Compared to 2010, since the implementation of the Affordable Care Act (ACA) and Medicaid expansion, fewer Americans are uninsured. Also, insurance coverage gaps are shorter since the ACA became law.
But since then, the Commonwealth Fund's health insurance survey finds more people are now "underinsured."
What does it mean to be underinsured?
Someone is considered underinsured if their out-of-pocket costs for the year are 10 percent or more of their household income, the report said, or if their deductible is 5 percent or more of their household income.
Also, for a family with an income under 200 percent of the federal poverty level, being underinsured means out-of-pocket costs are 5 percent or more of household income.
"Someone is more likely to struggle paying medical bills or skip care because of cost (if they are underinsured)," said Dr. David Blumenthal, president of The Commonwealth Fund.
Forty-one percent of underinsured adults reported they have delayed needed care due to cost. And almost half of underinsured adults report medical bills and debt problems, which is nearly twice the rate of those who are adequately insured.
The greatest increase among the underinsured population occurred among those enrolled in employer plans, the report said.
In 2003, roughly 10 percent of individuals with employer-provided coverage were underinsured. That number had risen to 20 percent in 2014, and nearly 28 percent in 2018.
"The ACA made only minor changes to employer insurance, and the erosion in cost protection has taken a bite out of the progress made in Americans' health coverages since the law's enactment," said Dr. Sara Collins, lead author of the study and vice president of health care coverage and access at The Commonwealth Fund.
Dr. Blumenthal added, "The results of this survey indicate that it may be time for policymakers to pay some serious attention to the relatively quick erosion of employer coverage and its impact on workers."
Although those enrolled in employer plans saw the greatest increase in being underinsured, those who bought plans on their own through the Marketplace were the most likely to be underinsured. The report found 42 percent of these individuals had inadequate coverage in 2018.
The report calls on state and federal lawmakers to expand and improve coverage, as well as slow overall growth of health care costs.
To increase coverage, The Commonwealth Fund recommends the following:
• Expand Medicaid without restrictions.
• Ban or plan limits on short-term health plans and non-ACA compliant plans.
• Reinstate outreach and navigator funding.
• Lift the 400 percent of poverty cap on eligibility for the Marketplace tax credits.
To reduce coverage gaps, The Commonwealth Fund recommends the following:
• Inform the public about special enrollment periods.
• Make it easy to enroll in and keep Medicaid.
• Extend the open enrollment period.
To lower out-of-pocket costs, The Commonwealth Fund recommends the following:
• Fund and extend the cost-sharing reduction subsidies.
• Increase required deductible exclusions.
• Refundable tax credits for high out-of-pocket costs.
• Protect consumers from surprise medical bills.
To slow the overall rate of growth in U.S. health care costs, The Commonwealth Fund recommends the following:
• Address impact of consolidation and lack of competition in health care.
• Apply clinical value assessments in prescription drug purchasing.
• Expand use of primary care to patients with complex care needs.
The report noted while Congress has taken actions to weaken the ACA, the adult uninsured rate has remained the same from 2016 to 2018 — 12.4 percent.
"U.S. working-age adults are significantly more likely to have health insurance since the ACA became law in 2010. But the improvement in uninsured rates has stalled," Dr. Collins said. "In addition, more people have health plans that fail to adequately protect them from health care costs, with the fastest deterioration in cost protection occurring in employer coverage. Moving forward, it will be essential to protect, and grow, the ACA’s coverage gains while also working to ensure people with health insurance can get and afford the care they need."
For the full report, visit commonwealthfund.org.
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