Stabilizing and Strengthening the Affordable Care Act: Opportunities for a New Administration

For the past decade, the Affordable Care Act (ACA) has successfully reduced uninsurance and improved access to and affordability of health care services for millions of Americans. But the law was weakened when the Trump administration shortened the open enrollment period in the federal Marketplace, reduced outreach and enrollment funding, and revised the public charge rule, among other actions. The Biden administration will have the chance to reverse some of these changes and further strengthen the law to improve health care access and affordability. In this article, the author explores options for expanding access to affordable coverage and care for those who do not qualify for Medicaid or marketplace financial assistance and further discusses opportunities for increasing enrollment among those who are already eligible. The author also examines opportunities for expanding access to specific services, including reproductive health care, among those with insurance. Any attempts to modify or build on the ACA will likely be complicated by the ongoing coronavirus pandemic as well as slim Democratic majorities in the House and Senate, but regulatory solutions will likely be easier to achieve than those that require changes to federal law or state policy.

Health Reform and Higher Ed: Campuses as Harbingers of Medicaid Universality and Medicare Commonality

Between 2010 and 2016, the percentage of uninsured higher education students dropped by more than half. All the Affordable Care Act's key access provisions contributed, but the most important factor appears to be the Medicaid expansion. This article is the first to highlight this phenomenon and ground it in data. It explores the reasons for this dramatic expansion of coverage, links it to theoretical frameworks, and considers its implications for the future of health reform. Drawing on Medicaid universality scholarship, I discuss potential consequences of including the educationally privileged in this historically stigmatized program. Extending this scholarship, I argue that the student experience and its reverberating effects portend support for emerging proposals to make Medicare a more common option. Woven into both analyses is the role of the Trump-era retrenchment, notably the administration's promotion of Medicaid "work or community engagement" requirements and of cheap, skimpy plans. Higher education students were an afterthought in the ACA's debates, and yet the law has profoundly impacted their coverage options. Students are now much more likely to have health insurance, and for it to be comprehensive. Looking to the next decade, the student experience harbingers support for both Medicaid universality and Medicare commonality.

Code Red: The Essential Yet Neglected Role of Emergency Care in Health Law Reform

The United States' health care system is mired in uncertainty. Public opinion on the Patient Protection and Affordable Care Act ("ACA") is undeniably mixed and politicized. The individual mandate, tax subsidies, and Medicaid expansion dominate the discussion. This Article argues that the ACA and reform discourse have given short shrift to a more static problem: the law of emergency care. The Emergency Medical Treatment and Active Labor Act of 1986 ("EMTALA") requires most hospitals to screen patients for emergency medical conditions and provide stabilizing treatment regardless of patients' insurance status or ability to pay. Remarkably, this law strengthened the health safety net in a country that has no universal health care. But it is an unfunded mandate that responded to the problem of emergency care in a flawed fashion and contributed to the supposed "free rider" problem that the ACA attempted to cure. But the ACA has also not been effective at addressing the issue of emergency care. The ACA's architects reduced funding for hospitals that serve a disproportionate percentage of the medically indigent but did not anticipate the Supreme Court's ruling in NFIB v. Sebelius, which made Medicaid expansion optional. Public and non-profit hospitals now face a scenario of less funding and potentially higher emergency room utilization due to continued uninsurance or underinsurance. Alternatives to the ACA have been insufficiently attentive to the importance of emergency care in our health system. This Article contends that any proposal that does not seriously consider EMTALA is incomplete and bound to produce some of the same problems that have dogged the American health care system for the past few decades. Moreover, the Article shows how notions of race, citizenship, and deservingness have filtered into this health care trajectory, and in the context of reform, have the potential to exacerbate existing health inequality. The paper concludes with normative suggestions on how to the mitigate EMTALA's problems in ways that might improve population health.

