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En español | As our nation navigates the COVID-19 pandemic, a milestone health care anniversary has arrived: This week marks the 10-year anniversary of the Affordable Care Act (ACA). The landmark health reform law of 2010 brought sweeping changes to the U.S. health care system.
These two historic developments — the ACA and our response to the pandemic — are closely linked.
Because of the ACA, over 20 million more Americans have health care coverage at a time when many people in this country, especially older individuals and those with health conditions, need access to life-saving health care. If it weren’t for the ACA’s expansion of health coverage and protections, many more adults ages 50 to 64 — who are not yet eligible for Medicare — would be without health coverage.
Or they’d be worrying about whether COVID-19-related expenses would be covered by their health plan. And unfortunately as unemployment rises and people lose access to job-based insurance, even more people may need to rely upon coverage guaranteed under the ACA.
High uninsured rates, even in a particular state, can increase the difficulty of managing the spread of a virus like the coronavirus, which has implications for all of us.
While the priority must be to deal with the immediate crisis, the COVID-19 pandemic illuminates areas in which our health coverage system is working, in part because of the ACA. It has also revealed areas that need major improvement.
In the face of this unprecedented public health crisis, not only do we need to take swift action to ensure that testing, treatment and recovery services are affordable and available to meet immediate needs — we also need to undertake the longer-term work of building on the ACA’s efforts to improve coverage and affordability for older adults.
But in recent years, the law has been weakened.
ACA’s key reforms — and growing gaps
The ACA’s reforms to the individual health insurance market were critical to the expansion in health insurance coverage for older adults. Prior to the ACA, many older adults without access to coverage through their employer were denied affordable coverage due to their age, health or a preexisting condition.
For the first time, the ACA guaranteed Americans access to health insurance coverage, limited how much premiums can vary by age, provided protections for people with preexisting conditions, and extended financial assistance to help people with low and modest incomes pay for premiums and out-of-pocket costs . These consumer protections now ensure that millions of older adults won’t have to worry about whether they have comprehensive insurance coverage — especially during a public health emergency like the coronavirus outbreak.
Under the ACA, health insurance plans must also cover 10 essential health benefits, including preventive and diagnostic services (which should cover COVID-19 tests), emergency services and hospitalizations, and prescription drug coverage. These benefits are especially important for older adults, who are more likely to have chronic health conditions, placing them at higher risk for serious illness from COVID-19 that may require hospitalization, medication or both.
The ACA got more people covered, but more needs to be done.
The ACA’s individual market reforms plus its expansion of the Medicaid program led to a 43 percent reduction in the uninsured rate among adults ages 50 to 64 between 2013 and 2016, the first few years of the law’s implementation. Older adult enrollment in the individual health insurance market grew 65 percent over the same time period.
But premiums rose in 2017, as the ACA’s federal transitional reinsurance program ended. In 2018, premiums rose with market instability, due to factors such as federal debate to repeal the law and the individual mandate (which was changed in the last tax reform bill), the halting of federal cost sharing reduction payments, and significantly reduced federal enrollment outreach and advertising.
The result: Older individual enrollment dropped from 10 to 9 percent, and the uninsured rate increased from 8 to 8.6 percent. That means that a smaller number of older Americans have the security of comprehensive insurance coverage than before.
State-by-state variations in individual enrollment and in the uninsured rate among adults ages 50 to 64 could also have big implications on the spread and impact of COVID-19. For example, the uninsured rate was 17 percent in Texas but just 3 percent in D.C., Rhode Island and Massachusetts, as of 2018.
High uninsured rates in some states, stemming from economics and state decisions such as whether to expand Medicaid under the ACA, can make state efforts to contain the spread of COVID-19 especially difficult. The uninsured may avoid seeking testing or treatment due to cost.
Building on the ACA in the face of COVID-19
We can build on the ACA to improve coverage for older adults. Our nation’s elected leaders, state official and insurers should work together to ensure that everyone has timely access to affordable COVID-19-related testing, treatment and recovery services and are shielded against high out-of-pocket costs.
For example, COVID-19-related services should be available to people with individual coverage without cost sharing and as pre-deductible services. Policymakers should remove barriers like prior authorization to such COVID-19 services, and prohibit surprise medical billing.
Policymakers must also work to improve access to similar affordable COVID-19 services for the uninsured and underinsured, such as through expanding special enrollment periods, including for those with short-term (or “skinny”) plans that do not comply with ACA consumer protections. These plans could lead to higher costs in the individual market and also offer limited benefits that may not cover some essential services, such as the cost of COVID-19 diagnostic testing or treatment.
Last week, Congress took the first step in enacting the Families First Coronavirus Response Act. And some states have already shown leadership and ordered insurers to waive cost-sharing for COVID-19 testing and treatment. Some have reopened their health insurance marketplaces to expand coverage and treatment for the uninsured amid the coronavirus pandemic. More still needs to be done.
Our elected leaders must continue expanding access to comprehensive, affordable coverage that provides adequate protection against health care costs for all Americans. States that haven’t expanded Medicaid should do so. Policymakers should work to bring health care costs down through efforts like reinsurance, expanding financial assistance to ensure coverage is affordable, and increasing funding for outreach and enrollment activities.
The coronavirus crisis presents us all with immediate challenges. But the crisis also highlights a serious issue that will stay with us. A health care system in which all Americans are covered and able to afford preventive care, treatment and recovery services can support the safety of us all and even ultimately save lives.
For more data and discussion of trends and characteristics of older enrollees in the nongroup market, check out our two new fact sheets from the AARP Public Policy Institute. Further state-level data on the uninsured and nongroup markets is also available on AARP DataExplorer, an interactive data visualization tool.
Jane Sung is a senior strategic policy advisor at the AARP Public Policy Institute. Her areas of expertise include private health insurance, Medicare Advantage and Medicare supplemental insurance.
Olivia Dean is a policy research senior analyst at the AARP Public Policy Institute. Her areas of expertise include public health, health disparities, private coverage and emerging health trends.