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Health Care Coverage and Access

In the 14 years since enactment of the most significant health reform legislation in half a century, it’s now clear that millions of Americans have benefited from the insurance coverage expansions, premium and cost-sharing subsidies, consumer protections, and market reforms ushered in by the Affordable Care Act (ACA).

During that time, the Health Care Coverage and Access program has monitored the law’s implementation and impact by conducting population-based survey research, analyzing insurance market trends, and tracking state and federal approaches to the ACA’s coverage provisions. Along with other surveys, the latest Commonwealth Fund Biennial Health Insurance Survey — the longest-running nonfederal survey of U.S. health coverage — shows that the nation’s uninsured rate has declined to its lowest level in more than a decade. Fund-supported research has found that the ACA’s provisions have lowered cost barriers to care and improved access and health outcomes, particularly in states that expanded Medicaid. People of color, who had the highest uninsured rates when the law passed, have seen some of the biggest gains.

While these achievement are substantial, longstanding problems with the U.S. health insurance system remain. Reaching the millions of adults who are still without coverage and health care security is one big challenge. Another is ensuring that those with coverage can afford their health plans and their health care without fear of medical debt. Recent Fund survey research has found that health care costs deter many Americans from getting the care they need, resulting in harm to their health. While having insurance is much better than going without it, coverage often fails to ensure people can afford the care they need — and that applies to all types of insurance, including the employer-based plans that cover more than half of Americans under age 65. Moreover, racial and ethnic disparities in coverage and access to care persist, especially in the 10 states that have yet to expand Medicaid.

Ongoing legal challenges and legislative debates over the ACA’s provisions are also leaving people at risk of losing coverage or facing higher out-of-pocket costs. Some temporary policies enacted during the COVID-19 pandemic that helped drive record enrollment in Medicaid and the insurance marketplaces have ended, triggering the loss of coverage and raising costs for millions of Americans. And a legal challenge could end the ACA’s free preventive services provision, which benefits 150 million people.

The Commonwealth Fund’s Health Care Coverage and Access program delivers timely information on the state of health coverage in the U.S. to federal and state policymakers, consumer groups, the media, and other key stakeholders. Its efforts include:

  • Providing timely information about federal and state legislation and rulemaking that affect the ACA’s reforms, health insurance coverage, access to care, and affordability of coverage and care.
  • Tracking enrollment in Medicaid, the ACA marketplaces, and employer insurance as well as overall uninsured rates.
  • Examining whether private and public health insurance enable people to get the health care they need without falling into debt.
  • Evaluating legislation and court decisions for their potential effects on: the extent and quality of health coverage; access to care; affordability of premiums and out-of-pocket costs for families with low or moderate income and people of color; health plan competition and choice; and insurance markets.
  • Analyzing and developing policy options for covering the remaining uninsured, addressing underinsurance, improving affordability and access, and limiting medical debt.
  • Identifying gaps in the ACA, proposed legislation, and regulations that may leave people of color and those with lower incomes uninsured, exposed to high costs, or lacking timely access to care.

Program Contact:

Sara R. Collins, Senior Scholar and Vice President, Health Care Coverage and Access

2024 Program Funding Priorities

  • Developing policy options to cover all people who remain uninsured and keep people continuously covered with comprehensive, cost-protective health plans
  • Studying consumer medical debt and its causes and evaluating policy options to relieve debt burdens and prevent them in the first place
  • Examining consumers’ increasing difficulties with affording coverage and care and navigating an increasingly complex health system, and how these problems affect people’s ability to maintain their health
  • Identifying gaps in employer coverage and developing legislative and regulatory approaches to improving the cost-protectiveness of plans

Our Experts

Sara R. Collins

Senior Scholar, Vice President, Health Care Coverage and Access & Tracking Health System Performance

Jesse C. Baumgartner

Former Senior Research Associate, Health Care Coverage and Access & Tracking Health System Performance

David C. Radley

Senior Scientist, Tracking Health System Performance

Relebohile Masitha

Senior Program Assistant, Health Care Coverage and Access