Most people, even me, talk about the reduction in the numbers of uninsured being the biggest impact of the ACA. But it’s important to remember that plenty of people are underinsured as well. That’s the focus of a recent paper published in JGIM, “Prevalence and Predictors of Underinsurance Among Low-Income Adults“:
BACKGROUND: Millions of adults will gain Medicaid or private insurance in 2014 under the Affordable Care Act, and prior research shows that underinsurance is common among middle-income adults. Less is known about underinsurance among low-income adults, particularly those with public insurance.
OBJECTIVE: To compare rates of underinsurance among low-income adults with private versus public insurance, and to identify predictors of being underinsured.
DESIGN: Descriptive and multivariate analysis of data from the 2005–2008 Medical Expenditure Panel Survey.
PARTICIPANTS: Adults 19–64 years of age with family income less than 125 % of the Federal Poverty Level (FPL) and full-year continuous coverage in one of four mutually exclusive insurance categories (N = 5,739): private insurance, Medicaid, Medicare, and combined Medicaid/Medicare coverage.
For the purposes of this study, underinsurance was defined as (1) having out-of-pocket expenses that were more than 5% of household income, (2) delaying or failing to get needed medical care because of cost, or (3) delaying or failing to get needed medications because of cost. This study specifically looked at adults who had full-year continuous coverage in some form, but had an income less than 125% of the poverty line. They speficially wanted to know how many of those people were still underinsured.
They found that more than a third of these adults were underinsured. What’s more is what kind of insurance left people underinsured. More than 65% of those people on Medicare were underinsured. More than 37% of people with private insurance were underinsured. But only 26% of people on Medicaid were underinsured. People who were underinsured were more likely to be White, in poor health, and unemployed. Even after adjusting for these factors, those on Medicaid were significantly less likely to be underinsured than those on private insurance (odds ratio 0.22).
The ACA could improve this in a number of ways. First, regulations for minimum coverage should make many of the private plans more robust. But more important is the Medicaid expansion. For all the flack Medicaid takes in the media, it should be apparent here that it’s much more comprehensive than many would have you believe. It certainly protects people from burdensome health care costs more than private insurance in this demographic. Let me be clear: These numbers are too high, period. It’s not good that even Medicaid, with its minimal cost sharing, resulted in more than a quarter of people being underinsured. That said, Medicaid still outperformed other options.
Remember this the next time that someone tells you that people will be “harmed” by getting Medicaid. Remember this the next time someone tells you that the poorest among us would be better off with cheap private insurance than Medicaid.