Federal policies could reverse states’ historic coverage gains: report

Dive Brief:

• All 50 states and Washington, D.C., have significantly lowered their uninsurance rates and increased access to care over the past decade — but those gains could be reversed due to federal policies like potential cuts to Medicaid, according to the Commonwealth Fund.
• The uninsurance rate for working age adults fell from 20.4% in 2013 to just 11% in 2023, according to the analysis. Additionally, 11.7% of adults reported avoiding care due to cost in 2023, down from nearly 16% a decade earlier. 
• However, cutting funding to Medicaid, implementing work requirements and allowing more generous federal assistance for Affordable Care Act marketplace plans to lapse could reverse these improvements, researchers said. “These gains are remarkable. They are also fragile,” Dr. Joseph Betancourt, president of the Commonwealth Fund, said during a press briefing Tuesday.

Dive Insight: 

States have made historic progress in decreasing the number of uninsured residents, largely due to the ACA’s coverage provisions like marketplace health plans and expanded eligibility for Medicaid, according to the report. 

Washington, D.C., reported the lowest uninsurance rate at just 3.4% for non-elderly adults in 2023, falling from more than 8% a decade earlier, according to the analysis, which studied states’ health system performance on metrics like access, affordability and health outcomes. 

However, many Americans still face barriers to coverage. In Texas, the state with the highest uninsurance rate, nearly 22% of adults didn’t have health insurance in 2023. Still, that’s down from nearly 30% in 2013.

Medicaid expansion was a key factor on coverage gains, according to the report. Three of the five lowest performing states on insurance haven’t expanded the safety-net coverage to adults with incomes up to 138% of the poverty level.

Falling uninsurance is linked to better healthcare access. Nearly every state saw fewer people avoiding care due to cost over the past decade — though there was still significant variation across states. For example, more than 18% of adults in Texas reported going without care due to cost in 2023, compared with nearly 7% in Hawaii, where the uninsurance rate was much lower at nearly 4%.

These coverage and access improvements could be reversed due to potential federal policy changes, researchers said. The reconciliation bill winding its way through Congress has a number of healthcare provisions, including work requirements for Medicaid beneficiaries and more frequent eligibility checks. 

Nearly 11 million more people would be uninsured in 2034 if the bill passes, according to an analysis by the Congressional Budget Office published earlier this month. More could lose coverage if enhanced premium subsidies for people buying coverage on the ACA exchanges expire at the end of the year. 

The ACA’s subsidized marketplace coverage and Medicaid expansion were meant to address a gap in the U.S. health system — and many people don’t have other insurance options, Sara Collins, senior scholar and vice president of healthcare coverage and access, and tracking health system performance at the Commonwealth Fund, said during the press briefing.

“The thing to remember about the Affordable Care Act is that it was put into place because not everybody has health insurance coverage through a job,” she said. “We’re likely to see people just becoming uninsured because the reality is they still don’t have access to employer-based coverage.”

The nation’s healthcare system faces other challenges, including a decline in the number of children who received all recommended early vaccines in most states. Only seven states report 75% of young children received all doses of a key vaccine series in 2023, according to the analysis.

High rates of vaccination are key to preventing infectious disease, according to the report. When enough people have been vaccinated, others who can’t receive vaccines, like newborns and the immunocompromised, are also more protected because the spread of disease is restrained. 

Additionally, premature deaths from avoidable causes — certain infections, injuries and illnesses that could be prevented through robust primary and preventive care — is still common in the U.S., though rates vary significantly across states.

For example, there were 445 premature avoidable deaths for every 100,000 people under age 75 in West Virginia, compared with 201 premature deaths in Massachusetts. 

Infant mortality rates also worsened in 20 states from 2018 to 2022, and there were significant racial and state disparities, according to the report.