More About Sarah Lueck

Sarah Lueck

Lueck joined the Center in November 2008 as a Senior Policy Analyst.

Full bio and recent public appearances | Research archive at

Critics’ Portrayal of Health Reform Doesn’t Match Reality

March 5, 2015 at 5:16 pm

As we explained yesterday, many of the benefits that three key House Republican committee chairs claim their health plan will offer are things that health reform already provides — and, in most cases, much more so than their plan likely would. Here’s another problem with their Wall Street Journal op-ed: its portrayal of health reform simply isn’t true. It portrays people “stuck” in health insurance they can’t afford, and paying for benefits they don’t want, just to avoid the penalty for not having coverage. The reality is quite different.

Many people buying their own insurance have more freedom of choice than before health reform. Before health reform, people without job-based coverage had few good options. Many couldn’t buy insurance on their own or faced exorbitant premiums because of pre-existing health conditions or other factors. And enrollees who wanted to switch plans often faced a battery of questions from the insurance company and higher premiums.

Now, people have numerous plan options to choose from and can switch each year to suit their needs, just like people with job-based coverage. Moreover, people who’ve enrolled through the marketplaces give their coverage high marks: seven in ten people surveyed last fall rated their coverage and the quality of their health care as excellent or good.

Coverage is more affordable for most Americans, not less. More than 80 percent of the people enrolling through the marketplaces are eligible for premium subsidies, which reduce premiums in the federal marketplaces by an average of 72 percent. Before health reform, premiums were out of reach for people with modest incomes. Now that insurers have to grant coverage to everyone and charge the same premiums regardless of past medical problems, a market that was closed to many with modest incomes is finally a viable source of health insurance. Recent data show other pocketbook improvements: fewer people skipped needed medical care or had problems paying medical bills as health reform took effect.

Before health reform, many plans lacked benefits that people wanted. Before health reform, many plans in the individual market lacked coverage of maternity care, substance abuse and mental health treatment, and prescription drugs. Health reform requires insurers to include those benefits. It also requires coverage of certain preventive care at no cost, bars annual and lifetime limits on benefits, and caps the amount people pay on deductibles and other cost-sharing charges each year.

It isn’t all about the individual mandate. To be sure, the penalty for not having insurance is a critical part of health reform since it encourages more healthy people to buy coverage. But the mandate isn’t the only reason people would purchase marketplace coverage, as the op-ed claims. The penalty hasn’t even fully phased in, yet numerous surveys show significant — even historic — gains in coverage (see here and here) through the marketplaces, as well as through health reform’s Medicaid expansion.

Those gains reflect the fact that people who are uninsured generally want coverage but either can’t afford it or don’t have coverage through a job. Now, however, health reform offers people a choice of marketplace plans with meaningful benefits and substantial help purchasing them.

Fewer People Having Trouble Paying Medical Bills

January 20, 2015 at 3:55 pm

Fewer people skipped needed health care due to its cost or reported trouble paying medical bills in 2014, a new survey finds.  These improvements, the first since the Commonwealth Fund began asking these questions roughly a decade ago, came as health reform’s major coverage expansions took effect in 2014.

Among the survey’s findings:

  • The number of people ages 19-64 without health insurance showed a statistically significant drop for the first time in the history of the biennial survey, from 36 million in 2012 to 29 million in 2014. The share of the population without insurance fell from 19 to 16 percent.
  • The share of people who failed to get needed health care because of cost fell from 43 percent in 2012 to 36 percent in 2014. This means fewer people said they skipped a recommended test, didn’t fill a prescription, avoided visiting a doctor or clinic when having a health problem, or failed to see a specialist for needed follow-up care.
  • The number of adults who reported problems with medical debt (such as difficulty paying bills) fell from an estimated 75 million in 2012 to 64 million in 2014.  The share of the population reporting these problems fell from 41 to 35 percent.
  • Critics of health reform suggested it would harm young adults, but the opposite appears to be the case. People ages 19-34 made the biggest coverage gains of any age group between 2012 and 2014, with those with incomes below about $47,000 for a family of four seeing the greatest improvement.

As the survey report notes, the gains in health coverage—and the related reductions in people’s financial problems — may partly reflect an improving economy.  However, the coverage gains were far greater in the recovery from the 2007-09 recession, just as health reform took effect, than in the recovery from the previous (2001) recession, our analysis of Centers for Disease Control and Prevention data shows — a sign that health reform’s coverage expansions also played an important role.

Health reform enabled millions of people to obtain more affordable coverage in 2014, through both the Medicaid expansion in many states and the creation of insurance marketplaces that provide federal subsidies to reduce people’s premiums and cost-sharing charges.  Health reform also improved access to coverage by barring health insurers in the individual market from denying coverage or charging higher premiums to people with health problems, and it limited how much insurers could charge older people compared to younger people.

Even before 2014, the law began improving access to coverage, including by requiring most insurance plans to cover adult dependents up to age 26 beginning in 2010.

Millions of Americans still have trouble affording health care, and we need to do more to address that problem.  But, in part due to health reform, the situation is looking up.

Another Health Reform Attack Falls Flat

October 2, 2014 at 3:00 pm

Many health reform opponents warned that people buying health insurance in the individual market would face a sharp, pervasive spike in premiums.  The Manhattan Institute predicted that “Obamacare” would bring double-digit premium increases, while the Heritage Foundation wrote, “individuals in most states will end up spending more on the exchanges” (or marketplaces) than they previously paid.  Not only did those dire predictions fail to come true, but there’s good news to report about premiums as open enrollment under the Affordable Care Act (ACA) approaches.

