Thursday, October 15, 2015
The Wall Street Journal
October 14, 2015
Covering the Remaining Uninsured: Not Just a Red-State Issue
By Drew Altman
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:
Eligible for Medicaid:
Eligible for tax credit:
Ineligible for financial assistance due to income, employer offer, or
In Medicaid "coverage gap":
California (no gap)
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.
Comment by Don McCanne
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
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
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