Even though the Affordable Care Act has stumbled lately, with large national insurers drastically reducing their footprints in the marketplaces, it's difficult to ignore how the law has greatly decreased the number of people who don't have health insurance.
The headline number from the Centers for Disease Control and Prevention's latest National Health Interview Survey is the 8.6% uninsured rate—a historic low. By the end of the first quarter this year, 27.3 million people across all ages, or 8.6% of the population, did not have health coverage. That's a reduction of 21.3 million people since the ACA went into effect in 2010.
For many people, the increased access to insurance—through the exchanges, expanded Medicaid or elsewhere—has meant the peace of mind of not getting denied coverage because of a pre-existing health condition. Out-of-pocket limits put a cap on health expenses. Free preventive screenings encourage people to stay out in front of any potential problems.
But deeper within the CDC report is a data point that is arguably just as important as the uninsured rate. Approximately 40% of Americans under age 65 were enrolled in some kind of high-deductible health plan as their primary coverage as of this past March, up heavily from 25.3% in 2010. Within that 40%, 24.7% of people were in a plan that was not paired with a health savings account. The other 15.3% did have an HSA, which is a tax-free pool of money that people save and can use on their healthcare.
The crux: More people are getting insurance, but they continue to be responsible for more of the cost of their care.
Employers and health insurers have moved people into high-deductible plans and increased cost-sharing mechanisms like copays and coinsurance as a way to keep premiums in check. They also have argued these types of plans force consumers to think more about costs before they get surgery, treatment or drugs.
But the increased cost-sharing has left many consumers underinsured and in a financial jam. Margot Sanger-Katz at the New York Times profiled several people earlier this year who have had serious difficulties in affording their healthcare bills even though they have insurance. One man from Minnesota had to use his retirement account to pay down the coinsurance on his knee replacement.
The ACA's out-of-pocket maximums help, but the limits of almost $7,000 for an individual plan and $13,700 for families are still very steep and unaffordable for many middle-class and poor people.
The economic literature on high deductibles and cost-sharing also is far from glowing, with some independent studies showing people reduce both necessary and unnecessary care when they are on the hook for more of the cost. Even HSAs, which are useful assuming people have money to save, lead to decreased utilization in both low- and high-value services among low-income workers, according to an August report from the Employee Benefit Research Institute.
Further, hospitals like the Cleveland Clinic have said collecting these deductibles from patients has not been easy. Ascension Health and other systems are screening patients to see if they are in high-deductible plans and if they can pay upfront.
Although the uninsured rate has dropped precipitously since the ACA was signed into law, there are still more than 27 million people with no form of health coverage, and the rise of patient cost-sharing continues “eroding the household incomes of average American families,” our editor Merrill Goozner said in May. As my colleague Harris Meyer also wrote in May, higher out-of-pocket spending is the “domestic policy elephant in the room.”
The rise in deductibles and cost-sharing must be watched in tandem with the uninsured rate.
Correction: An earlier version incorrectly stated the CDC high-deductible numbers as millions of Americans instead of percentages.