Last week, Dr. Ezekiel Emanuel, a key Obama Administration advisor on health care reform, described how several states, using the ACA, have achieved near-universal coverage. At the same time, the Trump Administration moved forward on a proposal that would turn the Medicaid program into a partial state block grant.

Emanuel writing in Politico said that six states (Hawaii, Iowa, Massachusetts, Minnesota, Rhode Island, Vermont) and Washington DC had achieved over 95 percent coverage. He points out that this has happened despite the Trump Administration’s efforts to undercut the ACA through reduced open enrollment period, cuts to navigators’ programs, and weakening patient coverage. According to the U.S. Census, health insurance coverage nationally went from 14.5 percent before the ACA to 8.6 percent in 2016 (before rising to 9 percent by 2018). A major part of the expanded coverage both in these states and across the country is the expansion of Medicaid coverage under the ACA, which allows states to extend coverage up to 138 percent of poverty for all adults, including single adults who never had coverage.

Emanuel points out the strategy of some states in expanding coverage such as increasing the open enrollment (sign up time) well beyond the narrow period the Trump Administration has allowed, increased use of navigator programs to assist enrollees (the Trump Administration has cut this funding), lowering premiums across fewer standard policies making it easier for people to compare and make choices, merging some smaller insurance pools thus leveraging the influence of large insurance pools, and utilizing “reinsurance.” Reinsurance has the government covering insurance costs above a certain high level of health care cost. For example, New Jersey covers 60 percent of health bills between $40,000 and $215,000. This has resulted in lower health insurance premiums for customers. This strategy has worked in Alaska, Maine, Maryland, Minnesota, New Jersey, Oregon, and Wisconsin.