Access to insurance coverage improved under the ACA, but more of those covered are now underinsured: survey

President Donald Trump
The Trump administration has canceled cost-sharing reduction payments, signed the repeal of the individual mandate and endorsed the expansion of short-term health plans—all actions that critics say have weakened the ACA's protections. (The White House)

The Trump administration's actions to cripple the Affordable Care Act haven't notably changed the number of uninsured people, according to the Commonwealth Fund, but they have weakened protections for those that have insurance.

About 12% of Americans were uninsured in 2018, according to the Fund's biennial survey—statistically unchanged from 2016, the last time the survey was taken. However, more of those who did have insurance were considered underinsured, meaning their out-of-pocket medical expenses exceeded a certain threshold. 

"The lack of continued improvement in overall access to care nationally reflects the fact that coverage gains have plateaued, and underinsured rates have climbed," the Commonwealth Fund wrote in its survey. "People who experience any time uninsured are more likely than any other group to delay getting care because of cost."


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"And among people with coverage all year, those who were underinsured reported cost-related delays in getting care at nearly double the rate of those who were not underinsured."

Underinsurance rates have grown by more than 5% since 2014—when many of the ACA's provisions went into effect—while uninsurance rates have dropped steadily since 2010, according to the report.

Furthermore, the biggest growth in underinsurance was among those who received coverage through their employer—historically the most robust insurance plans available. Workers have seen their deductibles and cost-sharing burdens increase over the years as employer-provided insurance plans tried to keep premium growth manageable, according to the survey.

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"Businesses have tried to hold down premium growth by asking workers to shoulder an increasing share of health costs, particularly in the form of higher deductibles," the survey said. "While the ACA’s employer mandate imposed a minimum coverage requirement on large companies, the requirement amounts to just 60% of typical person’s overall costs. This leaves the potential for high plan deductibles and copayments."

"Growth in Americans’ incomes has not kept pace with growth in health care costs. Even when health costs rise more slowly, they can take an increasingly larger bite out of incomes."

These changes have partially resulted from actions taken by the Trump administration to weaken the law, the Commonwealth Fund said. The administration canceled payments that were supposed to go to reducing cost sharing and expanded short-term and association health plans that lack the same coverage requirements as ACA-compatible plans. Congress also repealed the healthcare law's individual insurance mandate.

In order to improve measures, the Commonwealth Fund recommended expanding Medicaid further without restrictions, banning short-term health plans, expanding reinsurance programs, restoring funding for ACA outreach and navigator assistance, lifting the cap on eligibility for marketplace credits, increasing the ACA's minimum level of coverage for employer plans and making premium contributions tax deductible.

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