The Present and Future Uninsured.

I have often commented that public health ultimately aspires to create the conditions that make people healthy. While in many respects medical care then falls outside the remit of public health, it is clear that the provision of health coverage—ensuring that as many people as possible have access to health care when they need it—is indeed one of the conditions that contributes to the production of health, and as such is worth public health attention. The topic of health coverage has dominated much of the health discussion in this country over the past six years as the (ACA) became law and the subject of several court battles thereafter. The ACA refers to two legislations: the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. Together, the core components of these laws include the expansion of Medicaid, the ability for people under the age of 26 to remain on their parents’ insurance, the elimination of denied coverage for pre-existing conditions, and the availability of affordable insurance through Health Insurance Marketplaces. The Supreme Court limited the law expanding Medicaid in 2012 by striking down Congress’s decision to enforce the expansion program in all states and allowing the states to opt out if they so chose. Currently, there are 19 states not adopting the Medicaid expansion and 1 state where the adoption is under discussion. The remaining states, including DC, have adopted the expansion. Following months of deliberations, the Supreme Court recently upheld a key component of the ACA that provides health insurance subsidies to all qualifying Americans, ensuring the continuation of the ACA as it is currently being implemented.

The development of a health insurance system in the US can be traced back to the 1930s with the establishment of nonprofit Blue Cross plans for hospital care, followed by Blue Shield plans for physician care. Following the Second World War, a number of commercial (i.e. for-profit) insurers began to compete with Blue Cross and Blue Shield, leading to a dramatic growth in health insurance coverage. The introduction of Medicaid and Medicare in 1965 further expanded the coverage. Medicare is for people over the age of 65, certain younger populations, and those diagnosed with end-stage renal failure. The original Medicaid program is jointly funded by the states and the federal government and is designed to service those with low income, pregnant women, children, elderly people, and people with disabilities.

The US system of health insurance coverage is of course challenged by our absence of a single payer health system, as is the case with peer countries like Canada and the UK. Therefore, the ACA aims to “fill in the gaps”—to ensure that no American falls through the cracks of coverage between multiple different insurance providers. At core, the ACA aims to expand coverage for the lowest-income Americans (adults with incomes up to 133 percent of the federal poverty level and below the age of 65) by providing an opportunity for states to expand the eligibility of Medicaid.

At the level of absolute achievement, there is little question that the ACA has been a resounding success. The most recent numbers show that 17.6 million Americans gained coverage since October 2013, when the ACA took effect, and about 10.5 million more Americans are currently eligible for marketplace coverage in the upcoming enrollment. Data from the US census suggests that 10.4 percent of the population (33 million) was uninsured in 2014, showing a reduction by 2.9 percent from the previous year. Latinos have the highest rate of being uninsured (19.9 percent), followed by African Americans (11.8 percent) and Asians (9.3 percent), while non-Hispanic whites had the lowest uninsured rate (7.6 percent). The percentage of uninsured children under the age of 19 was 6.2 percent, while only 1.4 percent of those above 65 years old were uninsured. Most hearteningly, perhaps, the drop in the uninsured has been steeper among minority groups who were more likely to be uninsured at the outset. Specifically, there has been an 11.5 percent drop among Latinos during this period, a 10.3 percent drop among African Americans, and a 6 percent drop among whites.

The achievements of the ACA are real and laudable. Perhaps in some ways these achievements are brought into boldest relief when one considers the shortfalls in the coverage gap for low-income populations in states that did not expand Medicaid. It is estimated that due to the non-expansion decision in some states, about 4 million poor adults remain uninsured nationally (see Figure 1). Although the gap spans across the country, it is concentrated in states have which the largest uninsured populations such as Texas (26 percent), Florida (18 percent), North Carolina (10 percent), and Georgia (8 percent). Although low-income, employed people make up most of the remaining uninsured population, even if their employers offered an ACA coverage, these employees will not be able to afford the coverage without financial assistance; those remaining uninsured in these states are disproportionately minorities. Ironically enough, the states that opted out of the expansion are now seeing Medicaid costs rise more sharply.

Looking ahead, the Congressional Budget Office estimates that there currently remain about 35 million uninsured, potentially dropping to 26 million by 2019. The challenges in reaching these uninsured are, in some ways, mounting. About 30 percent of those who remain uninsured are unauthorized immigrants, representing a particular challenge in the US—though one where expanded health coverage can make a real difference. Another large percentage (45 percent) may be people who have access to insurance but choose not to enroll. The reasons here are mostly financial, as most of those who choose not to get insured have weighed the costs for insurance against the penalty for going uninsured, and continue to receive health care—despite the lack of insurance—through doctors and hospitals that take cash, through discount drug programs, by using natural remedies, or by receiving health care overseas. Reflecting perhaps the challenge of our patchwork health system, it has been convincingly argued that many of this latter group earn just a little too much to qualify for financial help but too little to be able to afford health insurance, and many have too little to be penalized for not having health insurance.

The ACA clearly represents an enormous triumph of social legislation, improving access of millions to health insurance, and better health coverage, in a relatively short period of time. The remaining uninsured represent an ongoing challenge, and in many ways are a reflection of a patchy system that is only imperfectly addressed via the ACA, particularly in the face of state-level intransigence. Public health stands to play a central role in coming years to ensure that limited access does not disproportionately affect marginalized groups who are already subject to substantial health burdens.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful for the contributions of Laura Sampson and Salma Abdalla MBBS to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/