How the Affordable Care Act Has Helped Women Gain Insurance and Improved Their Ability to Get Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016

ISSUE: Prior to the Affordable Care Act (ACA), one-third of women who tried to buy a health plan on their own were either turned down, charged a higher premium because of their health, or had specific health problems excluded from their plans. Beginning in 2010, ACA consumer protections, particularly coverage for preventive care screenings with no cost-sharing and a ban on plan benefit limits, improved the quality of health insurance for women. In 2014, the law’s major insurance reforms helped millions of women who did not have employer insurance to gain coverage through the ACA’s marketplaces or through Medicaid. GOALS: To examine the effects of ACA health reforms on women’s coverage and access to care. METHOD: Analysis of the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2016. FINDINGS AND CONCLUSIONS: Women ages 19 to 64 who shopped for new coverage on their own found it significantly easier to find affordable plans in 2016 compared to 2010. The percentage of women who reported delaying or skipping needed care because of costs fell to an all-time low. Insured women were more likely than uninsured women to receive preventive screenings, including Pap tests and mammograms.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

ISSUE: Prior to the Affordable Care Act (ACA), blacks and Hispanics were more likely than whites to face barriers in access to health care. GOAL: Assess the effect of the ACA’s major coverage expansions on disparities in access to care among adults. METHODS: Analysis of nationally representative data from the American Community Survey and the Behavioral Risk Factor Surveillance System. FINDINGS AND CONCLUSIONS: Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in states that expanded Medicaid under the ACA than in states that did not expand. Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states. The ACA’s coverage expansions were associated with increased access to care and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.

Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act

Using premium subsidies for private coverage, an individual mandate, and Medicaid expansion, the Affordable Care Act (ACA) has increased insurance coverage. We provide the first comprehensive assessment of these provisions' effects, using the 2012-2015 American Community Survey and a triple-difference estimation strategy that exploits variation by income, geography, and time. Overall, our model explains 60% of the coverage gains in 2014-2015. We find that coverage was moderately responsive to price subsidies, with larger gains in state-based insurance exchanges than the federal exchange. The individual mandate's exemptions and penalties had little impact on coverage rates. The law increased Medicaid among individuals gaining eligibility under the ACA and among previously-eligible populations ("woodwork effect") even in non-expansion states, with no resulting reductions in private insurance. Overall, exchange premium subsidies produced 40% of the coverage gains explained by our ACA policy measures, and Medicaid the other 60%, of which 1/2 occurred among previously-eligible individuals.

Repealing Federal Health Reform: Economic and Employment Consequences for States

Issue: The incoming Trump administration and Republicans in Congress are seeking to repeal the Affordable Care Act (ACA), likely beginning with the law’s insurance premium tax credits and expansion of Medicaid eligibility. Research shows that the loss of these two provisions would lead to a doubling of the number of uninsured, higher uncompensated care costs for providers, and higher taxes for low-income Americans. Goal: To determine the state-by-state effect of repeal on employment and economic activity. Methods: A multistate economic forecasting model (PI+ from Regional Economic Models, Inc.) was used to quantify for each state the effects of the federal spending cuts. Findings and Conclusions: Repeal results in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs (mostly in the private sector) that year across all states. A third of lost jobs are in health care, with the majority in other industries. If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output from 2019 to 2023. States and health care providers will be particularly hard hit by the funding cuts.

How the Affordable Care Act Has Improved Americans’ Ability to Buy Health Insurance on Their Own: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016

Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers’ experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people’s ability to buy health plans on their own following the passage of the ACA. For adults with family incomes less than $48,500, uninsured rates dropped about 17 percentage points below their 2010 peak. Lower-income whites, blacks, and Latinos have experienced drops this large, though Latinos are uninsured at higher rates. Among working-age adults who had shopped for plans in the individual market and ACA marketplaces over the prior three years, the percentage who reported it was very difficult to find affordable plans fell by nearly half from 2010, prior to the ACA reforms, to 2016. Coverage gains are helping working-age Americans get the care they need: the number of adults who reported problems getting needed health care and filling prescriptions because of costs fell from a high of 80 million in 2012 to an estimated 63 million in 2016.

Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply

We examined the effect of the expansion of Medicaid eligibility under the Affordable Care Act on health insurance coverage and labor supply of low-educated and low-income adults. We found that the Medicaid expansions were associated with large increases in Medicaid coverage, for example, 50 percent among childless adults, and corresponding decreases in the proportion uninsured. There was relatively little change in private insurance coverage, although the expansions tended to decrease such coverage slightly. In terms of labor supply, estimates indicated that the Medicaid expansions had little effect on work effort despite the substantial changes in health insurance coverage. Most estimates suggested that the expansions increased work effort, although not significantly.

