Counting the Benefits of the ACA

With spring’s arrival, we can observe and feel the flowering of the Affordable Care Act (ACA) all around us. An estimated 20.8 million people now have health insurance as a result of the ACA. This total includes more than 8 million people who enrolled through the State Health Insurance Marketplaces; 4.8 million who are newly covered by Medicaid/CHIP; 5 million who purchased individual plans outside the Marketplaces; and 3 million young adults under age 26 who have received coverage through their parents’ health insurance. This is an amazing story of success after a very soggy start in the fall.

Current Status. Where do we stand in our ACA quest to enroll 39 million uninsured people? Today, we only can provide an estimate: About 25% of that original number now have been newly enrolled in health insurance. The balance who have enrolled did so by moving from one health insurance plan to another, or previously were eligible for a prior Medicaid/CHIP program.

What do we know about those who have enrolled?

State Health Insurance Marketplace Enrollees.  Of the 8 million people who enrolled in Qualified Health Plans through the State Marketplaces, about 85% were determined to be eligible for a federal tax subsidy. About 66% chose a silver plan (pays 70% of costs) (Federal tax subsidies are based upon purchasing a silver plan.); 20%, a bronze plan (pays 60% of costs); 9%, a gold plan (pays 80% of costs); and 5%, a platinum plan (pays 90% of costs). About 28% of these 8 million enrollees are under age 35. This percentage is very important because it helps assure the sustainability of the Qualified Health Plans at a reasonable price.

Medicaid Expansion Enrollees.  About 4.8 million people enrolled in Medicaid/CHIP, an estimated 25% of the total eligible to enroll. Yet, the bigger story here is about those states that are not currently undertaking the Medicaid Expansion. As of today, 27 states, including DC, have begun the Medicaid Expansion. An additional 19 states have declined to do so, and 5 states are still debating the issue.

In the latter 24 states not currently doing the Medicaid Expansion, about 8.5 million low-income people would be eligible for Medicaid. Of this total, about 0.9 million already are eligible for traditional Medicaid. Of the remaining 7.6 million people, 2.8 million have incomes between 100 and 138% of the Federal Poverty Level (FPL) (annual incomes between $11,200 and $15,400) and thus are eligible to enroll in health insurance through their State Marketplaces and receive a federal tax subsidy. The balance, 4.8 million people, is not currently eligible for either program. This latter group is now called the “gap population”.

Next Steps.  Although the State Marketplaces now are closed for private insurance enrollment, they will reopen again on November 15, 2014, and remain open until February 15, 2015. Enrollment in the Medicaid Expansion will operate continuously throughout the year.

Going forward, we need to enroll as many uninsured people as possible through the Medicaid Expansion. The numbers of the uninsured are still extremely large: 19 million people eligible to enroll, less the 4.8 million who have enrolled, less the 4.8 million in the “gap population”, leaves 9.4 million uninsured people currently eligible to enroll in the Medicaid Expansion. Of this total, about 4 million have a prior mental health or substance use condition. We need to start this work today!

If you live in one of the 24 states not currently doing the Medicaid Expansion, you will need to engage in vigorous, non-traditional advocacy to alter this tragic situation. Very strong moral (i.e., social justice) and financial (i.e., outflow of tax dollars) considerations demand nothing less.

The ACA already has had a very significant salutary effect upon our society. The percent of uninsured Americans today is about 13.4%--the lowest ever recorded, and down from 17.1% at the end of 2013, according to a very recent Gallup Poll. And we can expect to see even further dramatic benefits from the ACA. A new study in Massachusetts shows an increase in length of life of Massachusetts residents since the implementation of mandatory health insurance in that state almost a decade ago.