RUNNING HEAD: PERSISTENCE OF COVERAGE GAPS

Persistence of Coverage Gaps Despite ACA Provisions

Health Policy and Management
Renee Altimari
Providence College

RUNNING HEAD: PERSISTENCE OF COVERAGE GAPS

The Affordable Care Act (ACA) has made significant strides in reforming the
United States healthcare system. Millions of individuals previously uninsured have
acquired health insurance through the online exchanges, Medicaid expansion or through
employers. Interestingly enough, the coverage gap persists despite the implementation
and policies of the ACA. Millions of people continue to remain uninsured and are unable
to receive adequate and affordable healthcare. The ACA has expanded access to
healthcare insurance for some, not all, and neglected reforms relating to an expansion of
health care. Having health insurance does not guarantee an individual affordable and
adequate health care. The following factors have influenced the provisions and
implementation of the ACA: 1) political opposition and controversy, 2) complexity and
fragmentation of payment systems and 3) a focus on reorganizing the system for cost
reduction rather than care expansion. As a result, the United States government falls short
of guaranteeing affordable and adequate health care for all citizens.
In the United States, political polarization and controversy has surfaced
throughout history. Fox and Markel (2010) describe that the political sphere in the United
States includes interest and advocacy groups that often cloud implementation by voicing
their concerns for certain issues. Specifically relating to health reform, politics largely
influence the success or failure of laws. Public programs that have been implemented in
the past faced much opposition prior to successful adoption. Present day public programs
like Medicare, Medicaid, CHIP and Social Security remain widely contested by
politicians today, despite their acceptance by the majority. The article explains how
interest groups and ideologies can change and thus influence stances and opinions on

RUNNING HEAD: PERSISTENCE OF COVERAGE GAPS

programs over time. Upon writing provisions and laws for the ACA, the rich history of
political controversy in the United States is readily obvious.
In White (2010)s article, he discusses the history of the Democratic Party and
how U.S politics largely influenced provision writing. Since President Truman, the
Democratic Party has hoped to achieve universal coverage. In the 2008 election, the
Democratic stance was as follows:
Democrats are united around a commitment that every American man, woman
and child be guaranteed affordable, comprehensive healthcare (Democratic
National Convention Committee, 2008:9) (White 2010: 2).
Obama began working on health reform shortly after his election; however, the resulting
provisions of the ACA fell short of guaranteeing affordable and comprehensive care for
all (White 2010). White (2010) explains how the ACA was unavoidably caught in the
complex political sphere and began writing laws more favorable to Congress. For
example, the ACA began making provisions optional and states could accept or reject
them. For example, ACA provisions made Medicaid expansion optional for states and
allowed states to run their own exchanges if they desired.
Republican states opposed the ACA prior to and post implementation. Jones,
Bradley and Oberlander (2014), focus on the dilemma between Republicans and the
ACA. Republican states were unsure of how to approach the ACA once it passed in
congress. They could either act as if it didnt exist in hopes of altering its fate, or assume
that the law would remain with strict deadlines and act in accordance. The
unpredictability of political opposition was clear when Republican states chose to let the
government run their exchanges instead of opting to set them up themselves. 27 states

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chose to wait out the ACA and let the federal government run the states exchange.
Furthermore, many Republican states highly opposed expanded their Medicaid program
that would extend insurance coverage to low income individuals (Jones et al 2014). The
states who have denied Medicaid expansion are further widening the coverage gap in
their state. Thus, denying millions more the ability to receive Medicaid and its basic
healthcare benefits.
Much controversy and opposition surrounds the provisions of the ACA.
Republican leaders stalled the implementation of the ACA by claiming it
unconstitutional, and collaborating together to take a stance against it. Republicans will
continue to debate provision implementation in states (Jones et al 2014). Thus, the effects
of ACA provisions will differ depending on states political affiliation.
Brown (2012) clearly exemplifies the disconnect between policymakers and
political controversy:
The proper ends of health policy seem clear enough. Everyone should have
timely access to good-quality care at reasonable cost. But timely, good and
reasonable mean different things to different beholders and some insist that the
three cannot be optimized simultaneously (Brown 2012: 587).
It is clear that politics influence the success and failure of policy implementation,
and also influence whether or not individuals are able to receive health insurance.
Republicans and Democrats will continue to debate over what a healthcare system that
ensures timely access to good-quality care at reasonable cost will look like in the
United States. Therefore, Republicans will contest the Democratic view and ideology, in

