A straightforward solution to the newly uninsured
In early April, my patient Lucas was four years into a job at a car dealership when the company laid off nearly all of its employees, including him. Forty-seven, divorced, with asthma and hypertension, he was unable to afford the continuing health insurance coverage of COBRA and is without insurance coverage for the first time in his life.
Before the novel coronavirus outbreak, approximately 28 million Americans were uninsured. Now another 27 million are estimated to lose insurance coverage as jobs are lost and employment-based insurance evaporates, more than 20 percent of which are projected to have no other source of coverage.
Becoming uninsured devastates families and causes lasting economic harm and damages our nation’s health. How will we pay for medical care, COVID-related or not, for the growing number of out-of-work individuals? The answer is obvious: expand Medicaid eligibility.
The Trump administration has been trying to roll back the Affordable Care Act since the president’s first day in the office and has resisted Medicaid expansion as an answer to the current need for coverage. After congressional repeal and replace efforts failed in 2017, the administration advanced other policies that undermine the goals of the ACA and cause greater health risks during a pandemic.
These actions have included promoting short term plans (often called junk insurance); diminishing advertising, limiting open enrollment, and decreasing support for enrollment in the federal Marketplace; refusing to pay financial support promised to private insurers bearing unusual risk (recently declared impermissible by the Supreme Court); undermining Medicaid eligibility expansion with novel policies such as work requirements, block grants, and frequent eligibility redeterminations; and other choices that have decreased insurance coverage nationwide.
Medicaid is the nation’s primary insurer for low-income individuals, a safety net protecting nearly 72 million Americans by paying for medical care and providing a resilient and flexible safety net that responds to the health care needs of the people it serves. Constituting one-fifth of all health care spending, Medicaid finances nearly half of all births, 40 percent of all pediatric care, and nearly two-thirds of all long-term care for the elderly and disabled.
Ten years ago, the ACA expanded eligibility to childless adults earning up to 138 percent of the federal poverty level, or $17,600 for a single person in 2020, as part of the goal to achieve near-universal insurance coverage. But, in 2012 the U.S. Supreme Court decided states could choose whether to expand.
Thirty-six states and the District of Columbia have done so, and their populations have gained well-documented improvements in access and affordability of care, diminished disparities in health, improved personal financial stability and decreased overall mortality compared to non-expansion states. The remaining 14 states have a “coverage gap” that leaves over 2 million residents without any form of coverage because they cannot gain it through employment, cannot afford to buy in a Marketplace, and cannot enroll in Medicaid.
With the pandemic-related surge in unemployment, all fifty states are suffering, but the non-expansion states have been hit the hardest because they are missing a key tool in their health toolbox. Medicaid is structured as a federal-state partnership, so states administer Medicaid with a guarantee of federal matching dollars without a cap for covered services.
In turn, states must pay their share of Medicaid financing from state and local revenues. But in a public health emergency, states lose their tax base as businesses close and citizens lose work at the very moment that more people become eligible for government assistance. State revenues are down 20 to 50 percent from last year.
The two federal stimulus bills recognized states’ financial needs and provided a 6.2 percent bump in Medicaid’s federal match for the duration of the pandemic. But this isn’t nearly enough to help cover the newly uninsured millions, it simply helps states to start to balance their budgets.
Further, the administration’s current plan to pay doctors and hospitals only for COVID-related testing costs is insufficient. The newly uninsured have no coverage for treatment related to COVID-19 or any other medical conditions.
Now is the time to let Medicaid serve as a lifesaver for those who have lost jobs during the pandemic-induced recession and those who fell in the coverage gap even before the pandemic. The reasons that people were uninsured no longer matter, whether they had private insurance through their employers, were unable to obtain insurance or were otherwise unprepared for the shockingly fast recession brought on by this pandemic. A public health approach seeks to reduce risk, and a healthier population is less likely to become seriously ill or die from novel coronavirus or another public health emergency.
Therefore, the remaining 14 states should expand Medicaid eligibility immediately. Whether or not the administration supports it, the law allows states to make this choice and with fast results. Medicaid expansion would shift most of the cost of care for the newly uninsured to the federal government, not just for COVID-19 but for all of Medicaid’s comprehensive benefits.
Additionally, states that are trying to “experiment” with limiting enrollment or capped spending should roll back such efforts, which could harm their residents. This includes reinstating Medicaid’s traditional three-month retroactive eligibility period and 12-month continuous eligibility, which is particularly effective for securing coverage in the face of a public health emergency where low-income workers are being infected in higher numbers and losing jobs more than other populations.
The current administration has emphasized reducing government spending and has not prioritized expanding insurance coverage, let alone Medicaid. But no other viable options exist to act quickly to protect the millions of Americans who, if they remain uninsured, are at risk of skipping necessary medical treatment or going bankrupt from high medical bills. Inattention to the newly uninsured population puts millions of lives at risk if these individuals avoid needed care.
It’s time to eliminate artificial barriers to coverage and protect the uninsured. Insurance coverage is the gateway to accessing health care and a backstop for financial, food, and housing stability for individuals, financial support for health care providers, and a source of financial stability for states’ budgets. Medicaid was created to support the most vulnerable and least healthy, which this month is Lucas, but the pandemic reveals could be any of us.
Michael Stein, M.D., a professor at Boston University, is the co-author of the new book, “PAINED: Uncomfortable Conversations About The Public’s Health.” Nicole Huberfeld is professor of Health Law, Ethics & Human Rights and professor of Law at Boston University.