Rejecting Kentucky Medicaid proposal would reaffirm commitment to full coverage

Kentucky Gov. Matt Bevin, representing a state where the uninsured rate has plummeted from 14.3% to 6% since adopting the Medicaid expansion under the Affordable Care Act, is proposing sweeping Medicaid changes that would make it harder for Kentuckians to keep their coverage. He threatens to cancel the Medicaid expansion if HHS doesn't approve his plan.

Giving Birth, Going Home: Influences on when Low-Income Women Leave Hospital

The US Newborns’ and Mothers’ Health Protection Act of 1996 (‘The Two-Day Law’) mandates insurance coverage for women who have just given birth to remain in hospital for two days post-partum. However, many women are being discharged from hospital after 24 hours. To assess why early discharge is still occurring, a study of 406 new mothers was conducted at an urban metropolitan hospital in the USA. The women were aware of the new law (95%) but decision making was often relinquished to hospital authorities. Patients who stayed longer tended to be more assertive in decision making, and used the Two-Day Law as leverage in discussions about going home. The study concluded that the nurses were authoritative and often influential agents in the decision-making process, and that patients were likely to interpret specific interactions with hospital staff as a signal to leave.

The Changing Landscape of Health Care Coverage and Access: Comparing States' Progress in the ACA's First Year

This analysis compares access to affordable health care across U.S. states after the first year of the Affordable Care Act’s major coverage expansions. It finds that in 2014, unin­sured rates for working-age adults declined in nearly every state compared with 2013. There was at least a three-percentage-point decline in 39 states. For children, uninsured rates declined by at least two percentage points in 16 states. The share of adults who said they went without care because of costs decreased by at least two points in 21 states, while the share of at-risk adults who had not had a recent checkup declined by that same amount in 11 states. Yet there was little progress in expanding access to dental care for adults, which is not a required insurance benefit under the ACA. Wide variation in insurance coverage and access to care persists, highlighting many opportunities for states to improve.

Policy Implications of a Literature Review of Cardiovascular Disease in Uninsured Immigrant Older Adults

The number of older adults emigrating to the United States is expected to quadruple by 2050. The health of immigrant older adults is complicated by the limited options for low-cost health insurance available to this population. Welfare reform has limited new immigrants' access to public assistance programs, such as Medicaid; and low-cost private insurance options rarely exist for individuals older than 65, even with the passage of the Patient Protection and Affordable Care Act (PPACA). Uninsured immigrant older adults have been found to forgo preventive care due to cost and are among the leading users of emergency departments for preventable complications of chronic disease, primarily cardiovascular disease (CVD). A review of the literature found that insurance coverage has a significant impact on CVD risk among immigrant older adults. The current article discusses the implications of welfare reform initiatives and the shortcomings of the PPACA in addressing the health care needs of immigrant older adults.

Comprehensive Legislative Reform to Protect the Integrity of the 340B Drug Discount Program

The 40B Drug Discount Program (340B Program) is a federally facilitated program that requires drug manufacturers to provide steep discounts on outpatient prescription drugs to qualifying safety net health care providers. The federal program is intended as a safeguard to ensure access to affordable drugs to the indigeut. However, over the last two decades safety net health care providers have exploited financial incentives under the 340B Program at the expense of drug manufacturers and patients, including the most needy and vulnerable populations-they are committed to serve. Although the federal government has been applauded for increasing effortsto combat health care fraud and abuse including recovering $3.3 billion in 2014, federal officials and the general public have paid markedly less attention to pervasive abuse of the 340B Program. In 2014, drug purchases of 340B-designated drugs totaled $7 billion and are expected to increase to $12 billion: by 2016 as a result of the expansion of the program under the Affordable Care Act. The 340B Program has completely lost its way, and comprehensive legislation is necessary to realign the program with its intent.

Medicaid program; disproportionate share hospital payments--uninsured definition. Final rule

This final rule addresses the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments under the Social Security Act (the Act). Under this limitation, DSH payments to a hospital cannot exceed the uncompensated costs of furnishing hospital services by the hospital to individuals who are Medicaid-eligible or "have no health insurance (or other source of third party coverage) for the services furnished during the year.'' This rule provides that, in auditing DSH payments, the quoted test will be applied on a service-specific basis; so that the calculation of uncompensated care for purposes of the hospital-specific DSH limit will include the cost of each service furnished to an individual by that hospital for which the individual had no health insurance or other source of third party coverage.