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hopes of influencing and changing provisions to closely resemble the Republican

political view.
Unlike healthcare systems in other developed nations, the United States
healthcare system remains complex and fragmented. Okma (2011) describes how nations
in Europe contain universal health care systems to ensure that every citizen has access to
healthcare. These nations consider healthcare as a right, and that the government should
spend more on public policies to ensure these rights. When nations face economic turns,
they prioritize public policy funding and reject any cutbacks in the budget. Roemer
(1972) explains that in nations where individualistic ideologies are greater, and affluence
is of high value in societies, social insurance in medical care delivery tends to be less.
Nations containing one-payer systems improves coordination of care and reduces costs
(White 2010). Whereas, in the U.S, insurers compete in markets to control prices.
However, as discussed by Anderson, Reinhardt, Hussey & Petrosyan (2003), a multipayer system has led to less coordination of care and a payment system that incurs higher
administrative fees. Furthermore, Cox, Levitt, Claxton, Ma & Duddy-Tenbrunsel (2014)
mention that reliance on the market to control prices renders the insurance marketplace
vulnerable to changes within the market, and additionally leaves prices subject to the
composition of the risk pool.
While health insurance is made more affordable to low income individuals
through the ACA, White (2010) estimates that only 24 million people are expected to
obtain insurance through exchanges, and the Congressional Budget Office (CBO) states
that the coverage gap will only close by 60%. As a result, close to 23 million uninsured
individuals will remain uninsured. States that have chosen not to expand their Medicaid

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program may face a larger proportion of uninsured individuals in their state. Those who
opt to buy insurance through the exchanges must choose between four levels of coverage:
catastrophic, bronze, silver and gold, that vary in premium and deductible costs (White
2010). However, whether or not individuals can realistically afford the healthcare
insurance offered in the exchanges is influenced by many factors (Cox et al 2014).
Despite the availability of tax credits to cushion individuals from premium increases,
some individuals will face premium increases if they are enrolled in a low-cost plan that
ceases to exist and they fail to switch during an open enrollment period. (Cox et al 2014).
As a result, an individual could be without insurance or be required to pay a higher
monthly premium to keep the plan. While lower-cost plans are more attractive to lowincome individuals, these plans require higher out of pocket costs when receiving care.
Therefore, individuals may not be able to afford premium prices and out of pocket costs,
increasing the risk of loosing access to healthcare by forgoing appointments due to cost
(Cox et al 2014).
More importantly, Cox et al (2014) notes that poverty levels are continuing to
increase in the U.S, and someone with a comparable income in 2014 will be at a lower
percentage of the federal poverty level in 2015. As incomes remain stagnant, and
premiums and deductibles continue to rise, obtaining health insurance to receive care is
becoming less affordable for low-income individuals. Thus, individuals who lack the
financial means to obtain affordable healthcare insurance and adequate healthcare fall
into the coverage gap.
The majority of the ACA provisions are intended to restructure the healthcare
system for cost reduction rather than expand quality and affordable care. The complexity

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of health insurance discussed earlier outlines the difficulties individuals face when
purchasing coverage, and further alludes to how health insurance influences the kind of
care individuals receive with their insurance. Schoen, Hayes, Collins, Lippa & Radley
(2014) look at the insured but underinsured population in the U.S. Someone is considered
underinsured if they spend 10% or more of their income on medical care, not including
premiums. Higher out of pocket costs accompany lower-cost plans and influence whether
individuals are able to receive adequate and quality care. In 2012, the study found that
31.7% of individuals were insured but underinsured, and 16 million (50%) of these
individuals were considered to be in less than 100% poverty threshold (Schoen et al
2014). It is essential to prioritize the accessibility of health insurance that ensures
adequate health care, otherwise the underinsured population in the U.S will increase.
ACA provisions focused on reforming the delivery of care through models such as
Accountable Care Organizations (ACOs) are intended to lower costs and improve the
quality of care. However, as discussed in Lewis, Larson, McClurg, Boswell & Fisher
(2012), the formation of ACOs depends on whether health systems and communities have
the capability to do so. The care given in an ACO relies on the ability of the organization
to obtain and utilize resources to ensure high quality of care to patients. Vulnerable
populations, those of lower socioeconomic status living in low-income communities with
limited resources, may not be able to receive the same benefits from ACOs as those
individuals in wealthier areas. Whether ACOs have the ability to reach vulnerable
populations is a necessary concern for the future, however, the ACA provision that
incentivizes these programs, aims to achieve cost control and better coordination of care
for those individuals who are have health insurance. Uninsured individuals will not have

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access to ACOs and underinsured individuals living in areas of low socioeconomic status
may not have the opportunity to receive care from an ACO.
Another provision of the ACA involves incentivizing the use of Electronic Health
Records (EHRs) in the delivery of care to reduce and control administrative costs.
Galbraith (2013) states that roughly 27 billion dollars has been given through the ACA to
encourage healthcare offices to use EHRs. Similar to ACOs, EHR implementation is
more likely in affluent areas and communities where there is a larger pool of resources.
Furthermore, EHR effectiveness is dependent on whether it improves patient care. The
digital divide introduced by Galbraith (2013) implies that those of lower socioeconomic
status are least likely to access the Internet and to understand how this high-tech tool can
benefit their health. Terry (2013) estimates in his article that the cost for a full national
EHR system is 400 billion dollars. Overall, the initial purpose for incentivizing providers
to implement EHR technology is to reduce administrative costs for hospitals and offices.
This represents another aspect of ACA provisions aimed at reorganizing our healthcare
system to reduce costs, while disregarding the accessibility and quality of care for all
citizens.
There are many provisions in the ACA directly and indirectly influencing
employer-sponsored health insurance. Employers with 50 or more full-time workers are
required to offer health insurance or otherwise face a penalty (Jecker 1993). In order to
keep costs low, many employers are implementing wellness programs to encourage
employees to maintain their health. ACA has incentivized companies to utilize wellness
programs because of their potential balancing the composition of risk pools (Kirkland
2014). However, employer-sponsored insurance coupled with wellness programs is