To be sure, some people buying coverage in the pre-health reform individual market saw their premiums rise, partly due to more robust benefits and market reforms under the ACA that barred insurers from charging higher premiums to people with health conditions.  But for many others, health reform’s consumer protections and premium subsidies to buy marketplace coverage brought lower premiums or the ability to buy coverage for the first time.  Now, as the November 15 start of the ACA’s second open enrollment season draws closer, the outlook for 2015 premiums in the individual market is even more encouraging.

Unsubsidized premiums for the silver-level “benchmark” plans in 16 cities around the country are falling by an average of 0.8 percent compared with 2014, according to a recent report by the Kaiser Family Foundation.  The cheapest bronze-level plan (a basic plan under health reform) in those same areas is rising by an average of just 3.3 percent in 2015.

Those rate changes mark an improvement over the pre-ACA market.  Individual-market health insurance premiums rose an average of 10 percent each year in 2008 through 2010, according to a Commonwealth Fund study.  For 2014 to 2015, the consulting firm PricewaterhouseCoopers estimates a 7 percent average increase in premiums (across all plan tiers and without accounting for subsidies) in the individual markets of those states for which it has data.  Premiums for the cheapest silver plans will rise an average of 8.4 percent in select states that the McKinsey Center for U.S. Health System Reform reviewed.

Of course, preliminary 2015 premiums vary significantly from state to state and insurer to insurer.  This variation means some consumers could see a higher price tag in 2015 for the plans they have now.  But many will be able to find coverage for the same or a lower price — provided they’re willing to shop around during open enrollment.

The bottom line: widespread rate shock isn’t happening.  Yet another attack on health reform is falling flat.

Big Issue for Insurance Marketplaces Is Enrollees’ Health, Not Age

February 14, 2014 at 1:02 pm

Despite what you may have heard, the share of enrollees in the new insurance marketplaces who are young isn’t the most critical factor in determining whether the marketplaces’ risk pool will be well balanced and whether their premiums may have to increase next year.  Instead, the health status of enrollees is far more important.  That’s the conclusion of a recent Commonwealth Fund-organized gathering of insurers, actuaries, researchers, and federal officials.

The misplaced idea that success hinges on whether enough young people sign up — since young people are generally healthier and thus less costly to cover — has gained undeserved traction in recent months.  And the release of the latest federal data on marketplace enrollment, including a breakdown by age, will likely bring renewed attention to the number of young enrollees.  But, as a Commonwealth report summarizing the meeting concludes, “there is no single right percentage for young adult participation.”

We made the same point a few weeks ago, explaining that the health status of enrollees at all ages is far more important in producing a balanced risk pool and ensuring that the marketplaces will have stable and affordable premiums over time.  Also important is how well each insurer predicted who would sign up for coverage this year.  If an insurer’s enrollees cost far more than it anticipated in setting its 2014 premiums, it might raise premiums in 2015 to better reflect its expected costs.

The Commonwealth Fund report also highlights some factors that could limit any losses that insurers may experience this year, which in turn could tamp down any 2015 premium increases.

For example, health reform’s risk corridors (along with its other risk-mitigation programs) limit insurers’ potential losses as the law’s major reforms take effect in the individual market and the new marketplaces become fully established.  And two health reform requirements — that insurers justify premium increases of 10 percent or more and spend a set percentage of their premiums on medical care rather than administration and profits — are expected to help hold down any rate increases in 2015.

It’s Too Soon to Go Negative on Health Reform’s Marketplaces

February 3, 2014 at 3:46 pm

Moody’s recently changed its outlook for health insurers from stable to negative, based in part on concerns about whether enough young, healthy people are enrolling in plans through the new health insurance marketplaces (also known as exchanges) under health reform.

This announcement by the well-known credit rating agency stoked another round of fretting about the marketplaces’ viability.  But it’s far too early to draw conclusions about the marketplaces.

Moody’s based its industry outlook in part on the mix of the insurance risk pool:  whether enough people with lower health costs will join, balancing out the higher costs of those with greater health needs.  But the data that will answer this question is still being generated, as we have explained — and it’s far more individualized per company than the rating agency’s sweeping, industry-wide generalization.

And although Moody’s cited a concern that that enrollment of younger people is lagging, the health status of enrollees is far more important to the risk pool’s balance than their age.

Risk pooling occurs within each state and on an insurer-by-insurer basis.  How any given insurance company that offers marketplace plans will fare depends substantially on how accurately it predicted who would enroll in its plans and the costs they would incur.  (WellPoint, one of the major Blue Cross and Blue Shield insurers, has highlighted this, saying that its preliminary analysis of who is enrolling in its plans is tracking with its assumptions when it set its marketplace premiums.)

Moody’s said several issues contributed to its negative outlook for the insurance industry.  For example, it said the Obama Administration’s recent decisions to allow people more time to enroll for 2014 and to keep policies that don’t comply with all the 2014 standards may add more risk than it previously expected for insurers this year.  But another factor that Moody’s raised is older news:  the coming announcement of reduced Medicare Advantage payments for 2015, which merely involves implementation of scheduled cuts enacted under health reform.  Moody’s assessment of the health insurance industry should have already factored in those cuts.

Amid the speculation about the impact that health reform will have on private insurance markets, it will take time to understand what is happening in this first year of implementation.  It’s far too early to declare that the news is bad.