By Jeff Goldsmith, Health Affairs Blog

After a summer of disappointing economic news, the recent Census report on the uninsured was a rare bit of sunshine.  The number of uninsured Americans declined by about 3 percent, or 1.34 million, to 48.6 million in 2011.  This was the largest one-year numerical decline in twelve years.  There were “only” about 1.7 million more uninsured in 2011 than there were in 2006, before the devastating recession.

Medicaid’s vital role.  The search for policy fingerprints on these findings points directly to Medicaid. For all the controversy over this program, the safety net did its job.  Medicaid enrollment rose another 4.4 percent in 2011, or 2.2 million people, likely masking continued shrinkage in private insurance coverage.   If Medicaid rolls had not expanded by 10 million folks from 2006 to 2011, the number of uninsured would have soared due to the recession.

Digging deeper into the Census numbers, one surprise was the relatively modest decline in the number of uninsured between the ages of 19 and 25, about 540,000, or about 40 percent of the overall drop. The reported reduction in the uncovered 19-25 year olds falls far short of the 3.1 million newly covered GenY’ers claimed by the Department of Health and Human Services due to the Affordable Care Act’s mandate to retain them on parents’ health policies.

A possible reason is that the Census survey was completed in March 2012, and may not have reflected the full effects of the ACA mandate, which affected policy renewals after October, 2010.   Since some employers changed their policies ahead of the deadline, some of the 2010 reduction of about 300,000 uninsured in this age group might have been due to the law.   Medicaid enrollment of the 19-25 year olds also grew by about 220,000 in 2011 according to Census estimates.    There nevertheless remains a huge gap between the 3.1 million coverage claim, which stretches over more than a single year, and the two years’ Census data we have so far on young adults’ coverage.

Breaking down the numbers by race and age.  All racial categories showed absolute declines in uninsured, except for Hispanics, where the number of uninsured rose fractionally to 15.8 million.  Even though the rate of uninsurance among Hispanics has fallen by four full percentage points since 2006, population growth kept the actual number of uninsured from falling along with the rest of the population.  Almost one-third of the uninsured in the US are of Hispanic descent.

Among age categories, gains in coverage were concentrated almost entirely among younger people.  People under age 25 accounted for half the decline, and those from 35-44 accounted for most of the rest.  In contrast, those just above the magic age of 26 saw a fractional increase over 2011, as did the boomers (age 45-64).

Of all the age categories, boomers’ health coverage fared the worst over the recession:  The number of uninsured boomers reached 13.4 million in 2011, a 25 percent increase over 2006 and a 33 percent increase over 2005!   All this despite the fact that the first wave of boomers entered Medicare in 2011.

The insurance status of the boomers continues to be largely invisible to the policy community, which seems to focus almost exclusively on the plight of younger people. It’s one thing being 24 and immortal and living in one’s parents’ basement and uninsured.   It is another thing entirely to be 52, freshly widowed and diabetic, and uninsured.

From a strategic standpoint,  the early onset and inadequate management  of chronic disease, the obesity epidemic, and the onrushing wave of diabetes among boomers are far more serious fiscal and public health threats than just about anything else on the horizon. A huge proportion of avoidable uncompensated care expense for hospitals is generated by uninsured boomers.

Losing sight of the centrality of coverage expansion.  It’s remarkable how little public attention has been paid during this dispiriting Presidential campaign to the core of health reform:  the coverage expansion. Other issues, like the individual mandate, coverage of contraceptives, equalizing women’s health premiums with men, and outlawing pre-existing conditions restrictions seem to have loomed larger.

The Supreme Court’s June decision on the ACA is looking more and more like a pyrrhic victory for coverage advocates.   Leaving the ACA’s Medicaid expansion “optional” for states could cut the projected coverage expansion by one-third, to little more than 20 million people, far short of universal coverage.  It’s like the news headline would have read:  “Al Qaeda Fails to Sink USS Cole”.  Even a twenty million person expansion is at risk in November’s election, since a Republican sweep would lead to the likely termination both of the insurance subsidies and the rest of the Medicaid expansion.

Republican silence on commitment to a health insurance coverage expansion has been deafening.  Republican plans post-ACA lean heavily upon a familiar and long-of-tooth collection of private insurance market reforms (expanding Health Savings Accounts, buying insurance across state lines, group purchasing of health insurance, high-risk pools, more “competition”, etc.).   It is not credible that these measures will meaningfully reduce the number of uninsured.  The Milliman Index for 2012 found that the all-in cost of private health insurance for a family of four is now almost $21,000 a year.  Significant overt public subsidy will be required to make a meaningful dent in the uninsured adult population.

The most significant impact on coverage from the Republican proposals is likely to come from converting Medicaid into block grants to states.  The clear intention of Medicaid block grants would be to permit states to restructure (e.g. shrink) their programs and reframe provider payment to fit within their budgets.  This restructuring would be “helped along” by an estimated 20 percent reduction in federal financial participation.  Rather than expanding in the next recession, block grants could end the “counter-cyclical” character of the Medicaid program.

The impact of delaying the ACA’s coverage expansion.  With the luminous glow of hindsight, it’s clear that postponing the ACA’s coverage expansion nearly four years was a terrible political mistake.  When Medicare was created, it took little more than a year to get the elderly their Medicare cards.   Perhaps given the arcane federal-state partnership in creating health exchanges (rather than a simpler federal exchange), the lengthy delay was unavoidable.

Paul Starr speculated in his recent book that the four-year delay was not merely contrived to make the program appear deficit neutral or better, or to buy time until the economy fully recovered.   It also reflected concerns that a more rapid coverage expansion could have been botched administratively, like the Medicare prescription drug benefit roll-out, blowing back on the Democrats in the 2012 election.  Even if the Democrats keep control over the White House and Congress, it’s far from clear that the 2014 expansion will be achievable on schedule.

Whatever the reason, the postponement of the coverage expansion deprived the 2012 political debate of the voices of tens of millions of grateful, newly covered people.  When the Medicaid expansion was dented by the Supreme Court, the loudest voices raised in protest seemed to be those of hospitals and nursing homes.  It’s not encouraging that the general public has centered its attention on the ACA’s increased federal regulatory role.  Even the Democrats seem disinclined to campaign on the equity and public health issues raised by having nearly 49 million uninsured Americans.

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