The US Doesn’t Have Universal Health Care But These States (Almost) Do

Universal health care remains an unrealistic dream for the United States. But in some parts of the country, that dream has moved closer to reality in the 13 years since the Affordable Care Act was passed.

Overall, the number of uninsured Americans has fallen from 46.5 million in 2010, the year President Barack Obama signed his signature health care law, to about 26 million today. There are still many gaps in the US health system, with more than 8 percent of the population uninsured, far higher than peer countries, and many people who technically have health insurance still find it difficult to cover part of their medical bills. Seems like Nevertheless, more people enjoy some financial protection against health care expenses than in any previous period in American history.

The country is moving towards universal coverage. If everyone who qualified for the ACA’s financial assistance or its Medicaid expansion is successfully enrolled in the program, we will get even closer: More than half of the uninsured are technically eligible for government health care assistance. Are eligible.

Particularly over the past few years, it has been states that have been most aggressively reducing the number of uninsured people, using the tools provided by the ACA.

Today, the uninsured rate in 10 states is less than 5 percent, which is not quite universal coverage, but getting close to it. Other states may hover around the national average, but this still represents a dramatic improvement from the pre-ACA reality: In New Mexico, for example, 23 percent of its population was uninsured in 2010; Now it is only 8 percent.

Their success indicates that, even without another major federal health care reform effort, it is possible to reduce the number of uninsured people in the United States. If states are more aggressive about using all the tools available to them under the ACA, the country can continue to reduce the number of uninsured people within its borders.

The law gave states the discretion to build on its basic structure. Many received approval from the federal government to create premium-reducing programs; Some also provide state subsidies in addition to federal assistance to reduce the cost of coverage, including for people who are not eligible for federal assistance, such as undocumented immigrants. Some states are also introducing new state-run health plans that will compete with private offerings.

I asked several leading health care experts which states were successful in completely weaponizing the ACA to reduce the number of uninsured people. There was not a single answer.

“I don’t think any state has taken advantage of everything,” said Larry Levitt, executive vice president of the KFF health policy think tank. No state has put all the pieces together to the full extent available under the ACA.

But steps taken in the last decade to strive toward universal health care have brought some to the fore.

Massachusetts (and New Mexico): streamlined enrollment and state subsidies

Massachusetts has the lowest uninsured rate of any state: only 2.4 percent of the population lacks coverage. It had a major head start: The legislation provided the model for the ACA itself, replacing the system of government subsidies for private plans sold in the public marketplace that existed before 2010.

But experts say it still deserves credit for the steps it has taken since the Massachusetts model was rolled out to the rest of the country. Matt Fiedler, a senior fellow at the Brookings Schaeffer Initiative on health policy, said two policies stand out above any others in increasing coverage: unifying the enrollment process for Medicaid and ACA marketplace plans and adding state-based assistance on top of federal subsidy laws. To offer. ,

Massachusetts was one of the first states to do both.

The former can do much to reduce the risk that people lose coverage when income changes, Fiedler told me, while the latter directly improves affordability and thus drives take-up. Promotes.

Unified enrollment means that, for the consumer, they can be directed to the ACA marketplace (where they can use government subsidies to purchase private coverage) or the state Medicaid program through a portal. They enter their information and the state tells them which program they should enroll in. Without that integration, people may have to apply for Medicaid first and then, if they don’t qualify, seek separate marketplace coverage. The more steps a person must take to successfully enroll in a health plan, the more likely it is that people will fall into the trap.

State aid, meanwhile, lowers premiums for people and makes it easier for them to afford more generous coverage, resulting in lower out-of-pocket costs when they actually use medical services. Nine states now receive state aid, including Massachusetts, with interest growing over the past few years.

For example, New Mexico recently transitioned to a state-based ACA marketplace and began offering additional assistance in 2023. Having already seen some dramatic improvements, it remains to be seen how much more progress the state can make toward universal coverage with that policy in place.

Minnesota and New York: Basic health plan explains

The basic structure of the ACA was as follows: Medicaid expansion for people living in or near poverty and marketplace plans for people with incomes above that. But the law included an option for states to more seamlessly integrate those two populations and so far, the two states that have taken advantage of it, Minnesota and New York, are also among the states with the lowest uninsured rates. Today only 4.3 percent of Minnesotans and 4.9 percent of New Yorkers lack coverage.

They both have basic health plans, the product of one of the more obscure provisions of the health care law. It is a state-regulated health insurance plan intended to cover people up to 200 percent of the federal poverty level (about $29,000 for an individual or $50,000 for a family of three). Those are people who may not technically qualify for Medicaid under the ACA, but who may still struggle to afford their monthly premiums and out-of-pocket obligations with a marketplace plan.

In both states, basic health plans offered insurance options with lower premiums and lower cost-sharing responsibilities than marketplace coverage they otherwise would have been left with. For example, in New York, people between 100 percent and 150 percent of the federal poverty level pay no premiums at all, while people between 150 percent and 200 percent pay just $20 a month.

There is good evidence that this approach has increased coverage: for example, in New York, when the state adopted its BHP in 2016, enrollment increased 42 percent among people below 200 percent of the poverty level, Which was compared to last year. When those people were pushed into traditional market coverage.

State interest in basic health plans has been limited so far, but Minnesota and New York provide a model that others could follow. Fiedler said part of the success of basic plans in those states is their use of Medicaid managed-care companies to administer the plan: Those insurers already pay providers lower rates than marketplace plans and pass on the savings. Gives money to states to reduce premiums and cost-sharing.

Colorado and Washington: Public options and assistance for the undocumented

These states have been innovative in countless ways. They are both early adopters of the public option, a government health plan that competes with private plans in the marketplace, a policy also being tested in Nevada.

There is another policy that unites them, a policy that addresses a large portion of the remaining uninsured nationwide: They both provide some state subsidies to undocumented immigrants.

Most uninsured Americans are already technically eligible for some form of government assistance, whether Medicaid or marketplace subsidies. But there is a large segment of people who are not: About 29 percent of uninsured Americans are ineligible for government assistance, including those who are in the country undocumented. Those people bear the full cost of their medical bills and may avoid care for that reason (for other reasons, of course).

Starting this year, Washington is allowing people with undocumented income to enroll in a program that would make them eligible for Medicaid expansion, and is making state subsidies available to people with higher incomes, regardless of their immigration status. yes. Colorado sets aside a small pool of money annually to provide state assistance to about 11,000 undocumented people. (After that limit is reached, those people can still enroll in a health plan but must pay the full price.)

Interest has been strong: Last year, Colorado passed the enrollment threshold after about a month. This year, enrollment closed in just two days, which suggests the state may need to put more money behind the effort.

Given the fraught national politics of immigration, it’s hard to imagine insurance subsidies for undocumented people rolling out across the country any time soon. But states are finding ways to make inroads on their own: California has made undocumented people eligible for Medicaid.

Through these and other means, they are helping America move toward universal health care.

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