23 percent of its population was uninsured in 2010; now only 8 percent.
Their success shows that even without another major federal health care reform effort, it is possible to reduce the number of uninsured in the United States. If states are more aggressive in using all the tools available under the ACA, the country can continue to reduce the number of uninsured people within its borders.
The law gave states the discretion to build their basic structure. Many received permission from the federal government to create programs that lower premiums; Some also offer state subsidies on top of federal aid to reduce premiums, including for people who don’t qualify for federal subsidies, such as illegal immigrants. A few states are even offering new state-run health plans that compete with private offerings.
I asked several leading health care experts which states stood out from them, fully armed with the ACA to reduce the number of uninsured. There was no single answer.
I don’t think any state has taken advantage of everything, said Larry Levitt, executive vice president of the KFF health policy think tank. No state has assembled all the pieces under the ACA.
But a few stood out for the steps they’ve taken over the past decade to move toward universal health care.
Massachusetts (and New Mexico): Streamlined enrollment and state subsidies
Massachusetts has the lowest uninsured rate of any state, with just 2.4 percent of the population lacking coverage. It had a head start: The law provided a model for the ACA itself and its system of government subsidies for private plans sold in the public marketplace that existed before 2010.
But experts say it still deserves credit for the actions it has taken since the Massachusetts model was applied to the rest of the country. Matt Fiedler, a senior fellow at Brookings Schaeffer’s health policy initiative, said two policies stood out in terms of expanding coverage: integrating the enrollment process into both Medicaid and ACA marketplace plans, and providing state assistance on top of federal laws. .
Massachusetts was among the first states to do both.
The former can do a lot to reduce the risk that people will lose coverage as incomes change, Fiedler told me, while the latter will directly improve affordability and thus promote adoption.
Integrated enrollment means consumers can be directed to either the ACAs marketplace (where they can use government subsidies to buy private coverage) or the state Medicaid program through a single portal. They enter their information and the state tells them which program they should enroll in. Without this integration, people may have to first apply for Medicaid and then, if they don’t qualify, apply separately for Marketplace coverage. The more steps a person has to take to successfully enroll in a health plan, the more likely people are to fall through the cracks.
Government support, in turn, both lowers people’s insurance premiums and makes it easier for them to book more coverage, and their out-of-pocket costs are lower when they actually use medical services. Nine states, including Massachusetts, now have state aid, and interest has increased in recent years.
New Mexico, for example, only recently became a state-specific ACA marketplace and began offering Supplemental Assistance in 2023. Having already seen dramatic improvements, it remains to be seen how much more progress the state can make toward universal coverage with this policy in place.
Minnesota and New York: The Basic Health Plan states
The basic structure of the ACA was this: Medicaid expansion for people living in or near poverty and marketplace plans for people with higher incomes. However, the law included an option for states to seamlessly integrate the two populations, and so far the two states that have taken advantage of it, Minnesota and New York, are also among the states with the lowest insured rates. Only 4.3 percent of Minnesotans and 4.9 percent of New Yorkers lack coverage today.
They both created basic health plans, the product of one of the health care law’s most obscure provisions. This is a state-regulated health insurance plan designed to cover people up to 200 percent of the federal poverty level (about $29,000 for an individual or $50,000 for a family of three). These are people who may not technically be eligible for Medicaid under the ACA, but are still struggling to pay their monthly premiums and payment obligations through a Marketplace plan.
In both states, primary health plans offered insurance options with lower premiums and lower cost-sharing responsibilities than the marketplace insurance they would otherwise have had. For example, in New York, people between 100 and 150 percent of the federal poverty level pay no premiums at all, while people living between 150 and 200 percent pay just $20 a month.
There is good evidence that the approach has increased coverage: New York, for example, saw a 42 percent increase in the number of people living below 200 percent of the poverty line when the state adopted BHP in 2016 compared to what it had been the year before. when those people were excluded from the coverage of the traditional marketplace.
State interest in primary health plans has so far been limited, but Minnesota and New York offer a model that others could follow. Fiedler said part of the success of basic plans in those states has been using Medicaid managed care companies to administer the plan: Insurers already pay providers lower prices than marketplace plans, and the savings give states money to share premiums and costs.
Colorado and Washington: Public Options and Help for the Undocumented
These states have been inventive in countless ways. They are both early adopters of the public option, a state health plan that competes with private plans on the market, and the policy is also being tested in Nevada.
They share another policy that affects a significant portion of the remaining uninsured nationwide: Both offer some government subsidies to undocumented immigrants.
Most uninsured Americans are already technically eligible for some form of government assistance, either through Medicaid or through the marketplace. But there are a large number of people who are not: About 29 percent of the uninsured in the United States are not eligible for government assistance, among them people who are in the country without documents. These people are responsible for all their medical bills and may avoid treatment for this reason (for others, of course).
Starting this year, Washington allows undocumented people whose income would make them eligible for a Medicaid expansion to participate in that program, and provides state subsidies to high-income people regardless of their immigration status. Colorado has set aside a small amount of money each year to provide state assistance to about 11,000 undocumented people. (Once this threshold is reached, these people can still enroll in a health plan, but they must pay full price.)
Interest has been strong: Last year, Colorado reached the enrollment limit after about a month. This year, enrollment closed in just two days, suggesting the state may need to put more money behind the effort.
It is difficult to imagine insurance subsidies for illegals nationwide in the near future, given the national immigration policy. But states are finding ways to make inroads of their own: California has made undocumented people eligible for Medicaid.
In these and other ways, they are helping America move toward universal health care.
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