When this year’s Open Enrollment period came to a close in January, we celebrated along with the Biden administration that more people than ever enrolled in ACA Marketplace health insurance plans. This was in large part due to policies which made tax credits to purchase a Marketplace plan more widely available to more people. For many people, their new coverage will mean the chance to see a doctor and get the treatment they’ve been putting off. But even with insurance, a majority of people may still face an upward battle to get the comprehensive coverage and care they want and need to stay healthy without going into medical debt.

In other words, a large open enrollment period is good, but not enough. And one of the main reasons is the growing medical debt crisis in this country.

100 million people have some form of medical debt in this country. It is a symptom of a system that has prioritized profits over people. Nearly 50% of adults struggle with costs related to health care in America, including 60% of Black and 65% of Hispanic adults – and yet health care CEOs pocketed four billion in profit in a single year. Further, it is hard to see how this course will naturally correct amidst the alarming growth of private equity in health care, health care premiums rising while wages are stagnant, and record profits for non-profit hospital systems.

People are delaying care, skipping appointments and even changing the food they eat to cut costs. This leaves far too many people forced to make the impossible choice between getting the care they need and going into crippling debt. 

This is not some abstract Washington debate. This is impacting real people. People like Christy, from Georgia. Christy was diagnosed with brain cancer at age 22 and was unable to work due to having brain surgery. Being unable to work she lost her health insurance and was not able to pay my medical bills. She applied for Social Security Disability Insurance three times and was denied each time. 3 years later Christy is not only fighting brain cancer but also mounting debt too. 

Christy is one of millions of people across the country who are pushing for a health system that is truly accessible, affordable and responsive to all people. 

As a record number of people are buying coverage through Marketplaces, the Biden administration has the opportunity to build on its commitment to health equity by taking additional action to address the medical debt crisis, which is felt most acutely in states where policymakers refuse to expand Medicaid, a popular and successful health care program. 

Doing so would help Christy and millions of others.

First, the Biden administration should work with Congress to bolster financial assistance for people who fall in the “Medicaid Gap”.

When the ACA was designed, the intention was that all those below 138% of the federal poverty level (today about $20,000 for an individual or $41,000 for a family of four) would qualify under an expansion of their state’s existing Medicaid program. Unfortunately, that hasn’t been the reality for far too many people in states like Texas, Georgia and Alabama, who fall into the gap for financial support due to a 2012 Supreme Court decision that made Medicaid expansion optional for states.

For many people who do not qualify for Medicaid because their state leaders continue to put politics over people, high deductibles and out of pocket costs continue to be a driver of medical debt. As we fight for more comprehensive health coverage, we cannot forget those in the coverage gap who for too long have been left without equal access to affordable health care due to long standing systemic and racist barriers to health and economic advancement.

Washington should step up where the states have not and extend Marketplace subsidies to those below the poverty level in all states or allow individuals to purchase Marketplace plans with minimal cost sharing such as low premiums and no deductibles. 

In addition, even if a family can access and afford health coverage, current plans don’t do nearly enough to support whole-person care. Vital services like dental care, abortion, postpartum care, vision benefits and gender-affirming care are not required to be covered by most insurance plans because they are not considered “Essential Health Benefits” bv the federal government. Others, like mental health care and substance use disorder treatment are woefully lacking. If the goal is to make sure everyone has what they want and need to be healthy, we’re far from it. The Biden administration can and should expand what is considered an Essential Health Benefit. This easy fix can be done without Congress and builds from the administration’s impactful action to expand access to adult dental care, a leading driver of medical debt.

And finally, similar to the Biden administration’s important focus on reigning in the promotion of predatory deferred interest credit cards in medical settings, there is another key driver of debt that is worthy of attention: hospital systems, including non-profit hospitals that get significant tax breaks but are operating more like for-profit entities. Hospital systems are a leading contributor to the medical debt crisis in America. And the Biden administration should take action to tackle the underlying drivers of hospital debt – including stronger regulations and better enforcement through the IRS to hold non-profit hospitals accountable to their tax breaks. 

Policymakers and the Biden administration have the opportunity to build on the steps taken to bolster financial support for those in the Medicaid gap, update and expand the Essential Health Benefits so that all health care plans cover essential care no matter what state you live in, and hold non-profit hospitals accountable to their tax breaks. We cannot let another Open Enrollment period come and go that forces people to enroll in plans that don’t provide the affordable coverage and care they want and need.

To truly tout open enrollment successes, we must acknowledge that the true measure of success lies in the lives improved and economic burdens lifted – a legacy that will far outlast any open enrollment figures.

This blog was originally published on The Messenger.