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inherently biased in favor of individuals with better health and higher incomes (Jecker
1993; Kirkland 2014). Employer-based insurance leaves out the poor and unemployed
population that tends to have worse health outcomes than wealthier populations. Here,
employees with higher income receive higher benefits; while lower paid employees
receive lower benefits, further exacerbating health disparities (Jecker 1993).
The political opposition and controversy within the U.S, the complexity of a
multi-payer system, and provisions aimed to reorganize aspects of the healthcare system
to control cost rather than expand care accessibility, have collectively swayed the ACA
away from ensuring low cost and high quality healthcare to all. Throughout U.S history,
achieving universal health care coverage has been confronted with complex politics and
controversy to leverage health reform away from implementing a public system. While
the ACA made great strides in expanding the accessibility of health insurance, adequate,
high quality care was not ensured, and many provisions focused on developing care
models and technology to control health care spending. Further development of the ACA
provisions must be aimed to achieve sufficient and affordable health care for all
individuals.

References

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10

Anderson, G. F., Reinhardt, U. E., Hussey, P. S., & Petrosyan, V. (2003). Its the prices,
stupid: why the United States is so different from other countries. Health Affairs,
22(3), 89-105. Retrieved from:
http://content.healthaffairs.org/content/22/3/89.full.html
Brown, L. D. (2012). The fox and the grapes: is real reform beyond reach in the United
States?. Journal of health politics, policy and law, 1597439. Retrieved from:
http://jhppl.dukejournals.org/content/early/2012/03/30/03616878-1597439.short
Cox, C., Levitt, L., Claxton, G., Ma, R., Duddy-Tenbrunsel, R. (2014). Analysis of 2015
Premium Changes in the Affordable Care Acts Health Insurance Marketplaces.
Henry J. Kaiser Family Foundation, 1-22.
Retrieved from: http://kaiserfamilyfoundation.files.wordpress.com/2014/09/8627analysis-of-2015- premium-changes.pdf
Fox, D. M., & Markel, H. (2010). Is history relevant to implementing health reform?.
JAMA, 303(17), 1749-1750. Retrieved from:
http://jama.jamanetwork.com/article.aspx?articleid=185773
Galbraith, K. L. (2013). What's so meaningful about meaningful use?. Hastings Center
Report, 43(2), 15-17. Retrieved from:
http://onlinelibrary.wiley.com/doi/10.1002/hast.154/abstract;jsessionid=9A4C0D8
0B6191E753D7ADDDA078E5535.f02t03?
deniedAccessCustomisedMessage=&userIsAuthenticated=false
Jecker, N. S. (1993). Can an employer-based health insurance system be just?. Journal of
health politics, policy and law, 18(3), 657-673. Retrieved from:
http://jhppl.dukejournals.org/content/18/3/657.short

RUNNING HEAD: PERSISTENCE OF COVERAGE GAPS

11

Jones, D. K., Bradley, K. W., & Oberlander, J. (2014). Pascal's wager: health insurance
exchanges, Obamacare, and the Republican dilemma. Journal of health politics,
policy and law, 39(1), 97-137. Retrieved from:
http://jhppl.dukejournals.org/content/39/1/97.short
Okma, K. G. (2011). Obama's Health Reform in European Perspective. Journal of health
politics, policy and law, 36(3), 577-579. Retrieved from:
http://jhppl.dukejournals.org/content/36/3/577.short
Roemer, M. I. (1972). Social Insurance as Leverage for Changing Health Care Systems:
International Experience. Bulletin of the New York Academy of Medicine, 48(1),
93. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1806667/
Schoen, C., Hayes, S. L., Collins, S. R., Lippa, J. A., & Radley, D. C. (2014). Americas
underinsured: A state-by-state look at health insurance affordability prior to the new
coverage expansions. New York: The Commonwealth Fund, March. Retrieved from:
http://www.commonwealthfund.org/publications/fund-
reports/2014/mar/americas-underinsured
Terry, N. P. (2013). Meaningful adoption: What we know or think we know about the
financing, effectiveness, quality, and safety of electronic medical records. Journal
of Legal Medicine, 34(1), 7-42. Retrieved from: Meaningful adoption: What we
know or think we know about the financing, effectiveness, quality, and safety of
electronic medical records.
Kirkland, A. (2014). Critical Perspectives on Wellness. Journal of health politics, policy
and law, 39(5), 971-988. Retrieved from:
http://jhppl.dukejournals.org/content/39/5/971.short

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12

White, J. (2013). The 2010 US health care reform: approaching and avoiding how other
countries finance health care. Health Economics, Policy and Law, 8(03), 289-315.
Retrieved from: http://journals.cambridge.org/action/displayAbstract?
fromPage=online&aid=8937197&fileId=S1744133112000308