Changes to Medicaid under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) are responsible for the majority of the coverage gains identified since the passage of the health reform law, according to a Perspective published in the New England Journal of Medicine (NEJM). For example, through Medicaid expansion, streamlined application processes, and growing public awareness, Medicaid was the biggest factor in coverage expansion in 2014, accounting for 63 percent of the identified coverage gains. Accordingly, state implementation through measures like the ACA’s Medicaid expansion continues to be a primary factor in determining the success, or failure, of the health law. In light of the impact that upcoming elections could have on health policy, the Perspective’s author’s warned: "although undermining coverage expansion may be politically expedient in some places, it is indefensible from a public health perspective."
ACA tools. The NEJM Perspective determined that of all the primary ACA tools—Medicaid expansion, tax credits for exchange coverage, and the individual mandate—the most influential factor has been Medicaid, the program’s expansion, and the ancillary effects that expansion has had on Medicaid program generally.
Medicaid. Coverage gains in 2014 that were based upon Medicaid were not exclusively derived from the ACA’s option for states to expand their programs. The NEJM Perspective determined that although almost one-third of previously uninsured newly eligible adults signed up for coverage, in states that expanded Medicaid in the expansion’s first year, those new enrollees only accounted for 19 percent of the overall coverage gains. The remaining 44 percent of the coverage gains were based upon new enrollees comprised of children and adults who were eligible for the program before 2014. Many of those individuals were made eligible for Medicaid coverage in states, like California, that elected to expand coverage prior to 2014. Among other individuals, who were eligible for Medicaid under pre-ACA criteria, the NEJM perspective indicates that streamlined enrollment, the removal of asset tests, and increased public awareness were significant factors in the coverage gains.
Subsidies and mandate. Premium subsidies accounted for the nearly 40 percent of coverage gains in 2014 that were unrelated to Medicaid. The analysis concluded that for every 10 percent subsidy to the average family premium, and additional 1.5 million Americans gained health insurance. The Perspective noted that while the gain is significant, it indicates lower than expected participation rates. The analysis also concluded that despite strong political opposition to the provisions, overall coverage gains did not respond to the individual mandate or the ACA’s provisions regarding employer-sponsored insurance.
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