What we are celebrating, and what we are still fighting for

(Originally posted on the National Physicians Alliance blog March 15, 2011)

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Next week marks the first anniversary of the passage of the Patient Protection and Accountable Care Act (PPACA).  This is a good time to remind ourselves what reforms were enacted in the PPACA.

The Robert Wood Johnson Foundation and the Urban Institute recently released a report (pdf) analyzing how the PPACA increases access to health insurance in the United States.  The study used the current (2011) baseline information regarding health insurance coverage, and then modeled the changes that would result if the PPACA was enacted all at once (instead of over the next few years).  This allows a more direct comparison of how the law's reforms affect health insurance coverage.  Some of the findings:

• The percentage of uninsured non-elderly adults would drop by 10.3%, from 18.9% to 8.7%, meaning that more than 27.6 million more Americans would have health insurance under the PPACA.  This increase in insurance coverage would be most dramatic in states where people have less access to employer-sponsored insurance and are less likely to meet Medicaid eligibility requirements.  This indicates that the PPACA's reforms benefit patients who lack other opportunities to obtain health insurance.
• Group health insurance exchanges would cover 8.9% of Americans.  The exchanges will have the greatest impact in states with limited access to employer-sponsored insurance and limited access to Medicaid.  Therefore, the health insurance exchanges provide an option for insurance coverage in areas where options would otherwise be limited.
• Nationally, just over 30% of those covered in the insurance exchanges would have income >400% of the federal poverty level (FPL).  These individuals will not receive any government subsidies for their insurance, but would find the exchanges an attractive alternative to purchasing expensive individual insurance in the current marketplace.
• The majority of cost-sharing and premium subsidies to help lower income individuals purchase insurance would help people under 200% of FPL.  63% of premium subsidies and 91% of cost-sharing subsidies would go to individuals under 200% FPL, meaning that these subsidies would increase health insurance access to those who are currently lacking it.
• Medicaid expansion will enroll just under 5 million people currently eligible for coverage, but who are not receiving it, and 12.2 million people will be newly eligible for Medicaid coverage.  The majority of new enrollees will be non-parent adults.  These new enrollees will on average have lower health care costs than those adults already receiving Medicaid, many of whom have multiple co-moribd conditions.  New enrollees will make up approximately 20% of patients receiving Medicaid, but will only account for 15% of medical costs.

From this analysis, then, it is clear that the PPACA's reforms stand to meet one of the law's major goals: to reduce the number of uninsured Americans.  The fact that this law is needed is evident when you look deeper into the numbers: the majority of those who will receive coverage through group health insurance exchanges and through the Medicaid expansion are adults who would be unable to obtain health insurance through other means as a result of low incomes, lack of employer-sponsored insurance, and current Medicaid eligibility standards.  These are individuals the pre-PPACA insurance market left out.

Despite the positive benefits of the PPACA's reforms, it continues to be the target of much partisan opposition.  Much of this opposition claims that this bill amounts to a government take-over of health care.  However, as evident in this study most newly insured Americans will be insured through the group health insurance exchanges where private health insurance companies will sell their products.  Although federal subsidies will support people purchasing plans in these exchanges, the coverage will be provided by commercial companies.

The PPACA has already led to significant reforms in its first year, including eliminating lifetime caps and yearly limits on benefits, allowing adult children to stay on parents' insurance plans until age 26, eliminating rescissions, requiring no-cost preventive care, and regulating how much of your premium dollars must be spent on paying for benefits.  Once fully enacted, the PPACA will expand access to health insurance to more than 27 million uninsured Americans.

Meanwhile, according to a recent Robert Wood Johnson Foundation report (pdf) there are still approximately 18.5 million adults who will lack insurance coverage despite the PPACA's reforms.  Approximately 37% of these are individuals who will qualify for Medicaid but will not be enrolled, nearly 23% will have access to affordable health insurance options, and 24% will be undocumented immigrants.  Despite the important reforms embodied in the PPACA, we will need to continue to ensure that those who qualify for insurance are able to take advantage of them and we must review options to insure undocumented individuals have access to needed care.

These needed reforms are worth celebrating, and worth fighting for.