Health Shouldn’t Require Wealth: How ACA Increases Coverage of the Uninsured
By Judith M. Glassgold, PsyD (Assoc. Exec. Director, APA’s Public Interest Government Relations Office)
According to the US Census, almost 47 million Americans lacked insurance in 2012. Moreover, a 2012 survey by the Centers for Disease Control and Prevention found that 15 million of these individuals went without health insurance for three years, with about 10 million uninsured for their entire life. Over 40% of the uninsured interviewed identified cost as the reason they lacked insurance.
Without health insurance, millions of Americans find themselves unable to access quality and affordable healthcare, which creates health inequities – differences in health outcomes and their determinants between segments of the population, in this case inequities based on income. Related, substantial racial and ethnic health disparities present a very troubling picture. For example, among uninsured adults, people of color are more likely to be uninsured than Whites (27% vs. 15%), with Hispanics most frequently lacking coverage (33%). When people lack health insurance coverage, they seek out less care, increasing the potential of ill-health.
The Affordable Care Act aims to reduce the number of uninsured, both by providing subsidies for low-income Americans to buy health insurance in the new exchanges and by expanding Medicaid. Initial newspaper reports indicate about 2 million Americans enrolled in the new exchanges and about 4 million newly enrolled in Medicaid to date. Some estimates report closer to 9 million Americans newly insured as a result of the law.
Despite this progress, even more Americans may be eligible for coverage. A map produced by Kaiser Family Foundation (KFF) illustrates how many Americans qualify for Medicaid or for subsidies in every state and the District of Columbia (DC). However, a Supreme Court decision made the Medicaid expansion optional, and as a result, twenty-three states chose not to expand Medicaid at this time and lack any future plans for expansion. Unfortunately, the ACA presumed that Medicaid would be expanded in all 50 states and DC. This disqualified low income individuals in states that chose not to expand Medicaid from the subsidies called for under the law. Thus, millions of Americans now fall into a coverage gap, ineligible for both Medicaid and subsidies. These and other Americans still find health insurance beyond their reach due to cost.
This coverage gap disproportionately affects people of color creating a health access inequity. KFF found that 40% of uninsured Blacks with incomes low enough to qualify for the Medicaid expansion fall into the coverage gap, compared to 24% of uninsured Hispanics and 29% of uninsured Whites. These insurance coverage gaps exacerbate racial and ethnic disparities in access to health care and potentially worsen health outcomes. These state differences may also create new geographic disparities or worsen existing disparities, especially in the rural South and parts of the Midwest.
APA and the Public Interest (PI) Directorate and its various programs take the reduction of health disparities as a key focus. The PI-Government Relations Office (PI-GRO) continues to monitor the implementation of the ACA and advocate for policies that increase health equity and reduce health disparities, including insurance, particularly among already at-risk populations.
If you know of people who are uninsured and struggle to find healthcare, please share their stories. If you have experience addressing these issues or suggestions or just want to share your thoughts about these issues, please comment below.
Also, if you are uninsured or know someone who is, please note, there is a referral resource for the uninsured – the Patient Advocate Foundation.
The Public Interest Directorate is extremely pleased to welcome Judith M. Glassgold, PsyD, as associate executive director for Public Interest and director of Government Relations for Public Interest. Glassgold, a clinical psychologist, is quite familiar with APA and the Public Interest Directorate, as she was a Catherine Acuff APA Congressional Fellow (2009-2010), served as the chair of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation (2007-2009), and was member and chair of the Committee on Lesbian, Gay, Bisexual and Transgender Issues (1999-2002).
After Glassgold’s congressional fellowship she served as a senior policy advisor on Domestic Social Policy to Representative Sander Levin, chair and then ranking member of the Ways and Means Committee, working on the implementation of the Affordable Care Act and the extension of long-term unemployment benefits. Most recently, she worked for the Congressional Research Service, a legislative branch agency providing nonpartisan authoritative policy analysis exclusively to Congress, as a senior health policy analyst. At the CRS she focused on chronic health, health care delivery, health disparities and mental health.
Prior to coming to Washington, D.C., as a congressional fellow, Glassgold maintained an independent practice in New Jersey specializing in sexual orientation and women’s issues. She also was a contributing faculty member at the Graduate School of Applied and Professional Psychology at Rutgers University, where she maintained an affiliation for 20 years teaching courses on diverse populations, women’s and gender issues, community psychology and psychoanalysis while supervising student training. Glassgold’s scholarly work includes numerous publications and presentations on psychotherapy with LGBT populations and women, including new affirmative approaches to treatment.
Glassgold has had a long involvement with organized psychology and with APA. She served as president of Div. 44, the Society for Psychological Study of Lesbian, Gay, Bisexual and Transgender Issues (2004) and was in leadership positions in her state psychological associations, serving as president of the New Jersey Psychological Association (2008), member and chair of the Ethics Committee, and founding member of the Task Force on Lesbian, Gay and Bisexual Concerns.
 Health equity focuses on reducing inequalities associated with social disadvantage and discrimination that lead to health disparities. Health inequalities are by definition ethically suspect. CDC Health disparities and inequalities report – United States, 2011. Morbidity and Mortality Weekly Report, 60 Supplement, 1-113.
 Kaiser Family Foundation, 2013. The impact of the coverage gap in states not expanding Medicaid by race and ethnicity [Issue brief]. Retrieved from http://kff.org/disparities-policy/issue-brief/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/.
 Kaiser Family Foundation (2013). Interactive: A state-by-state look at how the uninsured fare in the ACA [Interactive graph]. Retrieved from http://kff.org/state-profiles-uninsured-under-aca/?utm_campaign=KFF%253A%2520General&utm_source=hs_email&utm_medium=email&utm_content=11550261&_hsenc=p2ANqtz-9ZUI_VATmGQiUXCiV1bk-5HdNFqlTSyiE9lj9_wuHiTNXauAZiEdGLg-k-w0SOX8eAWc85zh2n8RMBvIDNzM-hhzQikw&_hsmi=11550261.
 The Medicaid program in Puerto Rico and territories is governed by complex rules.