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Health Care Coverage and Access

In the 13 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 Commonwealth Fund’s 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. This has helped narrow historic racial and ethnic disparities in coverage and access.

While these gains 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 who do have coverage can afford their health plans and their health care. Recent Fund research has found that the increasing size and prevalence of high deductibles and copayments in private health plans — including employer-based plans, which cover more than half the U.S population under age 65 — are causing many people with low or moderate incomes to delay needed health care or take on medical debt. Racial and ethnic disparities in coverage and access 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 coverage loss or rising out-of-pocket costs. Some temporary policies enacted during the COVID-19 pandemic that helped drive enrollment to record levels in Medicaid and the insurance marketplaces have ended, potentially triggering loss of coverage and higher costs for millions of Americans. And a legal challenge could end the ACA’s free preventive services provision, which benefits 150 million people.

The 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 current information about federal and state legislation and rule-making that affect the ACA’s reforms, health insurance coverage, access to care, and affordability of coverage and care.
  • Tracking enrollment in the ACA coverage expansions, both Medicaid and the marketplaces, and employer insurance, and the degree to which people can access needed care without falling into debt.
  • Evaluating court cases as well as federal and state legislation for their potential effects on: the extent and quality of health coverage; access to health care; affordability of premiums and out-of-pocket costs, especially for families with low or moderate income and people of color; health plan competition and choice; and the sustainability of insurance markets.
  • Analyzing and developing federal and state policy options to cover the remaining uninsured, address underinsurance, make insurance and care more affordable, improve access, and reduce medical debt.
  • Identifying gaps in the ACA as well as emerging legislation and regulations that may leave people of color and those with lower incomes without coverage, inadequately shielded from high costs, or lacking timely access to care.

Program Contact:

Sara R. Collins, Senior Scholar and Vice President

2023 Program Funding Priorities

  • Developing policy options to enroll all remaining uninsured people in coverage and to keep people continuously covered by comprehensive and cost-protective health plans
  • Studying trends and variation in consumer medical debt, their causes, and policy options to relieve debt burdens and prevent debt from accruing in the first place
  • Identifying gaps in employer coverage and developing state and federal legislative and regulatory approaches to lower the cost, and improve the cost protection, of employer health 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