Democrats worry that affordability challenges could worsen under Republican plans to repeal and replace the 2010 law.

Nov. 28—Six years after enactment of the Affordable Care Act (ACA), the share of U.S. adults reporting cost-related barriers to health care has not improved, according to a recent survey.

Thirty-three percent of U.S. adults said they did not fill a prescription, see a doctor when sick, or get recommended care because of the cost, according to the latest Commonwealth Fund survey of adults in the United States and 10 other high-income countries. That rate was unchanged from the same survey in 2010.

The share going without care slightly worsened to 37 percent in 2014 before returning to the 2010 level.

The results run counter to data from the Obama administration, which has credited the ACA with extending insurance coverage to 20 million people. For instance, a survey-based report from the Centers for Disease Control and Prevention found the share of all residents who “failed to get needed medical care because of costs” declined from 2010 to 2015 (the rate was unchanged from 2015 to 2016).

However, other data sources reinforced the Commonwealth findings. For instance, an annual Gallup survey reported the share of respondents who said they “put off medical treatment due to cost” increased from 30 percent in 2010 to 31 percent in 2015, the most recent year for which data were available.

Ongoing Challenge

The data indicate the ongoing affordability challenges faced by Americans. As Craig Hodges, CEO of Care Payment, noted earlier this year in testimony submitted to Congress, although nearly 90 percent of Americans now have insurance, “many of them still cannot afford to use it.”

The consequences of the affordability challenge were highlighted in a New York Times/Kaiser Family Foundation study earlier this year that found 20 percent of Americans with health insurance face problems dealing with medical debt.

Factors impacting affordability, according to some observers, may include issues with the ACA marketplaces, which were intended to improve access to care. Specifically, Hodges noted that 80 percent of ACA marketplace enrollees chose silver or bronze plans, which in 2015 had average individual deductibles of $5,731 and family deductibles of $11,601.

Some have tied such costs to the fact that 5.6 million tax filers opted to incur individual mandate penalties that averaged $442 instead of buying qualifying insurance in 2015. Additionally, more than 12 million taxpayers in 2015 claimed one or more coverage exemptions that allowed them to remain uninsured without facing penalties.

Shortcomings in the promise of the ACA to close the affordability gap were seen in other recent research, such as a recent study that found that—contrary to expectations—the ACA did not lead newly insured patients to stop using federal community health centers (CHCs), which provide care for the indigent. CHCs in California and New York, which embraced all ACA coverage options, subsequently saw sometimes-large increases in use by insured patients.

But affordability problems also grew in employer-sponsored insurance, which has shifted growing shares of costs onto workers in recent years. In 2015, 24 percent of all workers were enrolled in high-deductible health plans (HDHPs) with a savings option, compared to a share of 8 percent in HDHPs in 2009, according to the Kaiser Family Foundation’s 2015 Employer Health Benefits Survey.

Some have questioned whether that employer cost shift trend will continue or level off amid an increasingly tight labor market. Specifically, Matthew Borsch, a healthcare equity research analyst for Goldman Sachs, said at a Nov. 15 event that advisers for mid-sized-companies especially felt labor market pressure to avoid shifting more costs onto workers. Another factor that could help relieve pressure to shift to HDHPs is the expected end of the ACA’s so-called Cadillac tax on high-cost employer-sponsored health plans, said Ana Gupte, managing director and senior analyst, healthcare services, for Leerink Partners. Congress has delayed the tax and is widely expected to scrap it as part of an ACA repeal-and-replace plan.

Political Role

Those affordability concerns may have played a role in the recent election, in which the most important healthcare issue to voters was the costs of care, health insurance, and drugs, according to a recent poll by the Kaiser Family Foundation. President-elect Donald Trump and the Republican-led incoming Congress have promised to repeal and replace the ACA.

But it remains unknown whether a new plan will improve the affordability of and access to healthcare services and treatments.

“I’m just saying the president-elect has a vision of covering every American in an affordable way and helping reduce deductibles,” Chris Jennings, a former healthcare adviser to President Barack Obama, said at a recent Washington, D.C., briefing. “If that’s his vision, I think a lot of Democrats would like to work with him to that end. If it’s reducing coverage for 20 million Americans and increasing premiums for millions more, then they’re going to be very, I think, unified against, particularly if there's not an alternative at the time of repeal.”

Among specific Democratic concerns is the emphasis in Trump’s proposals on health savings accounts (HSAs), which together with HDHPs increasingly have been used by employers to control healthcare costs. Republicans pitched HSAs as particularly appealing to healthy young adults, whom the Obama administration was never able to lure to ACA plans in the numbers needed to stabilize those plans. But Democrats worry that HSAs and other Republican policies are insufficient to improve affordability among low-income people and could simply spike the number of uninsured.

Not all see such an outcome from repeal-and-replace.

“I do not believe the president-elect, I do not believe Congress is going to do something that fundamentally takes back insurance coverage for these 20 million individuals and doesn’t provide them or approximately that number with some type of coverage—not necessarily exactly the same number, certainly not exactly the same coverage, but with some kind of coverage,” said Gail Wilensky, a former administrator for Medicare and Medicaid. “It’s just not going to happen.”

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, November 29, 2016