The number of adults living in the United States without health coverage increased by more than half a million during President Trump’s first year in office, after steadily declining since the Affordable Care Act (ACA) passed in 2010 and began expanding health coverage for millions of people, according to data released Monday by the Kaiser Family Foundation.

Trump has promised to “blow up” the ACA and his administration has worked to weaken certain key provisions ever since Republicans in Congress failed to repeal and replace the health care law early 2017. The administration also drastically cut funding for and access to outreach programs that help people enroll in the ACA health coverage marketplace.

The number of uninsured adults under the age of 65 declined dramatically from 44 million in 2013 to just below 27 million in 2016, as ACA provisions expanding Medicaid and offering subsidized insurance plans for people with lower incomes went into effect, according to the Kaiser report. In the first year after Trump took office in 2017, the number of adults living without health coverage increased by nearly 700,000, when about 10 percent of US residents reported living without health insurance.

Multiple factors contributed to this steep decline in coverage. First, 13 of the 18 states with the highest rates of uninsured adults in 2017 had refused the ACA’s expansion of Medicaid, the public insurance program for people with lower incomes. Economic conditions and the availability of employer-sponsored health coverage also play a role in coverage rates, according to the Kaiser report.

Elizabeth Lower-Basch, director of income and work supports at the Center for Law and Social Policy, said non-expansion states could be experiencing a “ripple effect,” where higher numbers of uninsured people weaken ACA marketplace insurance pools and raise health care costs.

However, the Trump administration’s efforts to undermine the ACA could further widen the coverage gap.

“The Trump administration is doing a lot to make it harder for people to get and keep insurance,” Lower-Basch said in an interview. “Whether that is underfunding the navigators and advertisers for the [ACA] open enrollment seasons, or approving work requirements and waivers, and certainly the ‘public charge’ proposal, all of them will drive insurance coverage rates down.”

Work Requirements Could Increase Coverage Gap

Consider Arkansas, where the Trump administration approved a waiver allowing state officials to require that nonelderly adults without disabilities prove that they are employed a certain number of hours a month, in order to receive Medicaid benefits. About 12,000 low-income people lost their coverage after the waiver went into effect this summer, leading observers to declare the work requirement experiment a “scandal” and a “disaster.”

Adrian McGonigal, a plaintiff in a federal lawsuit against Medicaid work requirements in Arkansas, lost his job due to medical problems after he was unable to navigate red tape and prove his employment status to the state. The Urban Institute found that 25 percent of enrollees subject to work requirements in Arkansas are employed but do not have an internet connection at home, making it difficult to meet the state’s online reporting requirements — or know about them in the first place.

Fourteen other states have also applied for waivers to place work requirements on Medicaid enrollees, and legal challenges have been filed across the country. In Kentucky, a federal judge blocked work requirements from taking effect as legal challenges wind through the courts.

As Truthout has reported, most people enrolled in Medicaid who can work do have jobs, but their employers do not offer them medical benefits or pay them enough to afford their own insurance.

Even under the ACA, many people cannot afford health insurance, and many of those are unaware that they qualify for Medicaid or a subsidized ACA plan. Kaiser reports that 45 percent of adults said they were uninsured in 2017 because the cost of buying a health plan was too high. Most people without health coverage live in low-income households where at least one family member is working, according to Kaiser.

It’s no secret that navigating the health insurance bureaucracy can be difficult and time consuming, regardless of whether your coverage is public or private. Unfortunately for those seeking coverage under the ACA, the Trump administration has reduced funding for educational outreach and “navigator” services that help people sign up for coverage in the ACA marketplace from $63 million to $10 million since taking office, according to Fierce Healthcare.

Critics say it’s all part of a clear strategy to sabotage a major achievement of the Obama administration that Republicans have rallied against for years.

A Crackdown on Health Care for Immigrants

Strikingly, Kaiser found that a quarter of all uninsured people in 2017 were immigrants. The Trump administration’s “public charge” proposal, which would punish green card and visa applicants who qualify for public assistance such as Medicaid, could result in more working families going without health coverage. (Undocumented immigrants already are not eligible for Medicaid and ACA plans, and legal residents can only access Medicaid after living in the US for five years.)

Coupled with Trump’s harsh anti-immigrant rhetoric and the administration’s broad law enforcement crackdown on immigrant communities, Lower-Basch said the proposed public charge rule could have a “chilling effect” that dissuades immigrant families from accessing Medicaid and other services they are eligible for by simply being in the headlines, even if the administration never finalizes the rule itself.

“It’s incredibly counterproductive, because insurance keeps people both healthier and economically more secure, and lets both parents and children thrive,” Lower-Basch said. “When parents become uninsured, it hurts the kids, too; all of us are worse off when this happens.”

Last month, Georgetown University reported an uptick in the number of children without health coverage in 2017, after rates of uninsured minors hit a historic low in 2016. An estimated 3.9 million children under the age of 19 went without health coverage last year, despite programs like Medicaid and CHIP that are designed to ensure minors can access health care.

Researchers attributed the change to Republican attempts to undermine the ACA, along with harsh Trump administration policies targeting immigrant communities, which can deter immigrant parents from signing for programs like Medicaid and CHIP. One quarter of all children living in the US has at least one parent who is an immigrant, according to the Georgetown report.

After signing legislation eliminating the ACA’s tax penalty for uninsured adults, which could encourage more young and healthy people to go without coverage in 2018, the Trump administration has attempted to boost insurance coverage rates by eliminating regulations and allowing insurers to sell short-term plans with limited benefits that were outlawed by the ACA. Critics call them “junk plans,” but the administration wants to push premium prices down by giving consumers more choices and increasing market competition.

However, recent polling has found that up to 70 percent of people in the US would prefer a single-payer, Medicare for All insurance system where the government guarantees health coverage for everyone. Progressives are expected to push such proposals in Congress when the Democrats take control of the House next year.

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