ACA Coverage Trends Went This Way. Now They Are Headed That Way.


Robert Calandra

W​hatever its failings, the ACA reduced the number of Americans without health insurance. 

The combination of community rating, ACA exchange plans, Medicaid expansion, and the provision that allowed adult children to stay on their parents’ policies helped reduce the number of uninsured Americans from about 45 million in 2010, the year the ACA was signed into law, to just over 27 million in 2016, according to the Kaiser Family Foundation’s analysis of the Census Bureau’s American Community Survey data. During that same span, the number of Americans with Medicaid coverage increased from 51 million to 65.5 million. In 2015, 17.4 million Americans were insured in the individual market, 9.5 million through ACA exchange policies and 7.9 million through off-exchange policies, many of which were available because of the ACA guarantees of coverage for those with pre-existing conditions. 

In 2018 1,862,000 more Americans were uninsured for some of the year than in 2017.

But since 2016, many of these trend lines have changed direction. Republicans have failed to “repeal and replace” the ACA; it has been just over two years since the late Senator John McCain’s dramatic, early morning thumb-down gesture killed a pared-down “skinny repeal” of the ACA. Still, the Trump administration and the GOP have chipped away parts of the law, including repealing the individual mandate starting this year, ending cost-sharing reduction payments, and the loosening the rules for short-term insurance coverage. Kaiser’s numbers show the number of uninsured Americans ticking up from 27 million in 2016 to 27.8 million in 2017. In September, the Census Bureau released a report that indicated that the the uptick in the number of uninsured Americans continued from 2017 to 2018. The bureau uses data from two other sources in addition to the American Community Survey, so its numbers vary some from Kaiser’s but not in their general direction. According to the bureau’s tally, 25.6 million Americans were uninsured for some period of time in 2017. Last year, that number climbed to 27.5 million. 

Kaiser and the Census Bureau also show a reversal in the ACA-generated growth in the number of Americans covered by Medicaid. Kaiser’s tabulations show a peak in 2016 of 65.5 million that dipped to 65.2 million in 2017. Similarly, the Census Bureau’s numbers show a decline from 59.8 million covered by Medicaid in 2017 to 57.8 million in 2018. 

ACA-fueled trend lines change direction

Under the ACA, the uninsured went down and the Medicaid-covered went up. Now the reverse is happening.

Source: Kaiser Family Foundation, State health facts, 2008–2017

When Kaiser crunched the numbers for the individual market, they found a marked decrease in coverage from a peak of 17.4 million in 2015 to 13.8 million last year. Most of the decline has been in the off-exchange market where people aren’t eligible for any kind of subsidy. In the ACA exchange part of the individual market, enrollment has been fairly steady. Kaiser’s tabulations show enrollment peaking in 2016 at 12.7 million and then slipping during the Trump administration. Enrollment in exchange plans for the 2019 coverage year was 11.4 million.

The Trump administration has cut back funding for ACA advertising and enrollment, which will probably further dampen enrollment in exchange plans in 2020.

But the ACA, and the exchanges, have proved to be pretty resilient. More insurers have jumped into the exchange plan market. For example, Oscar moved into six new states for the 2020 coverage year, according to a Wall Street Journal story earlier this year. Anthem expanded into California and Virginia. The price of premiums is dropping—by an average of 4% for the second least expensive silver plan, according to a CMS announcement in October, which also said that “Obamacare remains unaffordable for millions of Americans.” Experts have many explanations for what is looking like an increasingly healthy ACA market. A 2018 report from the Commonwealth Fund found that the rampant adverse selection that many anticipated would occur in the ACA exchange market did not, in fact, materialize. 

Notwithstanding the various Medicare-for-all plans that Democrats are proposing and ACA’s lack of strong political appeal among likely voters in the party’s primaries, many of the the law’s provisions are popular, even across party lines, according to a recent Kaiser tracking poll. Among the most favored provisions are those that prohibit insurers from denying coverage for people with pre-existing conditions (72%); prohibiting insurers from denying coverage to pregnant women (71%); prohibiting insurers from charging sick people more (64%); requiring coverage for most preventive services (62%); and not allowing insurance companies to set life time limits (62%). 

Meanwhile, Republicans are calling for various kinds of deregulation, increased portability of health insurance for people who change jobs or insurance plans, and state-level risk pools that would cover people with pre-existing conditions.

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