Is it just red-state policies that cause so many to remain uninsured?

Covering the Remaining Uninsured: Not Just a Red-State Issue

By Drew Altman
The Wall Street Journal, October 14, 2015

About 32 million people in the U.S. remained uninsured as of early 2015, a Kaiser Family Foundation analysis of federal survey data has found, with about half of them eligible for Medicaid or subsidies under the Affordable Care Act. With the high-profile resistance in some states to Medicaid expansion and the ACA generally, you may think those places are the main obstacle to covering more of the uninsured. But the uninsured remain a problem in both red and blue states.

About half of the remaining uninsured, 16 million people, are in mostly blue states that have expanded Medicaid. The other 16 million are in states that have not expanded Medicaid and where there is strong anti-ACA sentiment. Consider the examples of California and Texas, the states with the largest populations of remaining uninsured, to understand the different challenges.

Remaining uninsured as of 2015:

  California  3,845,000

  Texas       4,425,000

Eligible for Medicaid:

  California  1,428,000

  Texas         493,000

Eligible for tax credit:

  California    623,000

  Texas       1,035,000

Ineligible for financial assistance due to income, employer offer, or citizenship status:

  California  1,795,000

  Texas       2,132,000

In Medicaid “coverage gap”:

  California  (no gap)

  Texas       766,000

Some elements of the remaining uninsured problem are uniquely a red state issue. The most prominent of these are 3.1 million people—or one in 10 of the uninsured—who fall in the “coverage gap” in 20 red states that have chosen not to expand Medicaid coverage. But as the examples of Texas and California demonstrate, progress on covering the remaining 32 million uninsured will depend on action in both red and blue states.



By Don McCanne, MD

Texas should be ashamed. They have the largest number of uninsured individuals in the nation, and yet they have failed to take advantage of the provisions in the Affordable Care Act (ACA) that would grant the state 90 percent of the costs of Medicaid expansion, plus they have failed to provide adequate outreach efforts to enroll individuals in exchange plans where they would be eligible for federal premium tax credits and cost-sharing subsidies. In contrast, California has been aggressive in trying to get as many individuals as possible covered by health insurance of one type or another. How do the results in California (a blue state) compare to those in Texas (a red state)?

In California, 10 percent remain uninsured, whereas in Texas, 16 percent lack insurance. California’s efforts have paid off… for some. But why should California, with its strong support of ACA, still have 3,845,000 people without any insurance? It’s very simple. ACA is a highly flawed model of reform.

Models which build on existing, fragmented, multi-payer systems are the most expensive models of reform, yet they fall short of many of the goals, including universality. Yet the least expensive comprehensive models of reform achieve the goals of universality, efficiency, affordability, equity, improved access, and better health care outcomes. These are the single payer national health insurance and national health service models.

Many suggest that we should celebrate our gains and move forward with incremental patches to the system. There are two problems with this approach. Incremental patches will add significant additional costs to the system, and patches cannot possibly repair the fundamental structural flaws in the financing system. Thus, under ACA, we will always fall short of the goals.

There is a better way. Fix Medicare and provide it to everyone. California would then achieve its goal of reducing its uninsured to zero. Texas would too, even if its politicians were opposed. One thing for sure, once everyone in Texas did have Medicare, the people would be overwhelmingly supportive.