Hostname: page-component-848d4c4894-wg55d Total loading time: 0 Render date: 2024-06-06T02:59:57.680Z Has data issue: false hasContentIssue false
  • English
  • Français

Making Health Care Truly Affordable after Health Care Reform

Published online by Cambridge University Press:  01 January 2021

Timothy Stoltzfus Jost  and
Harold A. Pollack
Get access Rights & Permissions [Opens in a new window]

Abstract

The Affordable Care Act (ACA) is an essential first step toward making health insurance more affordable for lower and moderate income Americans. It has accomplished historic reductions in the proportion of Americans who are uninsured. The number of Americans reporting delaying medical care for financial reasons has declined by approximately one-third since 2010. Medicaid expansions, in particular, have significantly reduced financial burdens and accompanying anxieties experienced by low-income Americans in states that have embraced this opportunity. Consistent with these finding, one recent analysis of credit report data finds that Medicaid expansion was associated with between a $600 and $1000 decline in collection balances among individuals who gained coverage. Notwithstanding these gains, premiums and cost-sharing are still too high for many Americans. And cost-sharing has continued to edge higher for the majority of Americans who have coverage through employer-based plans. Measures to address these challenges must build on the ACA to provide greater protection to millions of Americans and to address continued dissatisfaction with our health care financing system among middle-income Americans.

Type
Symposium Articles
Information
Journal of Law, Medicine & Ethics , Volume 44 , Issue 4: Health Reform: Assessing the Affordable Care Act and Moving Forward , Winter 2016 , pp. 546 - 554
Copyright
Copyright © American Society of Law, Medicine and Ethics 2016

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

Authors' Note

This essay was completed in early 2016. The intervening year has seen news of dramatic increases in Affordable Care Act marketplace premiums and of the withdrawal of health plan from the marketplaces. These developments reinforce the core insight of our essay: that the ACA has not yet definitively solved the problem of making health insurance and health care affordable for Americans and that further improvements are needed. Our essay suggests changes that can be made toward further achieving this goal.

