Health Care/Joan Retsinas

The Uninsured, Redux

Remember the uninsured? Those 45 million among us dominated the 2008 Presidential campaign, then the 2012 campaign. What could the nation do? We had outlawed pre-existing exemptions (thank you to the bipartisan enough Congress that passed HIPAA), we allowed dependents to stay on their parents’ insurance until age 25 (saving parents the problem of their unemployed uninsured progeny); we had extended Medicaid to let states cover more children (thanks to the Children’s Supplemental Health Insurance Program, another relic from a more bipartisan age). Still the problem seemed intractable.

At the same time, a corrollary problem emerged: Model T policies that wouldn’t propel a car. Enrollees had happily signed onto “affordable” policies that didn’t cover much; those enrollees didn’t discover the “not covereds” until they got sick.

The Affordable Care Act arrived under President Obama (with a lot of help from Speaker Nancy Pelosi). This flawed deus ex machina cobbled together subsidies for people to buy private insurance policies on regulated “exchanges”; it finally axed pre-existing conditions; it offered states subsidies to expand their Medicaid programs — if they wished (a codicil crucial to conservative states, one they seized). And, crucially, it regulated the “basic policies” that insurers had to offer, thereby getting at the corollary travesty: the underinsured, those folks who thought they were insured until they discovered that their insurance wouldn’t cover what ailed them.

At the end of the plotting, the plotters pared the number of the uninsured. (Some states, like Massachusetts, had already pared their numbers). We didn’t have universal coverage, but the “uninsured” no longer rebuked our notions of fairness. Conservative states that refused to extend Medicaid continued to see a swathe of their citizens uninsured, but that was the states’ choice.

Statistics-wise, more of us had decent coverage. We went from 46.5 million uninsured in 2010, to 35.9 in 2014, to 29.1 in 2015, to 26.7 in 2016.

Fast forward four years. The slide reversed: 27.4 in 2017, 27.9 in 2018, to today’s preliminary figures.

This president undercut the “individual mandate”of the Affordable Care Act: people don’t need to enroll, don’t need to pay a penalty tax. Of course, once people opt out, the financial underpinnings suffer (in contrast, we don’t let people opt out of Social Security or Medicare payments). This also leaves some people — those who opt out — without coverage.

This president’s “public charge” rule encouraged some legal immigrants to drop coverage. (Under this rule, which last month a federal judge temporarily blocked because of the COVID epidemic, immigrants who have used government benefits would have that taken into consideration when they apply for green cards).

This president enthusiastically brought back Model T policies, with cheap premiums and paltry benefits.

And now, when this president wants to shelve the Affordable Care Act entirely, we see more Americans losing their jobs, thanks to COVID. To date, more than 20 million Americans have lost their jobs because of this virus.

With loss of a job, comes the crisis of coverage.

Unemployment and COVID-related subsidies might barely cover a mortgage, food, and transportation as long as the subsidies last. Eventually the ex-employee risks losing the group health insurance with the employer-subsidized premiums.

There are some safeguards. The ex-employee can get insurance: if his/her income qualifies for Medicaid, and if the state has elected to extend Medicaid; if s/he qualifies for a subsidy on the state’s Affordable Exchange Act, though, since the subsidy is tied to the last salary, the marketplace premium might be too high; If s/he can afford COBRA and if the company still exists and if s/he can pay the total (non-group) premium, which can come to $1,000 annually for an individual; if s/he can go onto a spouse’s policy. If the company furloughs the employee, the company could defer premiums, letting the furloughed employee keep the policy — delaying payment until the company resumes operations. A lot of “ifs.”

We are returning to the past, as the number of people without health insurance rises — ironically, at a time when a lethal virus is making many of us sick. One estimate: 5.4 million Americans, laid off, have lost health insurance (compared to 3.9 million during the 2008-200 Great Recession).

California, Florida, New York, North Carolina, and Texas have suffered the most. In Texas, 30% of the working-age population have lost their insurance. By the end of 2020, pollsters predict 10 million Americans will have lost their insurance.

If we decimate the Affordable Act, we risk returning to our all-time highs. A sad return to the future.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, September 1, 2020

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