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For years, the percentage of Americans without health insurance remained in a narrow range.
For example, the uninsured rate in the five-year period ending in 2012 stayed within about 1.5 percentage points, hitting a high of 16.7% in 2009 and a low of 15.4% in 2012 and 2010.
That relative stability ended in 2014 when the uninsured rate fell, according to the Census Bureau, to an all-time low: 10.4%.
The widely acknowledged reason for the plunge: key provisions of the 2010 health care reform law — including rich federal premium subsidies for the lower-income uninsured to buy coverage in public exchanges and an expansion of Medicaid eligibility — took effect.
But if the Patient Protection and Affordable Care Act were repealed — which a majority of congressional Republicans have voted for numerous times and is supported by Donald Trump, the presumptive GOP presidential candidate — the uninsured rate would soar, according to a report released earlier this week.
According to an analysis by the Washington-based Urban Institute, the uninsured rate would leap to 19.4% by 2021 if the ACA were repealed, a whopping 81% increase compared with the projected 10.7% rate if the ACA remains. In all, 53.5 million Americans would be uninsured, compared with 29.6 million if the law stays.
The biggest drop in coverage would be within the nation's lower-income population. For example, enrollment in the Medicaid program would fall to 54.8 million in 2021, down from a projected 69.3 million, according to the study, which was partly funded by the Princeton, New Jersey-based Robert Wood Johnson Foundation.
That drop would be the result of the end of an ACA provision in which the federal government heavily subsidizes states that expand Medicaid eligibility to those earning up to 138% of the federal poverty level — or $33,534 for a family of four — up from the prior 100% of the federal poverty level limit of $24,300 for a family of four. About 30 states have accepted the federal subsidies by boosting income limits for Medicaid recipients.
In addition, 11.5 million people would have nongroup health coverage in 2021, 8.8 million fewer people than the projected 20.3 million with such coverage if the ACA were not repealed. That big reduction would be triggered by the loss of rich federal ACA premium subsidies available for the lower-income uninsured — those with incomes between 100% and 400% of the federal poverty level — to purchase coverage in public health insurance exchanges. For example, subsidies are available in 2016 for a family of four collectively earning up to $97,000.
If the law were to be repealed, “we would be back to the bad old days in terms of the uninsured rate,” said Kathy Hempstead, senior adviser for health care with the Robert Wood Johnson Foundation.
While there is widespread agreement that the ACA deserves credit for the large reduction in the uninsured rate, there are big problems with the law, especially the public exchanges.
“The stability of the health exchanges leaves us in doubt as some insurers who have lost massive amounts of money” are pulling out, said James Gelfand, senior vice president of health policy at the ERISA Industry Committee in Washington.
For example, citing huge losses, UnitedHealth Group Inc. disclosed earlier this month that it intends next year to exit public exchanges in all but a handful of states.
Mr. Gelfand said a big problem facing insurers writing coverage in the exchanges is one of adverse selection in which individuals opting for coverage are those most likely to have costly medical problems.
A stream of health insurer lawsuits over the government's failure to make promised risk corridor payments under the health care reform law faces an outcome that is far from certain.