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In 2020, the United States entered its most severe public health crisis in a century with 13% of Americans under the age of 65 — more than 35 million people — without health insurance.

Despite widespread concerns, though, the surging Covid-19 pandemic has not led to major increases in the number of people without health insurance. This is mainly because the massive job losses that began in March were concentrated in sectors in which people are less likely to get insurance through their jobs and many employers who furloughed workers continued to pay their employees’ health insurance premiums. And of the estimated 3 million people who did lose their health insurance in 2020, many were likely to get covered on another family member’s health plan or through the Affordable Care Act’s marketplaces and Medicaid expansions.


While this is better news than expected, it is not time for complacency. Although the rate of people without health care insurance declined dramatically following the ACA’s major coverage expansions in 2014, the uninsured rate has trended upward over the past four years.

Patrick Skerrett / STAT Source: U.S. Census Bureau

There are several reasons for this upward trend: Trump administration policies that undermined the ACA; ongoing resistance by several states to expand Medicaid eligibility; immigration policies, especially the so-called public charge rule, that have dissuaded even legal immigrants and their children from getting health insurance; and continuing affordability barriers for people looking for coverage through the marketplaces.

Faced with an onslaught of needs arising from the multipronged economic and health catastrophe caused by Covid-19, federal and state governments grasped at Band-Aids to help people without health care insurance. The CARES Act enabled states to use Medicaid to provide free Covid-19 testing for uninsured residents and gave money to hospitals to pay for the care of uninsured Covid-19 patients. Twelve states that run their own marketplaces opened up a special enrollment period for anyone who needed coverage.


The Trump administration, however, not only declined to open a special enrollment period in the 38 states where the federal government runs health insurance marketplaces but did not widely publicize the fact that people who lose their health insurance coverage can sign up immediately in a marketplace in any state. Nor did it follow past practice in both Republican and Democratic administrations during natural disasters to use the full force of Medicaid’s safety net to get people covered by health insurance.

A new administration and Congress getting to work offers an opportunity to reverse the uninsured trend line. This can be done quickly and without sweeping change to the health system. But it does require a bipartisan commitment by Democrats and Republicans to use the tools they have under current law.

Here is how the Biden administration can act:

  • Immediately open a national special enrollment period for the federal health insurance marketplaces
  • Reinstate funds cut by the Trump administration to inform people about their health insurance options and help them enroll in marketplace plans and Medicaid
  • Simplify marketplace plan choices
  • Increase marketplace subsidies by a greater amount each year
  • Curtail the sale of health plans that don’t protect people with preexisting conditions
  • End the failed policy of work requirements in Medicaid
  • Allow families in high-cost employer plans to enroll in marketplace plans

The new Congress can pass a bipartisan package of changes that could insure, and keep insured, millions of people by enhancing and extending marketplace premium subsidies to cover up to 4 million more people and allow eligible people in the 12 states that have yet to expand Medicaid to enroll in marketplace plans at zero premium.

Congress can also explore how bigger reforms, like how a public health insurance option could be designed and implemented. The chassis for these tools rests on a Supreme Court decision expected by June 2021 regarding the lawfulness of the ACA. But the court’s November oral arguments in California v. Texas suggest that a majority of the justices will likely vote to uphold the law — for the third time.

It is time to use the tools available under the law to begin to turn the uninsured trend line down again and help millions of Americans ravaged by the pandemic begin to rebuild their lives.

Sara R. Collins is vice president for health care coverage and access at The Commonwealth Fund.