As more lack health insurance and signups lag, Modern Healthcare editor worries what will happen if economy slows

The share of Kentucky children without health insurance rose last year.

"This shouldn't be happening," Editor Merrill Goozner writes in a Modern Healthcare editorial titled, "The canary in the open-enrollment coal mine."

Goozner is writing about an increase in the number of uninsured children and a decrease in the number of people who are signing up for federally subsidized health insurance for 2019. "The share of Americans without health coverage will undoubtedly tick up next year for the first time in nearly a decade," writes Goozner.

"This dubious achievement arrives just as the U.S. economy is nearing full employment," a time when employers are bolstering their benefit packages to attract workers, and people working in jobs that don't offer health insurance are finally making enough money to buy some, he writes.

"It clearly took a lot of work by the Trump administration and the current Congress to undermine the exchanges where individual policies are sold," he writes, ticking off many of their efforts to do so: removing insurance price stabilizers, ending cost-sharing subsidies for patients, slashing marketing and advertising budgets, expanding the availability of "short-term" plans, and doing away with the individual mandate that imposed a penalty for not having health insurance.

"If the current sign-up rate holds through the end of open enrollment on Dec. 15, more than 2 million fewer people will choose plans on the exchanges for 2019, about a 17 percent decline from 2018," he writes. "This will almost entirely offset the increase in employer-based coverage that one would expect from an improving economy."

He adds that states being allowed to add work requirements to their expanded Medicaid populations will only exacerbate this problem, pointing to Arkansas, which has dropped 12,000 from its Medicaid rolls since it implemented its work requirements three months ago. "It could get much worse," he writes, since Centers for Medicaid and Medicare Services Administrator Seema Verma has vowed to push for the requirements.

In addition to Arkansas, the Department for Health and Human Services has approved Medicaid work requirements in Kentucky, Indiana, New Hampshire and Wisconsin, with approvals pending for Alabama, Arizona, Kansas, Maine, Michigan, Mississippi, Ohio, South Dakota and Utah.

"It's poor timing for ideological rigidity," he writes. "If the economy slows next year, which many economists predict, the last thing you want to do is create higher hurdles for low-income people needing Medicaid." But with only one week left in open enrollment, Goozner writes that "the die for next year is mostly cast."

He warns that hospitals and providers need to begin preparing now for the coming fiscal realities, noting that they should expect another "upward lurch" in uncompensated care next year and prepare for a freeze on hiring.

He concludes: "You'd think the Trump administration would understand that's not what it wants going into a two-year battle to win re-election."