May 14, 2024 - Health

Health costs threaten to overshadow Biden's historic coverage gains

Illustration of a gold caduceus casting a dollar sign shadow

Illustration: Natalie Peeples/Axios

President Biden has come closer than any of his Democratic predecessors to reaching the party's long-standing goal of universal health coverage, but unaffordable care costs may overshadow the achievement.

Why it matters: Having health insurance by itself doesn't guarantee that care will be affordable, and voters feeling the pain of inflation are more concerned about their own health costs than whether everyone will have some level of coverage.

The big picture: The uninsured rate hit a record low of 7.7% briefly last year, though it's likely to tick up again as states continue to pare their Medicaid rolls after the pandemic.

  • Voters' most common health care priority by far is lowering out-of-pocket costs, KFF polling from earlier this year found.
  • "Certainly we have more people covered, whose concern has shifted from fear of being discriminated against [by insurers] to fear of not being able to access care affordably," said Democratic strategist Chris Jennings.
  • "Health reform efforts in the past have been largely framed around expanding insurance coverage," said KFF executive vice president Larry Levitt. "Whenever the next health reform debate comes, it will likely be focused on the cost burden, including for those with insurance."

Between the lines: Health care costs continued to rise after passage of the Affordable Care Act, albeit more slowly.

  • Employers attempted to contain costs by increasing deductibles and raising employees' out-of-pocket costs, though in recent years they've tried to limit how much cost they pass onto workers.
  • A Commonwealth Fund survey last year found that more than half of people who buy their own coverage on the ACA marketplaces or elsewhere said it was difficult to afford care.
  • The same survey found that 30% of adults with employer coverage were paying off debt from medical or dental care, as were a third of marketplace or individual market enrollees.

Findings like these help explain why the terms of the political conversation have shifted from coverage to affordability.

  • Concern about health care costs is layered over general stress about everyday expenses.
  • People have "always been concerned about health care costs, but the salience goes up when I can't pay for food and milk and gas and everything else," said Harvard professor emeritus Robert Blendon, an expert on public opinion and health care. "The temperature about this issue rises because they're having trouble paying their bills."

Yes, but: Health care is still a good political issue for Democrats.

  • One of Biden's biggest health care accomplishments was making ACA subsidies more generous for more people. Another was allowing Medicare to negotiate the price of certain drugs.
  • Protecting the ACA remains a powerful campaign promise, especially after former President Trump reignited the debate over repealing it.
  • Democrats this election cycle have emphasized policies aimed at making care more affordable, like capping insulin prices and extending ACA subsidies, over covering the remaining uninsured.

The bottom line: "We're always going to be [going] at the quality of health care and the cost," said Wendell Primus, a former adviser to House Speaker Nancy Pelosi who's now a visiting fellow at the Brooking Institution.

  • "Those issues are not going to go away. Even if we solve them temporarily, they're never going to go away."

Go deeper: The era of major U.S. health reform is over

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