Census Review: The Impact of the Affordable Care Act on the Uninsured

The Center for Community Solutions team has been analyzing the implications of the latest U.S. Census information. To learn more about this data more broadly, please click here to see the blog post by Kate Warren. With that said, I wanted to dive a bit more deeply into one set of metrics around the uninsured and the policy underpinnings that have led to the current data measurements.

The census data revealed that Ohio’s uninsured rate continues to decrease, showing a reduction of the uninsured by over 500 thousand since 2013. In just five years, Cuyahoga County has seen its uninsured rate cut in half (12.5 percent uninsured in 2010 to 6.1 percent in 2015), and Cleveland’s uninsured rate has dropped nearly 10 percentage points over the same period. This decrease is attributable, in large part, to the passage of the Patient Protection and Affordable Care Act (ACA) which provided coverage through an optional Medicaid expansion and the creation of the Health Insurance Marketplace (Marketplace). The effects of these two aspects of the law, however, are not limited to their existence and, in fact, the two have shown to have significant influence on one another.

The national Census data show the largest reductions came from states that have expanded Medicaid (see graphic below). This is logical as research shows many lower income individuals are still unable to afford the premiums on the Marketplace, and the subsidies to purchase insurance do not extend to people below 100 percent of the Federal Poverty Level (FPL). Additionally, many plans are leaving the Marketplace, which could have the effect of increasing costs for consumers due to a lack of competition. This is not true of all Marketplace participating plans, including those plans associated with health systems, which demonstrates the impact of value-based care in influencing the trend of narrow networks and the vertical integration between insurance and hospitals. Yet, despite some of these challenges, there are still many seemingly positive results which stem from this increased coverage.

First, premiums are much lower across all insurance options than what they would’ve been without these new coverage options. In fact, research shows that Medicaid expansion, specifically, has reduced the cost of premiums in Marketplace plans. Second, coverage also seems to have positive effects on consumers with sharp decreases in medical debt being reported, as well as a high number of individuals reporting they are satisfied with their choices. And, finally, there seem to be a number of positive effects on hospitals, with Medicaid expansion states seeing uncompensated care costs reduced by 26 percent. In fact, on a local level, Cleveland Clinic saw a 40 percent reduction of their charity care from 2013 to 2014 (nearly $70 million).

Studies have suggested there is a strong relationship between health and economic mobility. This makes the news of reductions in the uninsured a positive sign in the economic advancement of lower-income individuals and families. With that said, there still remain a number of challenges to ensure people have access to coverage and that their complex needs, often termed “social determinants of health,” are addressed. In New York, for example, the state has pursued a 1331 Waiver with the Center for Medicare and Medicaid Services, which creates an alternative Marketplace plan for lower-income individuals. This program, while still early in its adoption, has increased Marketplace enrollment by a third. But one does not need to look beyond Ohio to see some other innovative approaches, such as the Life Services venture of CareSource, which tries to connect Medicaid patients with workforce opportunities, thereby improving the economic stability, and potentially health, of their clientele.

Regardless of these examples, however, the latest data from the Census shows us the significant reduction in uninsured across the United States and in Ohio is but only one measure of substantial change in the health delivery system in the U.S. due to the ACA. Key in this conversation is the fact that there are still many states which have not expanded Medicaid; many policymakers who want to see the ACA enhanced, altered, or outright repealed; and many health systems, insurers, and interests trying to adapt to this new world of access and value. Depending on the outcome of this November’s election, and how Ohio policymakers want to address Medicaid and the Marketplace in the final budget of the Kasich administration, we may be looking at a very different landscape in future Census results.