The debate over the future of the Affordable Care Act, also known as Obamacare, is a hot topic in Washington. At the same time, hundreds of thousands of Central Valley residents have found insurance under the law. With the Republican replacement plan still very much a mystery, Valley Public Radio decided to take a look back at the raw data to see what has changed in the Central Valley.
Before the law’s insurance coverage expansion provisions took effect in the fall of 2013, all five of the Central Valley counties from Merced to Kern had uninsured rates of around 25%.
That means one in four residents lacked either private insurance, employer-sponsored coverage, or government health insurance through Medicare or Medi-Cal.
So how many people have gained insurance in the ensuing three years?
“We cut it in half. We cut the number of uninsured in half,” says John Capitman with the Central Valley Health Policy Institute.
He says the bulk of the decline came from enrollments in Medi-Cal, the government health insurance program for the area’s poorest residents.
The law allowed single childless adults to enroll. They had previously been excluded. According to the law, essentially anyone making less than about $16,000 a year per individual can now sign up.
All told, according to data from the state, the entire valley saw at least an additional 432,000 residents enroll in Medi-Cal. That is almost entirely due to the law’s Medi-Cal expansion, of which the federal government currently is paying 95% of the bill.
Capitman says that translates into roughly $2-billion a year in additional health care spending.
“That is a lot of money. And it may be more because we have had more of the Medicaid expansion here relatively to other places there are more people that fit in the category. And our health care system was relatively less richly funded so that money made more of a difference,” Capitman says.
Also, according to data from Covered California, which runs the state’s insurance exchange, another 67,000 people enrolled in subsidized private insurance. You might have expected that number to be higher, but experts say this is all about the valley’s income distribution. There were a lot of poor people but relatively few previously uninsured middle-income people who met the exchange’s earnings guidelines for subsidized insurance.
Linda Duchene, the deputy director for Medi-Cal in Fresno County, says enrollment exceeded their expectations.
“The take away is that we had a population here in Fresno County, that we couldn’t even fathom the number of people who needed health insurance that weren’t already accessing it,” Duchene says.
Duchene says they add to add additional staff to handle the increased case load. Duchene says other additions deep in the law have helped cover more people as well, notably an automatic enrollment provision for uninsured people who visit the hospital.
Job growth appears to be true across the valley’s health care industry. A new study by the UC Berkeley Center for Labor Research and Education estimates that the law saw the valley health care industry add 17,000 jobs over the last three years. Researchers say even with the recovery from the Great Recession, only the ACA could account for such a specific jump in employment in one industry.
There are also some factors in the law that are somewhat harder to measure but are frequently cited as downsides.
Primarily, the requirement that employers with more than then 50 employees provide insurance to any worker who works more than 30 hours a week. The law determined that mark to be ‘full time’.
Business advocates, especially for small businesses, argue that this requirement is an expensive burden that harmed economic growth.
They say that businesses cut schedules to keep employees under the 30-hour threshold, mostly for part-time employees who are the most economically vulnerable. Others suggest that they stopped hiring to stay under 50 employees and avoid the expensive employer match that is required when offering insurance to an employee.
It is likely true that some businesses took these steps or struggled to make the balance sheet work when required to offer insurance. However, this is difficult to measure in raw data, since it would be proving a negative of ‘jobs not created’ due to the law.
There is also the matter of more people attempting to visit the doctor when the San Joaquin Valley had a doctor shortage that long predated the ACA’s coverage expansion.
Michelle Quiogue with California Academy of Family Physicians says it’s like the state added more parking permits but not anymore more parking spaces.
“So what you have are patients with an insurance card but they don’t have access to get the right care at the right time all the time. I think you have seen a rise in emergency room visits because that primary care relationship, that promise hasn’t been delivered,” Quiogue says.
It is true that emergency room visits have increased, which goes against the pre-passage prediction by supporters that ER visits would decline after the law’s implementation.
Additionally, the state of California reduced Medi-Cal payments in the midst of the recession that coincided with Medi-Cal expansion. Lower payments do little to encourage doctors to take on new low-income patients, since state reimbursements often don’t cover the full expense of care.
The San Joaquin Valley also has a high percentage of undocumented adults who remain locked out of coverage expansion entirely.
All these raw numbers also leave out the impact of other provisions in the law, among them, the removal of life benefit caps, requiring insurance companies to cover people with pre-existing conditions, and the great simplification in shopping and comparing insurance plans.
Whatever the congressional Republicans decide to propose as a replacement, the numbers piled up by the ACA over the last three years will most likely be the benchmark many people will use when deciding if it was a change for the better or the worse.