THE BLOG
07/17/2014 01:22 pm ET Updated Sep 16, 2014

Surveys Show ACA Working, Popular With Enrollees (And Still No 'Alternative')

New survey and poll results show that the number of uninsured Americans has dropped to its lowest level since 2008.

Gallup Well-Being, the Commonwealth Fund and Kaiser Family Foundation released poll and survey information last week, and it gives us a picture of how the ACA is meeting its goals of insuring more Americans and providing greater access to health care. And while overall public opinion is still mixed, the Affordable Care Act appears to be rather popular among those who are newly covered, even among Republicans.

According to the Gallup survey, the total number of uninsured Americans has dropped from a high of 18 percent in 2013 to a low of 13.4 percent in 2014. Over that time, the number of uninsured adults (age 19-64) dropped by 9.5 million, the Commonwealth Fund found. The biggest increase in the number of insured (28 percent) was among young adults (19-34). That means about 5.7 million more young adults have insurance coverage now than did in 2013.

New enrollments in Medicaid have reached 6.7 million people since the program was expanded. In May alone, the last month for which data was available, enrollment increased by 920,000 across the U.S.

By the end of the ACA's first open-enrollment period, another 8 million Americans had signed up for private insurance through federal and state insurance exchanges. And incidentally, while final numbers from private insurers are not in, the vast majority of those policyholders appear to have paid for their coverage.

As of last month, 60 percent of newly insured adults (either through private insurance or Medicaid) reported that they had visited a doctor or hospital or filled a prescription. Of that number, 62 percent indicated that they could not have previously accessed or afforded that care.

While national polls show that a plurality of Americans still have an unfavorable opinion of the ACA, that is not reflected in the opinions of the newly insured.

According to the latest Kaiser Health Tracking Poll, about 45 percent of Americans still have an unfavorable view of the law (down from 50 percent in January). However, according to the Commonwealth Fund, 58 percent of Americans newly enrolled in Medicaid or private insurance say that they are better off now than they were before the law. Among the newly insured, 78 percent are satisfied to very satisfied with their coverage, including 74 percent of those who identify themselves as Republicans. Sixty percent of the newly covered have already started to use their new insurance, and most enrollees said they could get an appointment within two weeks.

There also is evidence that more private insurance companies want to offer coverage in the exchanges. In the 10 states for which data is available, at least 27 new carriers indicated that they will offer coverage in 2015. None of the carriers in those states has dropped out of the exchanges and many have plans to expand the number of policies they will offer next year. All of which suggests an increase in private-market competition.

Yet none of this seems to have quieted opposition to the Affordable Care Act. Part of the opposition stems from the law's reliance upon Medicaid.

Opponents claim that Medicaid is a wasteful and broken system that will ultimately lead to worse health options for Americans. Even though Medicaid is far from perfect, the highest satisfaction rates in the Commonwealth Fund survey came from new Medicaid enrollees. Almost 84 percent of those enrollees report being satisfied with their new coverage and 67 percent considered themselves better off than before.

But if Medicaid is a "broken system," then what are the alternatives offered by the opposition?

One is to simply opt out of the Medicaid expansion. No fewer than 21 states have refused to expand, and three are still debating whether to opt in. That has left nearly 5 million Americans under the federal poverty line uninsured and with no real options for access to health care.

Five states are looking at alternatives to Medicaid. Two of them, Arkansas and Iowa, have been approved by the administration for waivers that would allow federal money to be used to buy private insurance through the insurance exchanges.

The question is whether these experiments will be competitive with Medicaid's costs and coverage. Private coverage is almost always more expensive than traditional Medicaid, and as a result, subsidy assistance is likely to cost these states more. Milliman, an actuarial consulting firm, estimated that premium-assistance programs for private insurance could cost states 20 to 40 percent more than traditional Medicaid.

Another approach is a fundamental change in federal funding for state Medicaid programs. Known as a "state block grant," this alternative would lower and cap federal spending on Medicaid in exchange for reducing federal regulations over how money is spent. The ideological assumption is that states can manage these programs more efficiently if there was less federal oversight. Under this theory, we would not spend as much money on the program.

The so-called "Ryan" budget passed repeatedly by the U.S. House of Representatives includes a Medicaid state block grant. According to the Congressional Budget Office, under the first Ryan budget, federal spending for Medicaid would be 35 percent lower in 2022 and 49 percent lower in 2030 than currently projected. Given the opposition's main complaint that Medicaid is already financially unsustainable, is it reasonable to assume that more state oversight would compensate for the loss of hundreds of billions of dollars in federal spending?

Congressional Republicans have also authored multiple legislative alternatives to the ACA, but they still refuse to bring any of them to the floor for a vote. And each proposal has significant issues and limitations.

Time may be running out. With growing evidence that the ACA is succeeding in expanding health insurance coverage and access to health care, any alternative faces a higher and higher hill to climb. At one time, ideological pronouncements and empty talk of legislation worked in the abstract, but now we need real-world solutions that build on the gains we've made.