Near universal health coverage achieved in six states and DC

An article by Michael Rainey of The Fiscal Times (see link below), called “How six states achieved near universal coverage” noted the success of covering at least 95% of their people. These six states are Hawaii, Iowa, Massachusetts, Minnesota, Rhode Island and Vermont. The District of Columbia also fits the bill. Per the article:

“A half-dozen states and the District of Columbia have health care insurance rates of over 95%, achieving near-universal coverage. Three researchers at the University of Pennsylvania — including Ezekiel Emanuel, a key architect of Obamacare — said Monday that the Affordable Care Act has everything to do with those results.

Here’s how the states achieved such high insurance rates, according to the authors:

Expanding Medicaid: States that expanded their Medicaid programs as allowed under the ACA had about half the uninsured rate (6.6%) in 2018 as states that did not do so (12.4%). ‘Nearly 5 million people would gain health insurance if the remaining 14 states expanded Medicaid,’ they write.

Extending enrollment periods: High-coverage states countered the Trump administration’s efforts to shorten enrollment periods and reduce informational assistance.

Lowering premiums: States enacted additional subsidies and reinsurance programs to keep premiums low, a crucial factor in maintaining insurance coverage from year to year.

Simplifying options: Some states limited the number of options available to counteract “choice overload,” which can reduce signups through consumer paralysis.

Maintaining individual mandates: Five low uninsured states maintain some kind of individual and employer mandates, which may help persuade healthy people to sign up.

The lesson, the authors say, is that near-universal health coverage can be achieved without national legislation. ‘While it is easy to dismiss the ACA and focus on the promise of Medicare for All, there is a more straightforward path to universal coverage,’ they write, ‘adopting a handful of relatively simple policies and programs at the state level can ensure health insurance coverage for nearly all Americans.’”

This article echoes what can be achievable if Medicaid is expanded and the other above steps are taken. The three states who drag the results down for the country – Texas, Florida and Georgia – did not expand Medicaid nor run their own Healthcare exchanges. Of the six states over 95%, it should be noted Iowa and Hawaii use the federal Healthcare Exchange, while the other four run their own exchanges.

I have long said Medicare for All is something to be explored, but it requires detailed analyses (and time) of its costs and impact. In the interim, I have strongly advocated improving the Affordable Care Act. The goal is access to care, in my view. The employment paradigm has been changing for some time, where fewer full-time workers are being used than before. We are seeing several industries move to a largely part-time workforce, such as in the retail, restaurant, and hospitality industries. We have seen contractual employment continue as well as the growth of gig economies. Health care access needs to come from somewhere.

What I do not care for is the hyper-politicization of this topic. Republicans (including the president) have actively sabotaged the Affordable Care Act, cutting funding to insurers, not mentioning the negative talk about it. It has still survived. Some Democrats choose to throw progress out and go full bore with Medicare for All. Again, that is a detailed undertaking and no candidate can accomplish this without buy-in from both parties.

So, let’s improve what we have. States who have not expanded Medicaid have been economically short-sighted and harmed their citizens. I have argued for repaying insurers who were harmed by the reneging on funding commitments, inviting them back into markets. Where choice is not available, introduce a Medicare option. I would also lower the eligibility for Medicare to age 60 or 62.

These are practical options that may move the needle upward like in those six states. Let’s talk about that.


10 thoughts on “Near universal health coverage achieved in six states and DC

  1. Hello Keith. I can see interim programs while Medicare For All is implemented. My problem with a state level healthcare programs is you end up with 50 different versions of healthcare. It locks people into certain states and away from others. If on vacation traveling between states will their own state health benefits be honored in a different state? What about people forced to move because of their employment, they may have a great healthcare plan in state A but being forced to state B would cause them to lose valuable coverage. I remember when Republicans argued to do the same thing with same sex marriage, let every state decided. That left us with people being married in one state and in the next one not married. Go across the state line for a night out and lose all your spousal rights. It was unworkable, we needed it to be a country wide federal right. Healthcare needs to also be country wide and federal. IMO. Hugs

    • Scottie, you raise a key point. One of the challenges of considering Medicare for All is the Healthcare Industrial Complex. Giving the level of money in politics, Medicare for All is a long uphill battle. I said this in 2009 by the way when Obama abandoned that path.

      This is why I believe shoring up the current system and expanding Medicare eligibility to a lower age such as 60 or 62 has merit. From an actuarial standpoint, such a move would lower the average age in the exchanges and Medicare, which would lower the average monthly premium rate in both.

      I think this could be a first step, which could be measured. It would also help when workers who are near retirement are let go. Medicare, unlike Medicaid, works pretty well, even though it could be improved. Medicaid depends on the state competency. Keith

    • Hugh, California has shown it can do certain measures more effectively than the federal government. See my response to Scottie regarding his legitimate concern. Keith

  2. You make good points and have good ideas. Giving up on ACA, which was working, despite needing a bit of tweaking, is like “throwing out the baby with the bathwater”. It is good to see some states take the initiative, but I don’t expect to see southern states do the same.

    • Jill, thanks. They are islands, but Arkansas and Kentucky have expanded Medicaid. Kentucky runs its own exchange called Ky-Nect, which many do not realize is Obamacare. Virginia just passed Medicaid expansion. Keith

  3. While I favor Medicare 4 All as the ultimate destination, I realize that getting there w/o too much bungling will be a long hard slog.  People will still get sick in the meantime, so shoring up the ACA is still vital.  Maybe advocacy of M4A will jolt some Republicans into being friendlier to the ACA in the hope of deflating the M4A balloon.

    One of the reasons I prefer Warren over Sanders in the Dem primary is that she seems more pragmatic.  It’s easier to imagine her accepting lower priority for M4A in exchange for other progressive wins that include a more robust ACA.

    • Mellow, I would appreciate Sanders and Warren saying you just did. Let’s evaluate Medicare for All, but shore up the ACA for now. I feel the Dems are throwing away an advantage – I love the Bloomberg commercial which places the blame on Trump and GOP for what they have done.


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