Almost half a million veterans gained health care coverage during the first two years of the Affordable Care Act, a report finds.

In the years leading up to the implementation of the ACA’s major coverage provisions, from 2010 to 2013, nearly 1 million of the nation’s approximately 22 million veterans didn’t have health insurance. Almost half of all veterans are enrolled in the VA health system; others get health care through employers or Medicare. But some don’t quality for those options, and others don’t know that they have them.

Two years after the ACA’s implementation, 429,000 veterans under the age of 65 gained coverage, which is a 40 percent drop in vets without insurance from 2013 to 2015. The vets were covered for the most part through Medicaid expansion, privately purchased plans and marketplace coverage, according to the report.

The number of insured veterans rose across demographics like age, gender, race and education level. “The gains in coverage were really broad,” says Jennifer Haley, a research associate at the Urban Institute, a research group based in Washington, D.C., who was an author on the report.

Veterans with the lowest incomes saw the greatest increase in coverage, especially in states that adopted Medicaid expansion. Vets with incomes up to 138 percent of the federal poverty level, or $16,394 a year for an individual, became eligible for Medicaid in expansion states, the report notes.

In 2015, just 4.8 percent of veterans were uninsured in states that participated in Medicaid expansion, compared to 7.1 percent in states that did not.

One in 5 uninsured vets live in states that did not expand Medicaid and would have been eligible for coverage had their state chosen to expand the program, the report found. Haley says these are key data points when considering changes to policy.

“If states would adopt the expansion, more vets would qualify for publicly supported coverage,” she says. Currently, 31 states and the District of Columbia have expanded Medicaid programs, including California, New York, Pennsylvania and Illinois. Another 19 states, including Florida and Texas, have not expanded access to the program.

Veterans weren’t the only ones to benefit from expanded insurance access. Their family members had access to more coverage, too, and by a similar margin.

The overall rate of uninsurance among relatives sank from 9.2 percent in 2013 to 4.5 percent in 2015. For children, the rates fell from 4.5 to 2.9 percent. Overall, 730,000 fewer vets and their family members were lacking health insurance from 2013 to 2015.

The report, published by the Urban Institute, used data from the American Community Survey, which is performed annually by the U.S. Census Bureau. It surveys around 100,000 veterans and 100,000 family members of veterans. The report also considered data from the National Health Interview Survey which is conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics.

A repeal of the ACA or a rollback of Medicaid could negate these coverage increases and leave more vets without health insurance coverage, the authors note in their report. The VA health system continues to struggle with delays in delivery of services to veterans.

On Wednesday, President Donald Trump signed a law extending the Veterans Choice program, which allows some vets get health care from private providers paid for by the VA and was created to help improve access to timely care.

The $10 billion program has been riddled with problems, as Montana Public Radio’s Eric Whitney reports, including long waits, a confusing, complicated system and delayed payments to providers.

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The public could soon get a look at confidential reports about errors, mishaps and mix-ups in the nation’s hospitals that put patients’ health and safety at risk, under a groundbreaking proposal from federal health officials.

The Centers for Medicare and Medicaid Services wants to require that private health care accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by those accreditors, not the government.

There’s increasing concern among regulators that private accreditors aren’t picking up on serious problems at health facilities. Every year, CMS takes a sample of hospitals and other health care facilities accredited by private organizations and does its own inspections to validate the work of the groups. In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.

In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity “raises serious concerns regarding the [accrediting organizations’] ability to appropriately identify and cite health and safety deficiencies” during inspections, CMS officials wrote when they released draft regulations including the proposed change on Friday.

The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals. ProPublica has created a tool, Nursing Home Inspect, to allow people to more easily search through the nursing home deficiency reports; the Association of Health Care Journalists has done the same for hospital violations.

Those government inspection reports do not identify patients or medical staff, but they do offer a description—often detailed—of what went wrong. This includes medication errors, operations on the wrong patient or the wrong body part, and patient abuse.

But private accrediting organizations, the largest of which is The Joint Commission, have not followed suit, creating a patchwork of disclosure in which some inspections are public and others are not. CMS’ proposed rules are designed to fix this.