References

DiJulio, B., Firth, J., Kirzinger, A., and Brodie, M., “Kaiser Health Tracking Poll, January 2016,” January 28, 2016, available at <http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-january-2016/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
“New Kaiser/New York Times Survey Finds One in Five Working-Age Americans with Health Insurance Report Problems Paying Medical Bills,” January 5, 2016, available at <http://kff.org/health-costs/press-release/new-kaisernew-york-times-survey-finds-one-in-five-working-age-americans-with-health-insurance-report-problems-paying-medical-bills/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Collins, S. and Blumenthal, D., “New Federal Survey Shows Gains in Private Health Coverage and Fewer Cost-Related Problems Getting Care,” February 24, 2016, available at <http://www.commonwealthfund.org/publications/blog/2016/feb/new-federal-survey-shows-gains-in-private-health-coverage> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Baicker, K. et al., “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes,” New England Journal of Medicine 368, no. 18 (2013): 1713–1722, at 1718.Google Scholar
Hu, L. et al., “The Effect of the Patient Protection and Affordable Care Act Medicaid Expansions on Financial Well-Being,” NBER Working Paper Series, April 2016, available at <http://www.nber.org/papers/w22170> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Collins, S. et al., “How High Is America's Health Care Cost Burden, Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, July–August 2015,” available at <http://www.commonwealthfund.org/publications/issue-briefs/2015/nov/how-high-health-care-burden> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Kaiser Family Foundation/Health Research and Education Trust, “2015 Employer Health Benefits Survey,” September 22, 2015, available at <http://kff.org/health-costs/report/2015-employer-health-benefits-survey/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Keehan, S. et al., “National Health Expenditure Projections, 2014–24: Spending Growth Faster Than Recent Trends,” Health Affairs, 34, no 8 (2015): 1407–1417.CrossRefGoogle Scholar
Statista, “Number of People per Household in the United States from 1960 to 2015, available at <http://www.statista.com/statistics/183648/average-size-of-households-in-the-us/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
DeNavas-Walt, C. and Proctor, B., Income and Poverty in the United States 2014 (U.S. Census Bureau, 2015): at 5.Google Scholar
Kaiser Family Foundation, “Concentration of Health Care Spending in the U.S. Population, 2010,” March 13, 2013, available at <http://kff.org/health-costs/slide/concentration-of-health-care-spending-in-the-u-s-population-2010/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Brot-Goldberg, Z., Chandra, A., Handel, B., and Kolstad, J., “What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics,” NBER Working Paper no. 21632, National Bureau of Economic Research, October 2015.Google Scholar
Board of Governors, Federal Reserve System, Report on the Economic Well-Being of U.S. Households in 2014 (Washington, D.C.: Federal Reserve, 2015): at 2.Google Scholar
Claxton, G., Rae, M., and Panchal, N., “Consumer Assets and Patient Cost-Sharing,” Kaiser Family Foundation, March 11, 2015, available at <http://kff.org/health-costs/issue-brief/consumer-assets-and-patient-cost-sharing/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
See Keehan, supra note 8.Google Scholar
Congressional Budget Office, Federal Subsidies for Health Insurance Coverage for People Under Age 65 (Washington D.C.: Congressional Budget Office, 2016).Google Scholar
42 U.S.C 1396a(a)(10)(A)(i)(VIII).Google Scholar
NFIB v. Burwell, 132 S.Ct. 2566 (2012).Google Scholar
Garfield, R. and Damico, A., “The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid – An Update,” Kaiser Family Foundation, January 21, 2016, available at <http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Gabel, J., “More than Half of Individual Health Plans offer Coverage That Falls Short of What Can Be Sold through Exchanges as of 2014,” Health Affairs, May 2012, available at <http://content.healthaffairs.org/content/early/2012/05/22/hlthaff.2011.1082.abstract> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Brooks, T., “The Family Glitch,” Health Affairs Health Policy Briefs, November 10, 2014, available at <http://www.healthaf-fairs.org/healthpolicybriefs/brief.php?brief_id=129> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
26 C.F.R. 1-36B-2(c)(3)(v)(A).Google Scholar
Rosenbaum, S. and Kenney, G. M., “The Search for a National Child Health Coverage Policy,” Health Affairs 33, no. 12 (2014): 2125–2135.Google Scholar
See Claxton et al., supra note 14.Google Scholar
See KFF/HRET, supra note 7.Google Scholar
Barber, C. et al., “Ensuring Consumers' Access to Care: Network Adequacy State Insurance Survey Findings and Recommendations for Regulatory Reforms in a Changing Insurance Market,” at 6, Health Management Associates, November 2014, <http://www.naic.org/documents> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Starr, P., Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (New Haven: Yale University Press, 2011): at 72–76.Google Scholar
Pollack, H., “Medicare for All — If It Were Politically Possible—Would Necessarily Replicate the Defects of Our Current System,” Journal of Health Politics, Policy and Law 40, no. 4 (2015): 921–929.CrossRefGoogle Scholar
Jost, T., “Repeal, and Replace, the Employer Mandate,” Health Affairs Blog, available at <http://healthaffairs.org/blog/2014/06/04/repeal-and-replace-the-employer-mandate/> (last visited October 21, 2015).+(last+visited+October+21,+2015).>Google Scholar