Readmission penalties and health insurance expansions: a dispatch from Massachusetts

BACKGROUND

Payers are penalizing hospitals for high readmission rates. It is unknown whether major changes in population insurance coverage can affect readmission rates, despite the Affordable Care Act's coverage expansions coming into effect this year.

OBJECTIVE

To evaluate the impact of a large-scale insurance expansion on hospital readmissions, using Massachusetts' 2006 health reform as a natural experiment.

DESIGN

Difference-in-difference time-series design.

SETTING

All Massachusetts acute-care hospitals.

PATIENTS

Inpatient visits from 2004 to 2010.

MEASUREMENTS

Primary outcome was the hospital 30-day readmission rate. Readmissions to any Massachusetts hospital were tracked.

RESULTS

Decreases in uninsurance rates during and after reform were largely limited to the hospital quartile with the highest prereform uninsurance rates (from 14% uninsured at the start of the reform to 2.9% by the end of the study period). The other hospitals collectively experienced a smaller decline in their uninsured admissions (5.9% at the start of reform to 2.5% by the end of the study period). According to difference-in-difference regression analysis, the highest uninsured hospital quartile experienced a modest increase in their unadjusted readmission rate of 0.6 percentage points (95% confidence interval: 0.1%-1.1%) during the reform period as compared to the other hospital quartiles (P = 0.01). This represents a relative increase of 4.5% in the readmission rate. Risk-adjusted readmission rates showed no corresponding change.

CONCLUSIONS

The Affordable Care Act's insurance expansion may be associated with an increase in unadjusted readmission rates among hospitals that cared for disproportionate numbers of uninsured patients. Risk-adjustment appears to take this effect into account.

Too high a price: out-of-pocket health care costs in the United States. Findings from the Commonwealth Fund Health Care Affordability Tracking Survey. September-October 2014

Whether they have health insurance through an employer or buy it on their own, Americans are paying more out-of-pocket for health care now than they did in the past decade. A Commonwealth Fund survey fielded in the fall of 2014 asked consumers about these costs. More than one of five 19-to-64-year-old adults who were insured all year spent 5 percent or more of their income on out-of-pocket costs, not including premiums, and 13 percent spent 10 percent or more. Adults with low incomes had the highest rates of steep out-of-pocket costs. About three of five privately insured adults with low incomes and half of those with moderate incomes reported that their deductibles are difficult to afford. Two of five adults with private insurance who had high deductibles relative to their income said they had delayed needed care because of the deductible.

Are Americans finding affordable coverage in the health insurance marketplaces? Results from the Commonwealth Fund Affordable Care Act Tracking Survey

By the end of the first open enrollment period for coverage offered through the Affordable Care Act's marketplaces, increasing numbers of people said they found it easy to find a plan they could afford, according to The Commonwealth Fund's Affordable Care Act Tracking Survey, April-June 2014. Adults with low or moderate incomes were more likely to say it was easy to find an affordable plan than were adults with higher incomes. Adults with low or moderate incomes who purchased a plan through the marketplaces this year have similar premium costs and deductibles as adults in the same income ranges with employer-provided coverage. A majority of adults with marketplace coverage gave high ratings to their insurance and were confident in their ability to afford the care they need when sick.

Gaining ground: Americans' health insurance coverage and access to care after the Affordable Care Act's first open enrollment period

A new Commonwealth Fund survey finds that in the wake of the Affordable Care Act's first open enrollment period, significantly fewer working-age adults are uninsured than just before the sign-up period began, and many have used their new coverage to obtain needed care. The uninsured rate for people ages 19 to 64 declined from 20 percent in the July-to-September 2013 period to 15 percent in the April-to-June 2014 period. An estimated 9.5 million fewer adults were uninsured. Young men and women drove a large part of the decline: the uninsured rate for 19-to-34-year-olds declined from 28 percent to 18 percent, with an estimated 5.7 million fewer young adults uninsured. By June, 60 percent of adults with new coverage through the marketplaces or Medicaid reported they had visited a doctor or hospital or filled a prescription; of these, 62 percent said they could not have accessed or afforded this care previously.

