There is a difference between access to health coverage vs. access to health care. More than 99% of Americans have access to health coverage. That is regardless of their income or medical condition. That’s what last month’s census report told us.
The overwhelming majority of those lacking insurance could have obtained coverage but did not enroll. Why is that?
Let’s figure out what is needed
At this point; why have those pushing mandatory health insurance not figured this out? Many of those with lower incomes did not sign up. They know they can receive care at little or no cost to themselves even if they remain uninsured. They arrive at a clinic then sign up. Those in the top two income quintiles remain largely uninsured too. They find government intervention in health insurance markets has created a menu of unattractive products. Worse yet the unattractive products have even less attractive prices.
The system does not work for the poor or the wealthy. The message from that result is that those designing the system did not actually care about covering everyone. What they actually cared about was control over the dollars spent in the healthcare sector of the economy. This was and is an expansion of government control to one-fifth of our lives.
Don’t Americans across the income spectrum deserve a better approach to health care? Policymakers do not apparently understand the distinction between lack of healthcare and lack of access to coverage.
A Kaiser Family Foundation analysis of last year’s Census Bureau report found an estimated 27.4 million non-elderly people who were uninsured in 2017:
. Six million, eight hundred thousand (25%) were eligible for Medicaid or the Children’s Health Insurance Program, but not enrolled.
. 30% or 8.2 million were eligible for Obamacare subsidies but did not enroll.
. 3.8 million (14%) declined an offer of employer-sponsored coverage.
. 7% or 1.9 million were not eligible for subsidies because they had income more than four times the federal poverty threshold, which put them in the top two income quintiles.
. 4.1 million (15%) were ineligible for subsidies because they were not lawful U.S. residents. Their situation is a matter to be settled by immigration policy, not health care policy.
• 2.5 million (9%) were under the poverty line but ineligible for federal assistance. They represented just 0.7% of the population.
These 2.5 million lawful U.S. residents ineligible for federal assistance lived in states without expanded Medicaid eligibility to non-elderly, non-disabled adults with incomes up to 138% of the federal poverty level. They are eligible for free care at 3,000 federally-funded health centers in the non-expansion states and 11,000 nationwide. All public and nonprofit hospitals are required to have programs to provide free or low-cost care to low-income patients. These hospitals can enroll low-income people in Medicaid when they show up for care. This is a reason some Medicaid-eligible people wait until they need to see a doctor to sign up for their free coverage.
Access to coverage vs. access to care
It is important to draw a second crucial distinction: between access to coverage and access to care. The federal government has not done a good job of covering those who are eligible for assistance. Heritage Foundation found that while 8.2 million people claimed Obamacare subsidies in 2017. An additional 8.2 million people who were eligible for those subsidies remained uninsured. That means that only half the people eligible for subsidies claimed them. The heavily regulated individual policies are unattractive to millions of people, even at steeply discounted prices.
Things are even worse among the unsubsidized, who have dropped individual coverage at an alarming rate. Between 2015 and 2018, the number of unsubsidized people with individual coverage fell by half, from 7.9 million to 3.9 million. Millions remain uninsured. That isn’t because the federal government is doing too little. Rather, it is because the federal government is spending a lot and doing it badly.
Advocates of expanding government control of health care take the Census Bureau’s estimate of the number of uninsured out of context. They use it as a call for the government to do more. That is not what the numbers tell us. Some advocate government takeover of health care financing, as in “Medicare for All.” Others seek further expansions of Medicare, Medicaid, and Obamacare subsidies. Still, others will call for the creation of a “public option,” a government-run insurance company that “competes” with private insurers. These are all line extensions of an already-failing approach.
A different approach
A different approach is needed, one rooted in a better understanding of the problem. Working together, dozens of health care analysts and policy leaders have developed such an approach. The Health Care Choices Proposal would convert the $1.6 trillion in Obamacare entitlement spending into grants to states. States would use these fixed allotments to establish consumer-centered programs that make health insurance affordable regardless of income or medical condition.
This approach would: expand health savings accounts. They help people save tax-free for routine medical expenses. It would write into law Trump administration regulations that expand consumer choices. The approach also addresses high medical costs through choice and competition. It would require states to establish programs that concentrate public resources on people with pre-existing medical conditions. In states that have obtained federal waivers to establish such programs, people have seen substantial premium reductions.
The proposal would enhance health care choices for all Americans, including those with low incomes. And it would reduce premiums for individual policies by up to one-third. The Health Care Choices Proposal represents a commonsense approach to solving a poorly understood uninsured problem. There is a difference between access to health coverage vs. access to health care.