Despite the threat of repeal, Affordable Care Act (ACA) marketplace enrollment is running ahead of last year’s pace. This week, the U.S. Department of Health and Human Services (HHS) reported that 6.4 million people have newly enrolled in health plans through HealthCare.gov, the ACA’s federal health insurance marketplace. This enrollment number doesn't include sign-ups in the 11 states that have their own marketplaces, or those who have opted for auto-renewal. HHS projected in October that about 11.4 million people would be enrolled in the marketplaces in 2017. Latest estimates show that more than 16 million people have gained coverage through Medicaid and the Children’s Health Insurance Program since October 2013.
Effects of the ACA Coverage Expansions
Critics of the ACA question whether this new coverage is helping people get affordable health insurance and health care. Yet, national survey data and stories told by Americans who have gained insurance through the law’s coverage expansions strongly suggest it has. A Commonwealth Fund report out this week finds the percentage of working-age adults without health insurance fell in every state and the District of Columbia between 2013 and 2015. The report also found that millions more Americans can afford doctor visits: the share of people who reported not going to the doctor when sick because of cost dropped in 38 states and the District of Columbia over that period. People with family incomes under $50,000 made particularly large gains in coverage and access. In Kentucky, for example, where more than 350,000 people have gained coverage since 2013, uninsured rates among low- and moderate-income adults dropped from 38 percent to 13 percent, the largest decline in the nation. Adults in Kentucky also reported the largest gains in the ability to get affordable doctor visits.
Consumer Voices
We also have heard stories from consumers about their experiences with ACA health insurance coverage over the past few years. My colleague, Douglas McCarthy, heard from a former classmate named Will who lost his insurance coverage at a time when he needed health care more than ever. Formerly assistant dean and basketball coach for a Midwestern community college, Will suffered a stroke in the middle of a game he was coaching.
“I worked and was employer-covered my whole life,” he says. But following the stroke and a long hospital stay and recovery, he lost his job. Fortunately, today he has coverage through ACA marketplace. “I require injections every three months,” he says. “Without those, life is so painful it's not worth living. The ACA gives me insurance for $117 a month. I can afford it. I still have a life worth living. If I lose it, I'm a goner. No insurance company will touch me unless mandated.”
Last year, anthropologist Susan Sered heard similar stories from people she interviewed across the country about their health care. One Illinois woman, Laura, owned her own cleaning business and lacked health insurance for most of her life. After an expensive emergency visit to the hospital in her 40s, she was left with a large bill that she couldn’t pay, and the hospital took out a lien against her home. She has high blood pressure, but could not afford to go to the doctor during those years, and delayed other care like screenings for cancer and dental check-ups. In 2015, Illinois expanded eligibility for Medicaid under the ACA and Laura enrolled at age 60. After years of cleaning homes, her knee had worn out. She was able to have knee surgery with her new coverage, an unthinkable expense in Laura's life prior to the reform law.
Fund researchers interviewed a handful of consumers that year as well, including Virginia Lindahl of Alexandria, Va., a self-employed clinical psychologist who suffers from migraines and restless leg syndrome. After separating from her partner in 2006, she sought individual coverage, but at that time insurers were allowed to charge people more on the basis of their health, and exclude those with preexisting conditions. Lindahl bought a bare-bones plan with a $5,000 deductible and an annual limit on coverage. But out of fear of amassing large medical bills, she routinely put off needed care. In 2014, Lindahl signed up for health insurance in the marketplace immediately. "On that first Monday of January 2014 [after the plan went into effect], I got on the phone with all my doctors and made appointments with all of them," Lindahl said.
Looking Forward
In this time of uncertainty about the future of the ACA, it is important to keep in mind the financial and medical protection health insurance provides to individuals and families, as illustrated by these stories. In 2002, the Institute of Medicine’s (IOM) seminal study on the uninsured found that uninsured people get about half the care that people who are insured all year get. People who lack health insurance for most of their lives have fundamentally different life experiences than those who are insured continuously.
The IOM study triggered what became the nation’s most serious debate over expanding insurance coverage, which culminated in the passage of the Affordable Care Act in 2010. Rather than mark the end of that effort, the law’s passage should be viewed as the beginning. With shortcomings in the law now apparent, including inadequate subsidies for families with incomes over $60,000 and the need to stabilize some state marketplaces, it is time for policymakers to join forces in a bipartisan effort to address these issues through changes to the law. A repeal would not only set the nation back decades, but hurt hard-working people like Laura and Virginia who waited decades to gain access to affordable health care—and do not want to lose it.