Sanders, B., “Medicare for All: Leaving No One Behind,” available at <https://berniesanders.com/issues/medicare-for-all/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Thorpe, K., “An Analysis of Senator Sanders Single-Payer Plan,” available at <https://www.scribd.com/doc/296831690/Kenneth-Thorpe-s-analysis-of-Bernie-Sanders-s-single-payer-proposal> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Cannon, M., “Large HSAs Trump ‘ObamaCare-Lite’ Tax Credits at Delivering Better Health Care,” Cato Institute, available at <http://www.cato.org/publications/commentary/large-hsas-trump-obamacare-lite-tax-credits-delivering-better-health-care> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Klein, P., Overcoming Obamacare: Three Approaches to Reversing the Government Takeover of Health Care (Washington D.C.: Washington Examiner, 2015).Google Scholar
Kaiser Family Foundation, “Key Facts about the Uninsured Population,” October 5, 2015, available at <http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Pollack, H., “High-Risk Pools for the Sick and Uninsured Under Health Reform: Too Little and Thus Too Late,” Journal of General Internal Medicine 26, no. 1 (2011): 91–94.Google Scholar
Hall, J., “Why High Risk Pools (Still) Won't Work,” Commonwealth Fund, February 13, 2015, available at <http://www.commonwealthfund.org/publications/blog/2015/feb/why-high-risk-pools-still-will-not-work> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
NCPPR, Health Plan Summaries, available at <https://docs.google.com/spreadsheets/d/1A8Nmb0PAfxCcOAbKn85JmuYihDAFg2VZ_eOX7nclBWw/edit?pli=1#gid=404794951> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Salzman, E. and Eibner, C., “What Happens If the ACA's Tax Credits Are Replaced with Premium Support?” Commonwealth Fund Blog, November 24, 2015, available at <http://www.commonwealthfund.org/publications/blog/2015/nov/what-happens-if-the-acas-tax-credits-are-replaced-with-premium-support> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Percy, A, “Coverage Effects of Limiting the Tax Exclusion for Employment-Based Health Insurance,” Congressional Budget Office, June 23, 2014, available at <https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0ahUKEwiX2JW4l8jKAhWBBY4KHYpvD9oQFgg0MAM&url=https%3A%2F%2Fwww.cbo.gov%2Fsites%2Fdefault%2Ffiles%2Fpresentation%2F45456-ashe-presentation0.pdf&usg=AFQjCNEsW4QNuP9Fl61uE_qrW9bAlyIRGw&sig2=Q> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Salzman, E. and Eibner, C., “The Ramifications of Repealing the Individual Mandate,” Commonwealth Fund Blog, August 13, 2015, available at <http://www.commonwealthfund.org/publications/blog/2015/aug/the-ramifications-of-repealing-the-individual-mandate> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Corlette, S. et al., “Selling Health Insurance Across State Lines: An Assessment of State Laws and Implications for Improving Choice and Affordability of Coverage,” Center on Health Insurance Reform, October 2012, available at <www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf401409> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Hall, M., “The Geography of Health Insurance Regulation,” Health Affairs, Mar./Apr. 2000, at 173–184, at 182.Google Scholar
Park, E., “Proposed Medicaid Block Grant Would Add Millions to Uninsured and Underinsured,” Center on Budget and Policy Priorities, March 17, 2015, available at <http://www.cbpp.org/blog/proposed-medicaid-block-grant-would-add-millions-touninsured-and-underinsured> (last visited October 21, 2016); E. Park, “Medicaid Per Capita Cap Would Shift Costs to States and Undermine Key Part of Health Reform,” Center on Budget and Policy Priorities, May 8, 2013, available at <http://www.cbpp.org/research/medicaid-per-capita-cap-would-shift-costs-to-states-and-undermine-key-part-of-health-reform> (last visited October 21, 2016).+(last+visited+October+21,+2016);+E.+Park,+“Medicaid+Per+Capita+Cap+Would+Shift+Costs+to+States+and+Undermine+Key+Part+of+Health+Reform,”+Center+on+Budget+and+Policy+Priorities,+May+8,+2013,+available+at++(last+visited+October+21,+2016).>Google Scholar
See Saltzman and Eibner, supra note 38.Google Scholar
See NFIB, supra note 18.Google Scholar
Health Pocket, “Almost No Existing Health Plans Meet New ACA Essential Health Benefit Standards,” available at <https://www.healthpocket.com/healthcare-research/infostat/few-existing-health-plans-meet-new-aca-essential-health-benefit-stands/#WA7ZxpMrJXQ> (last visited October 24, 2016).+(last+visited+October+24,+2016).>Google Scholar
Blumberg, L. and Holahan, J., “After King v. Burwell: Next Steps for the Affordable Care Act,” Urban Institute, August 2015, available at <http://www.urban.org/research/publication/after-king-v-burwell-next-steps-affordable-care-act> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Id.Google Scholar
Helmchen, L. et al., “Health Savings Accounts: Growth Concentrated among High-Income Households and Large Employers,” Health Affairs 34, no. 9 (September 2015): 1594–1598.CrossRefGoogle Scholar
See Blumberg and Holahan, supra note 47.Google Scholar
CBO, supra note 16.Google Scholar
Martinez, M., Cohen, R., and Zammitti, E., “Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January–September 2015,” National Health Interview Survey Early Release Program, February 2016, available at <www.cdc.gov/nchs/data/nhis/earlyrelease/insur201602.pdf> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
Marken, S., “U.S. Uninsured Rate 11.9% in Fourth Quarter of 2015,” Gallup, January 7, 2016, available at <http://www.gallup.com/poll/188045/uninsured-rate-fourth-quarter-2015.aspx?g_source=CATEGORY_HEALTHCARE&g_medium=topic&g_campaign=tiles> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar
CMS Blog, “20 Million People have Gained Health Insurance Coverage Because of the Affordable Care Act, New Estimates Show,” March 3, 2016, available at <http://www.hhs.gov/about/news/2016/03/03/20-million-people-have-gained-health-insurance-coverage-because-affordable-care-act-new-estimates> (last visited October 21, 2016).+(last+visited+October+21,+2016).>Google Scholar