President Donald Trump has said that, politically, the best thing he could do is to let the Affordable Care Act “explode.”
Though the ACA certainly hasn’t exploded, fresh Census Bureau data released this week provides the clearest evidence yet that the Trump administration’s policies are eroding the law’s historic coverage gains.
All three of the major federal health surveys show that the number of Americans without insurance has increased by 1 million or more since 2016, despite a growing economy and falling unemployment. That’s following six years of coverage gains that brought the uninsured rate to its lowest level in history.
But while this erosion is harmful, a full-scale ACA repeal, which the administration is continuing to pursue through the courts, would make matters far, far worse.
Trump’s policies undermine the ACA
Trump policies that have undermined coverage include a repeal of the ACA’s individual mandate, the requirement that people have coverage or pay a penalty. And while a repeal did not take effect until 2019, experts have concluded it reduced coverage significantly starting in 2018 because of consumer confusion.
The administration has also cut federal outreach and advertising for the ACA marketplaces by 90% and is supporting harsh new state policies that make it harder for people to enroll or stay enrolled in Medicaid.
In addition, the administration’s harsh anti-immigrant stance — including changing how Medicaid eligibility affects decisions concerning who can legally enter the US and which immigrants here legally can adjust to lawful permanent resident status — have sown widespread fear and confusion in immigrant communities, likely increasing uninsured rates in families that include immigrant members.
The new census data offers suggestive evidence that this climate of fear is taking a toll on health coverage. The uninsured rate among Latinos rose 1.6 percentage points, more than for other racial or ethnic groups, and the uninsured rate among Latino children rose 1 percentage point. Also suggestive, coverage losses were especially large among foreign-born residents, both noncitizens and citizens.
Looking beyond 2018, coverage losses from administration policies will most likely keep growing. For the first time this year, the census report includes some preliminary data on uninsured rates for the current year. These data shows a further rise in the uninsured rate between March 2018 and March 2019.
The real danger is a full ACA repeal
Even with coverage trends moving in the wrong direction, however, the “Census American Community Survey” shows that the uninsured rate remains 40% below its 2010 level, which means that 21 million more people have health coverage. The Centers for Disease Control’s “National Health Interview Survey” shows that despite this year’s reversal, the uninsured rate remains lower than in any other year from 1963 through 2014.
That’s because the ACA’s major coverage provisions are continuing to cover millions of people who would otherwise be uninsured. Consistent with that, the “National Health Interview Survey” data also shows that the share of Americans who went without care because of cost in 2018 was down 30% relative to its 2010 peak.
But with 18 Republican state attorneys general, the administration is continuing to seek the ACA’s full repeal through the courts. And while it claims to have a replacement for the ACA in mind, the administration’s budget proposals endorse a “repeal and replace” plan that would still eliminate the ACA’s expansion of Medicaid to low-income adults, the ACA marketplaces, and nationwide protections for people with preexisting conditions.
Based on Urban Institute projections, we estimate that if courts struck down the ACA this year, the uninsured rate would rise above pre-ACA levels to 18.7%, with nearly 20 million more people becoming uninsured.
Keep your eye on the courts, because the harm from a full-scale ACA repeal would dwarf the coverage erosion of 2018 that we see in the latest data.
Aviva Aron-Dine is the vice president for health policy at the Center on Budget and Policy Priorities. Before rejoining the Center, in 2017, Aron-Dine served as a senior counselor to the secretary at the Department of Health and Human Services, with responsibility for Affordable Care Act implementation as well as Medicaid, Medicare, and delivery-system reform.
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