Ready for ACA? how community health centers are preparing for health care reform

Community health centers (CHCs) are a cornerstone of the health care safety net. They are the primary source of care for many low-income populations, including both those newly insured under the Affordable Care Act (ACA) and those who were left out and will remain uninsured. The ACA provides challenges and opportunities for CHCs, which will require significant changes in infrastructure and care delivery approaches to meet those challenges. This policy brief assesses the progress made by CHCs in Los Angeles County in meeting a number of key indicators of ACA readiness in early 2014. The authors find that 39 percent of CHCs are well prepared, 23 percent have made some progress, and the rest are at the initial phases of preparation and/or lack adequate resources to meet the requirements. The latter group of CHCs require help to embark on strategic improvements in infrastructure and care delivery.

The potential conflict between policy and ethics in caring for undocumented immigrants at academic health centers

Academic health centers (AHCs) are at the forefront of delivering care to the diverse medically underserved and uninsured populations in the United States, as well as training the majority of the health care workforce, who are professionally obligated to serve all patients regardless of race or immigration status. Despite AHCs' central leadership role in these endeavors, few consolidated efforts have emerged to resolve potential conflicts between national, state, and local policies that exclude certain classifications of immigrants from receiving federal public assistance and health professionals' social missions and ethical oath to serve humanity. For instance, whereas the 2010 Patient Protection and Affordable Care Act provides a pathway to insurance coverage for more than 30 million Americans, undocumented immigrants and legally documented immigrants residing in the United States for less than five years are ineligible for Medicaid and excluded from purchasing any type of coverage through state exchanges. To inform this debate, the authors describe their experience at the University of New Mexico Hospital (UNMH) and discuss how the UNMH has responded to this challenge and overcome barriers. They offer three recommendations for aligning AHCs' social missions and professional ethics with organizational policies: (1) that AHCs determine eligibility for financial assistance based on residency rather than citizenship, (2) that models of medical education and health professions training provide students with service-learning opportunities and applied community experience, and (3) that frontline staff and health care professionals receive standardized training on eligibility policies to minimize discrimination towards immigrant patients.

The health of healthcare, Part IV: Standing before the court

In 2012, when the U.S. Supreme Court upheld Obamacare, the law had not been implemented. No one was directly affected by the Patient Protection and Affordable Health Care Act until January 2014. After that time, if individuals can show proof of harm caused by Obamacare, they will have legal "standing" and can sue the federal government.

Trends in insurance coverage and source of private coverage among young adults aged 19-25: United States, 2008-2012

Data from the National Health Interview Survey, 2008-2012. The percentage of young adults with private health insurance coverage increased from the last 6 months of 2010 through the last 6 months of 2012 (52.0% to 57.9%). Except for an increase in the first 6 months of 2011, the percentage of privately insured young adults who had a gap in coverage during the past 12 months decreased from the first 6 months of 2008 through the last 6 months of 2012 (10.5% to 7.8%). The percentage of privately insured young adults with coverage in their own name decreased from 40.8% in the last 6 months of 2010 to 27.2% in the last 6 months of 2012. The percentage of privately insured young adults with employer-sponsored health insurance increased from the last 6 months of 2010 to the last 6 months of 2012 (85.6% to 92.5%). Young adults often experience instability with regard to work, school, residential status, and financial independence. This could contribute to a lack of or gaps in insurance coverage (1,2). In September 2010, the Affordable Care Act (ACA) extended dependent health coverage to young adults up to age 26. This provision was expected to lead to increases in private coverage for young adults aged 19-25 when they became eligible for coverage through their parents' employment (3,4). This report provides estimates describing the previous insurance status and sources of coverage among privately insured young adults aged 19-25, using data from the 2008-2012 National Health Interview Survey (NHIS). Comparisons are made with adults aged 26-34, the most similar age group that was not affected by the ACA provision.

Medicaid expansion: the dynamic health care policy landscape

The Supreme Court decision of June 2012 left states free to decide on how to undertake Medicaid expansion without facing the substantial financial penalties envisioned by the Affordable Care Act. Currently, 25 states and the District of Columbia are moving forward with the expansion; 22 have decided not to move forward and the remaining 3 are still debating the issue. The evidence to date suggests Medicaid expansion would have several benefits to states including improved population health from expanded coverage, improved financial positions of hospitals and other providers, and economic benefits such as increased employment and tax revenues. Because of these potential impacts of Medicaid expansion on patients and providers of health care, the nursing profession may wish to play an educational or advocacy role in the ongoing debate.

