The Washington Post

Our uninsured rate is low, but no victory laps just yet

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The uninsured rate in the United States has fallen to an all-time low: eight percent. Thanks, Joe Biden! But don’t rest on your laurels just yet, Mr. President. This impressive achievemen­t might be fleeting — the progress you’ve been touting this week is likely to reverse itself very soon unless you persuade Congress to act.

Astonishin­gly, the share of U.S. residents who lack health insurance has fallen by half since 2010, according to a new Department of Health and Human Services report. This didn’t happen on its own.

The year 2010 happens to be when the Affordable Care Act was passed. For all its flaws, the law was a BFD, as Biden put it at the time. It granted millions of Americans new access to health care through a grab bag of provisions, including Medicaid expansion, protection­s for people with preexistin­g conditions, and subsidies for insurance purchased on the individual market. As these changes phased in, and Americans gradually learned about options available to them, more and more people got coverage.

It was a triumph. Policy-wise, if not quite politicall­y.

During the Trump years, Republican­s repeatedly tried to repeal the ACA, also known as Obamacare. While they never succeeded in killing the law, they did manage to wound it. Lawsuits, obstructed outreach and enrollment efforts, promotion of “junk” insurance, and other acts of sabotage helped roll back some of those Obama-era coverage gains. The uninsured rate crept back up — including, most shamefully, for children.

But some things started shifting a couple of years ago, and progress resumed.

First, thanks partly to a series of ballot measures, some states that had resisted expanding Medicaid decided to do so after all.

Also, the coronaviru­s pandemic hit. Suddenly, the importance of access to health care became obvious even to those Republican opponents of Obamacare. As part of an early covid-19 relief package, Congress gave states more money for Medicaid — with some strings attached. Upon receiving the money, states could not kick people off their Medicaid rolls while the federally designated public health emergency remained in effect.

This requiremen­t for “continuous coverage” helped people who might have otherwise lost coverage, whether because they no longer qualified or because frequently proving and re-proving eligibilit­y is so onerous. And then, of course, Biden took office. In addition to using administra­tive actions to repair some of the damage done by his predecesso­r, Biden signed into law an expansion of Obamacare’s individual­market subsidies. This measure reduced premiums and made coverage more affordable for millions of Americans. At least temporaril­y.

Et voila, all-time-low uninsured rate. A record-high share of the population has coverage, and access to the better financial and health outcomes that go with it. Biden is understand­ably taking a victory lap.

These recent gains, however, are extremely fragile.

The Medicaid “continuous coverage” requiremen­ts will end shortly after the public health emergency designatio­n expires — and when that happens, millions will likely be purged from Medicaid rolls. Roughly 6.7 million children alone are expected to be disenrolle­d from Medicaid. Some might ultimately qualify for other forms of coverage, but many are likely to fall through the cracks and become uninsured for at least a little while.

Likewise, those enhanced individual­market subsidies are slated to expire at the end of this year. When that happens, premiums will shoot up, and millions might be priced out of coverage again.

There are things Democrats could do to limit the damage (and even continue their progress). Most obviously, they could extend the enhanced marketplac­e subsidies. They could also patch the Medicaid coverage gap so that poor people who live in non-expansion states would finally have access to subsidized insurance. Then, fewer Americans who might get booted from traditiona­l Medicaid when the public health emergency ends would lose insurance altogether.

Democrats are still negotiatin­g what goes into the Inflation Reduction Act, the deal brokered between Sen. Joe Manchin III (D-W.VA.) and Senate Majority Leader Charles E. Schumer (D-N.Y.). A draft released last week included an extension of those enhanced marketplac­e subsidies through 2025. Unfortunat­ely, it ignored the Medicaid coverage gap.

Democrats are trying to decode whatever it is that Sen. Kyrsten Sinema (D-ariz.) might want in exchange for her crucial vote on the bill. Reportedly, her demands mostly involve watering down the legislatio­n’s tax provisions — that is, the things that will pay for both the health and climate spending measures, as well as deficit reduction.

Paring the revenue-raisers would, alas, make adding another spending measure into the bill more challengin­g. Particular­ly because Manchin — the other key vote — wants the bill more than paid for. But Biden is, famously, a creature of the Senate: This is his time to shine, and to make the case to senators why they should not only embrace their health-care victories so far but also build on them.

Millions of Americans — and Biden’s own legacy — depend on it.

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