The Affordable Care Act brought the share of Americans without health insurance to a historic low. Things have changed since Donald Trump became president.

About 7 million fewer Americans had health insurance at the end of last year compared with two years prior, and the share of people who are uninsured is the highest it’s been since 2014, according to a new survey.

During the fourth quarter of 2018, 14 percent of Americans were uninsured. That’s up from 11 percent at the end of 2016, and the increase has been steady over the months since then, according to the latest figures from the Gallup National Health and Well-Being Index, released Wednesday. Women, people who earn less than $48,000 a year and adults younger than 35 saw the highest increases in the uninsured rate.

The Affordable Care Act, which became law in March 2010, began to expand health coverage through broadened access to Medicaid benefits for low-income adults and through subsidized private health insurance sold to low- and middle-income households beginning in January 2014. From the fourth quarter of 2013, when the uninsured rate was 17 percent, the share of Americans without health insurance reached its low point of 11 percent in the third and fourth quarters of 2016. At the time, President Barack Obama’s administration estimated that 20 million previously uninsured people gained coverage during that period.

The tide has shifted, however, and the gains seen during the early years of Obamacare are being reversed. The Gallup survey doesn’t ask respondents why they don’t have health insurance, but the report does point to several likely causes, including rising prices and policy changes made by President Donald Trump’s administration and the Republican majority in Congress.

Credit: Marc Janks/HuffPost

High premiums for people who earn too much to qualify for federal tax credits to subsidize their costs have been a problem on the health insurance exchanges since they began for the 2014 enrollment period, and they’ve only gotten worse. Rates for the “benchmark” policies on the exchanges in each state ― these are mid-level Silver plans that are used to determine the value of premium subsidies ― are 85 percent higher this year than they were in 2014, according to federal data compiled by the nonpartisan Henry J. Kaiser Family Foundation.

During the first few years of Obamacare, premium increases mainly were the result of health insurance companies underestimating the costs their new customers would generate. The companies made up for this by charging more in subsequent years. The market began to stabilize in 2015 and 2016, even though prices remained high, and it appeared that large annual rate hikes might cease.

Instead, the Trump administration has taken a number of steps that have had the effect of further driving up premiums for exchange customers and those who buy policies directly from insurers or through brokers. While subsidized consumers generally are shielded from higher premiums because their tax credits increase along with the prices, people who earn more than four times the federal poverty level ― that’s about $49,000 a year for a single person ― must pay full price for their coverage.

Since his first day in office, Trump has directed and overseen policies that undermine the health insurance exchanges.

The administration has dramatically reduced funding for advertising, marketing and outreach to draw eligible customers to the exchanges during open enrollment and for programs that help consumers navigate the sign-up process. The Republican tax package Trump enacted in 2017 repealed the Affordable Care Act’s fines on people who didn’t obtain health coverage under the law’s individual mandate, freeing people to go uninsured without penalty and causing insurers to increase prices on the assumption that healthier people are less likely to buy coverage in the absence of fines. Perhaps most consequentially, Trump ended payments to health insurance companies serving the lowest-income customers, which led insurers to increase prices to make up for the lost revenue.

After the GOP Congress failed to repeal the Affordable Care Act in 2017, Trump stepped up the use of regulatory and administrative powers in ways that also could weaken the insurance exchanges. The administration relaxed rules that limited the sale of so-called short-term, limited duration plans, policies that don’t have to include all the benefits required for exchange coverage and that can reject people with pre-existing conditions or charge them higher prices, for example.

These and other alternative forms of coverage the Trump administration supports are expected to draw some healthier, and therefore less expensive, customers away from the exchanges. That would leave a relatively sicker and costlier pool of consumers inside the exchanges, and insurers would have to raise premiums to compensate.

And the administration unveiled a proposed regulation last week designed to increase how much consumers will pay for health insurance in future years.

Enrollment on the federal insurance marketplace, which serves consumers in 39 states, fell for the second consecutive year during the 2019 open enrollment period that ended in December.

On the horizon is a lawsuit that could undo the entire Affordable Care Act and cause millions to lose health coverage. Texas Attorney General Ken Paxton and GOP officials from 19 other states won the case in federal district court last month from a judge who agreed with their contention that the law is unconstitutional. The Trump administration supports the challenge to the Affordable Care Act. The case is under appeal.

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