MORE AMERICANS ARE insured than in the past, but millions are enrolled in skimpy health plans that often keep them from seeking care, according to a new report from The Commonwealth Fund.
Researchers estimate that in 2018, 45 percent of working-age adults, or 87 million people, were either underinsured or had no coverage for at least part of the last year – a share that is essentially unchanged from 2010, despite monumental shifts in health policy during that time.
The Affordable Care Act, which was enacted in 2010 and saw key provisions put in effect in 2014, expanded Medicaid eligibility and subsidized coverage for millions of Americans who were low-income or didn’t have access to health insurance through their employers, but largely left employer-based coverage alone. Nearly 20 million people gained access to health coverage as a result.
RELATED CONTENTNumber of Uninsured Rises
Yet the country also is now grappling with a larger pool of people who are underinsured – meaning they have health coverage, but also have high out-of-pocket health care costs relative to their incomes and are more likely to put off care or struggle to pay medical expenses, according to the report.
“U.S. working-age adults are significantly more likely to have health insurance since the ACA became law in 2010,” Sara Collins, lead author of the study and The Commonwealth Fund’s vice president for health care coverage and access, said in a statement. “But the improvement in uninsured rates has stalled (and) more people have health plans that fail to adequately protect them from health care costs.”
More than half of adults under age 65 are insured through their jobs, while about a quarter are enrolled in Medicaid or have insurance through the individual market, the report said. Among those with health coverage, 29 percent said they were underinsured in 2018, up from 23 percent in 2014, the survey found.
In 2018, 41 percent of underinsured adults said they had delayed care and 47 percent said they had trouble paying their medical bills. Among those with adequate health coverage, meanwhile, 23 percent said they had put off care, while 25 percent said they had problems with medical expenses.
“Inadequate insurance coverage leaves people exposed to high health care costs, and these expenses can quickly turn into medical debt,” the report said.
The increase in Americans with leaner health coverage has largely been driven by employer-based plans, not the ACA’s individual marketplaces, The Commonwealth Fund found. As health care costs have risen, employers have asked workers to shoulder some of the burden by offering plans with higher deductibles or requiring them to pay a larger share of premiums.
About 42 percent of people with individual health coverage said they were underinsured in 2018, compared with 28 percent of those with job-based coverage, the report found. Yet from 2010 to 2018, the greatest growth in the underinsured rate was among adults with employer-based plans.
The findings indicate efforts to get people onto job-based plans aren’t enough to get them access to care, and that policymakers should address the “relatively quick erosion of employer coverage and its impact on workers,” Dr. David Blumenthal, president of the Commonwealth Fund, said in a statement.
Coverage gaps due to reasons like job loss also affect people’s ability to access care, even if these lapses are temporary. While coverage gaps tend to be shorter now than before the ACA, adults with continuous health insurance were more likely to get their recommended primary care and cancer screenings than those with gaps in coverage, the survey found, even if they were underinsured.
That’s due in part because the ACA requires insurers and employers to cover these services without cost-sharing, the report notes.
Efforts by the Trump administration to weaken the ACA also play a role. Last year, for example, the administration issued new insurance rules that expanded access to inexpensive, short-term health plans, which are exempt from ACA protections for pre-existing conditions. But nearly a dozen states have set their own short-term plan limits since then, according to the Center on Budget and Policy Priorities.
“Health care costs are primarily what’s driving growth in premiums across all health insurance markets,” the report said, and policy efforts to improve health coverage should be paired with attempts to cut medical spending. The Commonwealth Fund cited the shift toward payment models that reward health care providers by health outcomes, not by the volume of services they deliver, as a promising effort.
Policymakers also can address the rising cost of prescription drugs, which President Donald Trump cited as a priority during his State of the Union address this week, and should closely monitor proposed mergers between providers and payers, the report said.
“Moving forward, it will be essential to protect, and grow, the ACA’s coverage gains while also working to ensure people with health insurance can get and afford the care they need,” Collins said.
