In an article published online on March 27 in The New England Journal of Medicine, a team of healthcare policy researchers lays out potential paths to universal coverage, based on the foundation for such expansion created by the Affordable Care Act (ACA), passed into law in 2010.
This analysis is contained in article entitled “Building on the ACA to Achieve Universal Coverage,” and was authored by Matthew Fiedler, Ph.D., Henry J. Aaron, Ph.D., Loren Adler, Paul B. Ginsburg, Ph.D., and Christen L. Young.
“For decades leading up to enactment of the Affordable Care Act (ACA), the United States failed to reduce the percentage of Americans who lacked health insurance coverage,” the authors write in their analysis. “Since the ACA’s passage, the percentage of U.S. residents without coverage has fallen by almost half, from 16 percentage to approximately 9 percentage. Yet more needs to be done if we are to achieve universal coverage.”
How to move forward? “[A]chieving universal coverage within the framework created by the ACA requires four basic steps: implementing the ACA’s Medicaid expansion in all states, increasing and expanding financial assistance to people who purchase coverage through the health insurance marketplace to make coverage more attractive, ensuring that people actually enroll in the affordable coverage for which they are eligible, and addressing coverage for undocumented immigrants,” the authors write. “Policymakers can tackle each of these steps and thereby finish the job of ensuring universal coverage by building on the ACA. The framework presented here has many elements in common with proposals put forward by others, including teams at the Urban Institute and the Center for American Progress. The similarities among these proposals reflect the fact that each seeks to fill the same gaps in the U.S. health insurance system.”
Further, they state, “For people who are concerned about the fiscal cost, political feasibility, or disruption associated with a single-payer approach to providing universal coverage, this framework may be viewed as an alternative. Or it can be seen as a stepping stone to such a system. Although we see these four steps as an integrated whole, policymakers could expand coverage by enacting only some of these proposals, and states could implement some without federal action.”
As for the first step in their framework, the authors write that “ensuring that all states expand Medicaid coverage to people with incomes below 138 percent of the federal poverty level, the standard set in the ACA—can be achieved with a combination of carrots and sticks,” the stick being a reduction in the base federal matching rate for Medicaid spending in states that continue to refuse to expand Medicaid; and the carrot being an increase in that same matching rate, for the states that do expand. Such changes could be relatively small, they argue.
Meanwhile, the researchers argue, the subsidies available through the ACA’s health insurance marketplaces needed to be increased and expanded, in order to encourage individuals to sign up, while marketplace subsidies need to be extended to workers currently ineligible because they are offered coverage through their employers that is considered “affordable” under the ACA’s, but which still imposes “onerous” premiums. That group, they note, accounted for 10 percent of the uninsured in 2017—a significant number of people.
Meanwhile, the researchers argue, for those with higher incomes—those neither eligible for Medicaid or for the CHIP (Children’s Health Insurance Program), and who lack other coverage, could be automatically enrolled in a “backstop” insurance plan, which could be either public or private, with healthcare providers submitting claims to that plan whenever such individuals used healthcare services. The tax system, they argue, could be used to help facilitate that change, with individuals lacking coverage other than the backstop plan for at least one month during the year paying a premium for the backstop plan for each month they lacked other coverage, whether or not they used the backstop coverage, with that premium reduced by the amount of any tax credit for which they were eligible.
That set of policy changes would cover all documented U.S. residents; the final step to universal coverage, the authors argue, would be to create a path to citizenship through reforming immigration policy.
