This has happened despite the fact that the Trump administration has tried to sabotage health care expansion. The administration has cut the insurance exchange open enrollment period by 50 percent, reduced advertising and navigators to help people buy insurance by nearly 90 percent, added requirements to Medicaid to discourage enrollment, and authorized “skinny” insurance options with bare-bones coverage designed to lure healthy enrollees away from comprehensive plans in the ACA insurance pools.

The Census Bureau’s American Community Survey, which calculates average national and state-level uninsured rates over the course of the year, reports that Trump has succeeded in increasing the number of uninsured. In 2013, just before the ACA exchanges and Medicaid expansion went into effect, the uninsured rate was 14.5 percent. It dropped to a low of 8.6 percent in 2016. Despite a booming economy and record low unemployment, the Trump administration increased the uninsured rate to 9 percent in 2018.

But the trend is not uniform across the country. Some Republican-controlled states have especially high uninsured rates. Texas has an uninsured rate of 17.7 percent, with a fifth of the nation’s uninsured children. Georgia’s uninsured rate is 13.7 percent, and Florida’s is 13 percent. Together, just these three states account for roughly a third of all uninsured Americans.

Countering these failing states are Hawaii, Iowa, Massachusetts, Minnesota, Rhode Island, Vermont and D.C., which, using the tools provided in the ACA, have all achieved coverage rates over 95 percent and as high as 98 percent.

How? There are five very feasible policies that can get the U.S. to near-universal coverage.

First, Medicaid expansion. In 2018, the uninsured rate was 6.6 percent in expansion states, but nearly double, 12.4 percent, in non-expansion states. Nearly 5 million people would gain health insurance if the remaining 14 states expanded Medicaid.

Second, states with higher insurance coverage have found ways to protect their exchanges from the Trump administration’s attempts to undermine them. New York and Massachusetts have basically doubled the open-enrollment period by ending it in late January instead of mid-December. This is especially helpful because asking households to make large financial decisions during the financially stressful holidays dampens their willingness to buy insurance. Extending the open enrollment period for federally run exchanges into the New Year ensures more insurance coverage. And instead of cutting funding for health care navigators, the Massachusetts Health Connector has increased investment in its navigator program every year since 2016.

Third, states have taken measures that have kept exchange premiums low. Nearly 8 million uninsured Americans are eligible for exchange subsidies. The number one reason eligible people report not taking up exchange plans is cost. Studies show that for every $40 increase in monthly premiums, 25 percent fewer people sign up. Hence, the key to robust exchange enrollment is low premiums.

Lowering premiums is possible with a few simple policies. Massachusetts, whose exchange enrollment has doubled since 2015, has supplemented the federal premium subsidies. The monthly premium is $0 for people with incomes below 150 percent of the poverty line, compared to $48 to $63 per month in other states. Similarly, people with incomes between 200 percent and 250 percent of the poverty line pay $85 per month, while in other states the monthly cost ranges from $132 to $211. Minnesota and New York have also tried to reduce exchange premiums. In addition, high coverage states have merged individual and small group insurance pools, creating a larger—and therefore more stable—market, which is less susceptible to price hikes and premium fluctuations.

The result is competitive exchanges that generate lower premiums. In New York, all but three counties have at least three competing insurers, and many rural counties, such as Tioga County (population 49,000) and Schoharie County (population 33,000), have four competing insurers. In both counties, premiums are slightly lower than the state average. In Massachusetts, seven insurance companies offer plans in Boston and seven in Springfield, producing the lowest exchange premiums in the country.

Another way to reduce exchange premiums is through reinsurance, allowing insurance companies to insure themselves against unexpectedly high-cost patients—the proverbial “million-dollar baby.” This keeps overall expenses for insurers lower, reducing premiums. Seven states—Alaska, Maine, Maryland, Minnesota, New Jersey, Oregon and Wisconsin–have introduced their own reinsurance programs.

Fourth, some states simplified options on the exchange. Beyond cost, policymakers can address the well-known behavioral economic principle of “choice overload”—when given too many options, many people freeze and buy nothing at all. To counter this phenomenon, the Netherlands, which has 22 competing private health insurance companies for 17 million people, requires insurers to provide the same basic set of benefits with nearly identical cost-sharing. The standardization—along with a mandate—helps the Netherlands achieve 99 percent health insurance coverage.

Adopting a similar approach, Massachusetts requires insurers to provide standardized plans, with identical out-of-pocket costs for most benefits. Plans predominantly vary based on premium and network composition—simplifying exchange choices. This approach is also used in other states such as California, which has enrolled over 1.5 million people in its exchange.

Finally, the oft-maligned individual and employer mandates, which were zeroed out by the GOP tax bill, remain in place in some form in five states and DC, including New Jersey, Vermont, and Rhode Island—all of which have low uninsured rates. Although the federal mandate was struck down, state-imposed health insurance mandates are constitutional. While mandates are not as important as premium subsidies in increasing coverage, the experience in these states shows that mandates may persuade a few more healthy people to get insurance, stabilizing premiums even more.

These five changes to achieve near-universal coverage have been done without national legislation. Of course, there are federal initiatives that could help even more. One is for the federal government to reinstate cost-sharing subsidy payments to insurance companies suspended by Trump, which would lower exchange premiums. National reinsurance and risk corridors are very low-cost policies to reduce premiums. And some form of auto-enrollment into Medicaid would also help reduce the uninsured rate.

But states can go a long way without those federal supports. While it is easy to dismiss the ACA and focus on the promise of Medicare for All, there is a more straightforward path to universal coverage: adopting a handful of relatively simple policies and programs at the state level can ensure health insurance coverage for nearly all Americans.

