The Issue

The Affordable Care Act (ACA) significantly improved health insurance coverage in the United States, but too many Americans remain uninsured or underinsured. In a Health Affairs article, Chiquita Brooks-LaSure and Gayle Mauser of Manatt Health, along with the Commonwealth Fund’s Elizabeth Fowler, examine federal efforts under consideration that would build on the ACA to provide comprehensive coverage to all low-income Americans and make it more affordable for middle-income Americans.

Building on the Gains of the Affordable Care Act

  • Improving coverage for low-income Americans. Coverage for low-income Americans is the most significant unfinished business of the ACA. Policy options include extending the 100 percent federal matching rate to states that have not expanded Medicaid and offering subsidies to people with incomes below 100 percent of the federal poverty level who would not otherwise qualify for Medicaid.

Some near-term policy options that build on the ACA could make a difference in the lives of millions of Americans.

  • Addressing affordability for middle-income Americans. Middle-income Americans who do not have employer-sponsored coverage or do not qualify for premium tax credits and cost-sharing assistance have challenges getting affordable coverage. To make premiums more affordable, policymakers could offer tax credits to people with incomes above the current eligibility threshold and increase the generosity of tax credits for those already eligible. They also could make reinsurance, which protects individual market plans against high medical costs, permanent. To lower cost-sharing, policy options include tying tax credits to the premium of the second-lowest-cost gold plan rather than the equivalent silver plan and extending federal assistance to people with incomes above the current threshold.
  • Establishing a public option. A “public option” or buy-in that could be implemented at the federal level could help address affordability and coverage issues. Several states are studying buy-in and public option proposals.

The Big Picture

After 10 years, the ACA has achieved many of its goals; the uninsured rate nationwide has been cut nearly in half. However, 27 million people still lack health insurance. Some near-term policy options that build on the ACA could make a difference in the lives of millions of Americans and set the stage for future reforms.

The Bottom Line

The ACA provided health coverage for millions of Americans, but out-of-pocket health spending is unaffordable for many. Some families with low and middle incomes still struggle to find affordable coverage.