- Paul Rosenberg
By Paul Rosenberg, Senior Editor
The United States is the only advanced industrial nation that doesn’t provide healthcare for all, but under the Affordable Care Act, also known as Obamacare, the number of uninsured Americans younger than age 65 fell dramatically—by an estimated 17.8 million, from 2013 to 2016.
Then came Donald Trump.
While Republicans failed dramatically in their central effort to repeal Obamacare, their year-end tax cut threatened healthcare in two ways. First, it repealed the individual mandate, which the Congressional Budget Office projects will increase the number of the uninsured by 4 million in 2019 and 13 million in 2027. Second, it balloons future deficits by $1.4 trillion within 10 years, which Republicans will want to “balance” by cutting Medicare, Medicaid and Social Security. Trump also used executive actions to further undermine Obamacare—raising rates and making enrollment more difficult.
The year ahead promises more of the same.
Random Lengths News reached out to some experts for insight and advice: Susan Hayes, senior researcher at the Commonwealth Fund, Judith Solomon, vice president of Health Policy at the Center for Budget and Policy Priorities, and Anthony Wright, executive director of Health Access California.
Hayes is the lead author of the Commonwealth Fund’s What’s At Stake report, which chronicles the gains under Obamacare. What’s At Stake explains that:
Between 2013 and 2016, the uninsured rate for adults ages 19 to 64 declined in all states and the District of Columbia, and fell by at least 5 percentage points in 47 states. Among children, uninsured rates declined by at least 2 percentage points in 33 states.
But increased coverage was only part of the story, according to all three experts.
“We increased the kind of coverage they had by having standards for essential health benefits, in both the small groups and the individual health insurance market, as well as eliminating annual and lifetime benefit caps, preventing people from being barred based on pre-existing conditions, not charging women more than men, and all those market reforms are still in place,” Solomon said.
However, they’re under attack.
“This historic reduction in uninsured rates was accompanied by widespread reductions in people saying they could not get care because of the cost … and in improvements in people at risk for poor health outcomes getting access to the care they need,” Hayes said.
In California, the percentage of adults who didn’t see a doctor because of costs dropped from 16 percent to 11 percent.
“This 5-percentage point reduction meant that an estimated 1.1 million fewer people in California skipped needed care because of costs in 2016 compared to 2013,” she said.
The ACA marketplace played some role, but Medicaid expansion has been central to that success, she explained.
“States that accepted federal funds to expand their Medicaid program under the ACA, as California did, saw the greatest gains in access,” she said.
“California had the biggest reduction of our uninsured rate of all 50 states,” Wright noted. “We went from about 7 million uninsured to less than 3 million — with millions now in coverage under the Medicaid expansion and another over a million getting subsidies to better afford individual coverage in Covered California.”
This past year, the Trump administration tried to cripple Obamacare enrollment by cutting the time available to sign up for coverage in half and slashing money spent on outreach by 90 percent, from $100 million to $10 million. But almost 9 million people still signed up — a decline of just 400,000.
California was a leader in fighting back against this, by passing a law maintaining its existing 90-day annual open enrollment period for future years, and by expanding the money spent on outreach, enrollment and marketing. As a state-operated exchange, Covered California has its own revenue sources. It boosted spending by around 10 percent to $111 million.
The Trump administration also cut off making cost-sharing reduction payments to insurers, which help lower out-of-pocket healthcare costs for roughly 6 million low- and moderate-income earners. Far from saving money, an Urban Institute analysis found it would cost the federal government $7.2 billion in 2018, as a result.
“The loss of the [cost-sharing reduction]s has made the premiums go up, the [loss of the individual] mandate will make the premiums go up, so anybody who is not eligible for a subsidy is going to have a hard time,” Solomon pointed out. “The subsidies go up with the prices, so the people who are eligible for subsidies can still buy something.”
But it makes the whole system more costly, and leaves many people out.
“Something to relieve those folks who are buying in the individual market and not eligible for subsidies could be helpful,” she said. “I just don’t see the will right now to focus on that.”
The more complicated it gets, the more ways there are for people to lose.
This year, the most imminent threat comes from additional executive actions. Solomon called attention to the first such example, announced on Jan. 4: new rules allowing small businesses and trade groups to form associations to buy health care that “don’t have to cover all of the benefits,” she listed above.
“Their plan is to allow short-term plans that are not subject to the market reforms rules,” she said. “We’re beginning to see — via these executive orders and possibly continued efforts on the legislative side — moves to erode the comprehensiveness of coverage that we gained.”
Legislative threats are less certain, but more ominous.
“We are most concerned about another run at ACA repeal, or efforts to cut and cap Medicaid and/or Medicare, as proposed in the federal budget outline,” Wright said. “The ACA repeal proposals not just would have set us back the five years of progress but by 50 years by ending the key commitments of Medicaid.”
“There’s still that looming threat,” Solomon agreed.
“We are preparing for the mother of all Medicaid and Medicare battles in this new year,” Wright said. “The GOP Congressional leadership has been clear that they plan to pay for the tax giveaway to the wealthy and corporations by seeking cuts to Medicare and Medicaid — at a massive scale…. Their budget resolution outlined $1.5 trillion in cuts to Medicaid.”
If the resistance to Trump’s agenda nationwide can block such drastic action, there’s a real chance California’s healthcare could improve.
“Congressional action repealing the ACA, block-granting Medicaid, or anything like that would be catastrophic, costing California tens of billions of dollars a year,” Wright warned. “The previous proposals were the equivalent of all the money that California spends on higher education, prisons and parks—combined…. It would be very, very hard to backfill. The save and salvage operation would still leave millions uninsured, benefits slashed and provider payments cut…. California can use our progress as a platform to take additional steps to universal coverage…. We can continue to expand Medi-Cal to cover all income-eligible Californians regardless of immigration status. We can improve affordability assistance in Covered California, to get better sign-ups in a high-cost-of-living state. We can continue to take steps to address the cost of care, like we did last year with prescription drug price transparency to require justifications for price hikes.”
With enough breathing room, other states could follow California’s example, Hayes said.
“One of the biggest steps that could be taken to strengthen the gains already achieved would be for the 19 states that have not yet expanded Medicaid to decide to do so,” Hayes said. “We found that low-income adults fared better in terms of access in Medicaid expansion states than their counterparts in non-expansion states. For example, nine expansion states, including California, slashed their uninsured rate for low-income adults by more than 20 percentage points between 2013 and 2016…. The share of low-income adults going without health care because of costs declined by more than seven points, on average, in the states that expanded Medicaid, compared to three points in states that did not.”
California did slightly better than average, with an eight point decline.
“States can also follow California’s lead in outreach and enrollment efforts for both marketplace and Medicaid managed care plans to ensure their residents get the coverage they are entitled to under federal law,” Hayes said.
While the number and variety of threats can be overwhelming, the bottom line for Californians is relatively simple.
“If we can prevent wholesale ACA repeal or major Medicaid cuts and caps, California has the will and the wherewithal to hold consumers harmless from the administrative attacks of the Trump administration,” Wright explained.