Medicaid program; state disproportionate share hospital allotment reductions. Final rule

The statute, as amended by the Affordable Care Act, requires aggregate reductions to state Medicaid Disproportionate Share Hospital (DSH) allotments annually from fiscal year (FY) 2014 through FY 2020. This final rule delineates a methodology to implement the annual reductions for FY 2014 and FY 2015. The rule also includes additional DSH reporting requirements for use in implementing the DSH health reform methodology.

What Americans think of the new insurance marketplaces and Medicaid expansion: findings from the Commonwealth Fund Health Insurance Marketplace Survey, 2013

The Affordable Care Act's health insurance marketplaces are opening for enrollment on October 1, 2013. The Commonwealth Fund Health Insurance Marketplace Survey, 2013, finds that only two of five adults are aware of the marketplaces or of potential financial help that may be available to them to pay for plans purchased though the marketplaces. However, three of five adults who might be eligible for these new options said they were likely to take advantage of them. The survey also finds broad support for state expansion of the Medicaid program, even in states that have not yet decided to expand their programs. While outreach and education are critical to ensuring that those eligible for the new coverage options will enroll, the survey results suggest that eligible Americans will likely take advantage of the law's insurance reforms in the months and years to come.

Protecting uninsured patients from high hospital charges: lessons from California

Key findings. (1) In 1997, the amount California hospitals billed uninsured patients was more than twice the amount hospitals received from Medicare for the same services. By 2010, billed charges had grown to be five times what Medicare paid, which trans­lated into a gap of more than $10,000 per day in the hospital. (2) Five years after the passage of the state's Hospital Fair Pricing Act, most California hospitals had financial assistance policies in place to make care more affordable for the state's uninsured population. (3) As of 2011, 81 percent of California hospitals reported charging low-income uninsured patients prices that were at or below Medicare rates. (4) While not required by the law, nearly all California hospitals reported offering free care to uninsured patients with incomes at or below 100 percent of poverty.

If the price is right, most uninsured--even young invincibles--likely to consider new health insurance marketplaces

A key issue for the new insurance exchanges under national health reform is whether enough younger and healthier people will take advantage of new subsidized coverage on Jan. 1, 2014. Without enough good risks to offset older and sicker people who are likely to jump at the opportunity to gain more-affordable coverage, the exchanges risk significant adverse selection--attracting a sicker-than-average population--that will drive up premiums. Key to persuading younger and healthier uninsured people to opt for cover­age will be convincing them that health insurance is a good deal, according to a new national study by the Center for Studying Health System Change (HSC). While most uninsured people believe health insurance is important, far fewer now believe coverage is affordable and worth the cost. However, new federal subsidies for lower-to-middle-income people may change the calculus of whether coverage is affordable. While uninsured people who are younger, have few or no health prob­lems, and are self-described risk-takers are more likely to believe they can go without health insurance, even a majority of these so-called young invincibles believe health insurance is important. The findings indicate that most uninsured people are not inherently resistant to the idea of having health insurance. The main challenge will be to convince them that new coverage options under national health reform are affordable and offer enough protection to offset the medical and financial risks of going without health coverage.

In states' hands: how the decision to expand Medicaid will affect the most financially vulnerable Americans: findings from the Commonwealth Fund Health Insurance Tracking Surveys of U.S. Adults, 2011 and 2012

Between 2010 and 2012, nearly one-third (32%) of U.S. adults ages 19 to 64, or an estimated 55 million people, were either continuously uninsured or spent a period of time uninsured. Data from the 2011 and 2012 Commonwealth Fund Health Insurance Tracking Surveys of U.S. Adults show that people with incomes below 133 percent of the federal poverty level (i.e., the level that will make them eligible for Medicaid in 2014 under the Affordable Care Act) were uninsured at the highest rates. Yet, fewer than half the states are currently planning to expand their Medicaid programs, because the 2012 Supreme Court decision allows states to choose whether to expand eligibility. In those states that have not yet decided to expand, as many as two of five (42%) adults who were uninsured for any time over the two years would not have access to the new coverage provisions in the law.