2010 law fits safety-net bill for health, economic crises

In past recessions, the uninsured rate would surge. Now, for the first time, Americans are experiencing a recession with the Patient Protection and Affordable Care Act in place.

The health law's expansion of Medicaid and its offer of subsidized health plans have provided a new safety net for those who have lost their jobs and their health insurance.

The Affordable Care Act gave states the option to cover poor residents through Medicaid, and it offered tax credits to help low- and middle-income Americans buy health insurance. Since the coronavirus pandemic set off job losses this spring, enrollment in both programs has been growing. Experts say sign-ups would probably be higher still if not for Trump administration moves that included slashing the health law's advertising budget and declining to have an additional sign-up period when the pandemic hit.

State Medicaid enrollment, according to one report, had an 11% increase from February to September in the 36 states that have released data. Another paper, from Manatt Health, shows those gains concentrated in states that have participated in the health law's Medicaid expansion, with an enrollment growth rate of 22.2% between February and November.

Sign-ups for plans in marketplaces run by the federal government are up 6.6% compared with last year, according to a new federal tally. It is the only year during the Trump administration when enrollment increased, and amounts to a half-million more people seeking coverage from the federal marketplace. The total is still down compared with 2016, the last year the Obama administration was running the program.

Charts based on an analysis of census data by Matt Bruenig, president of the People's Policy Project, show how the overall health insurance landscape has changed since the Affordable Care Act took effect. In 2009, 16.7% of Americans lacked health insurance, and, for those of working age, the poorer the person was, the more likely he would fall in that category.

Medicaid enrollment among low-income Americans has since surged, particularly in states that expanded their programs, reducing the disparities. Enrollment in subsidized private coverage also has grown among those earning slightly more. As the population has aged, more people also have become eligible for another public program: Medicare. The 2020 chart shows survey results collected early in the year, so these numbers do not reflect the impact of the covid recession.

Bruenig said he was struck by how many low-income people remained uninsured, a sign, he said, that the new system was not yet reaching everyone it was designed to help.

While data is still coming, there are early signs that the Affordable Care Act is making health coverage less dependent on employment.

In a paper published in October, Dr. Benjamin Sommers and Dr. Sumit Agarwal looked at what happened to the health insurance status of Americans who lost a job. Before the Affordable Care Act, these newly unemployed workers experienced a 4.6-percentage-point increase in their uninsured rate.

After the law took effect, the association between job loss and higher uninsured rates disappeared.

Early, incomplete evidence suggests the law is serving that function during the coronavirus economic downturn. A federal report last month showed an increase in marketplace sign-ups this spring as the unemployment rate mounted. Between January and May, healthcare.gov had about 150,000 more enrollments than usual.

A recent analysis of insurance industry data by Kaiser Family Foundation researchers found that roughly 2 million to 3 million Americans lost their job-based coverage between March and September. During the same period, around 5 million enrolled in Medicaid.

"When the economy suffers, the Affordable Care Act plays an important role in making sure people can still maintain insurance coverage in ways that didn't exist before," said Cynthia Cox, a vice president at the foundation. But Cox said that, even with this cushion, millions of Americans remain uninsured during a public-health crisis. Many of those people, she said, are eligible for free coverage, a sign that the programs are not reaching everyone they could.

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