“We believe it is important to continue to lead the effort to make information regarding a health care facility’s compliance with health and safety requirements” publicly available, CMS officials wrote.

“It’s huge, absolutely,” says Rosemary Gibson, a patient safety expert who wrote a book, Wall of Silence, about medical errors. “Right now the public has very little information about the places where they’re putting their life on the line, and that’s just not acceptable. If you’re a good place, what are they afraid of?”

Medical errors are a leading cause of death and injuries in U.S. hospitals. A 1999 report by the Institute of Medicine estimated that up to 98,000 people a year die because of mistakes in hospitals; subsequent reports have said the number is much higher.

To qualify for federal funding, health facilities have to meet minimum requirements, known as Medicare conditions of participation. If a health facility has problems and doesn’t fix them, it stands to lose its Medicare funding. Though this rarely happens, it can be crippling for an institution and could force it to close.

State health departments get funding from CMS to inspect facilities to ensure they comply with these requirements. But the law also allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight. The Joint Commission conducts unannounced inspections at hospitals at least once every 39 months, and more often if complaints arise.

Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,018 hospitals listed on the The Joint Commission’s website, more than 99 percent have full accreditation and only seven are on track to lose their “gold seal of approval.”

The Joint Commission said it is reviewing the CMS proposal and couldn’t comment further. A smaller competitor, the Healthcare Facilities Accreditation Program, said it supports the goal of transparency but is studying what the change would mean in practice, both in terms of staffing and costs. “We haven’t talked to our hospital partners,” says Gary Ley, its executive director. “It would be a major change for them also. It’s hard not to support the goals but we have to look at the execution.”

For its part, the American Hospital Association said it supports providing the public “useful information” about hospital quality, but has doubts that detailed inspection reports fit that description.

“It’s important that the information shared with consumers has a clear purpose, is transparent and is readily understood by folks from all walks of life, not just those with deep expertise in health care,” says Nancy Foster, AHA’s vice president of quality and patient safety, in a statement. “We are concerned that sharing a detailed report may not be the most useful or effective strategy for informing the public.”

Foster says it might be more useful to provide a one- or two-page “accurate summary” of inspection findings, with “key takeaways” and why they are important. “This summary could also draw from the plan of correction the hospital creates and summarize how the hospital plans to address the findings,” Foster says.

For years, accreditors have been accused of putting the interests of the facilities that pay them ahead of patient safety. In 2002, the Chicago Tribune reported how The Joint Commission gave its seal of approval to “medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.”

Last week, BuzzFeed News reported how an Oklahoma psychiatric hospital was named a “Top Performer in Key Quality Measures” by The Joint Commission even though police records, state inspection reports and lawsuit records showed that it “is a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as 5 are separated from their parents and held in dangerous situations, and where wards lack adequate staffing and staff lack adequate training.”

In a response to BuzzFeed, the company that runs the hospital, Universal Health Services, said it “is proud of the care it provides patients at Shadow Mountain Behavioral Health.”

On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information of what went wrong, even when hospitals are described as receiving a “preliminary denial of accreditation.” For one hospital, the explanation is: “Existence at time of survey of a condition, which in The Joint Commission’s view, poses a threat to patients or other individuals served.” The threat itself is not disclosed.

Consumers Union’s Safe Patient Project and other patient safety organizations have been pushing for years for more information about hospital inspections. Lisa McGiffert, who directs the Safe Patient Project, hopes this may be the opportunity for change. “The information that’s available now is so minimal and would not really inform anyone about real quality of a hospital,” she says.

Comments on the proposal may be submitted from April 28 to June 13 through the CMS website.

Disclosure: Ornstein was previously president of the Association of Health Care Journalists. While he served in that position, AHCJ called for The Joint Commission to make its inspection reports public. The Joint Commission declined to do so. Have you complained about a hospital to The Joint Commission or another accrediting body? We’d like to hear from you. Email Charles.ornstein@propublica.org. ProPublica is an independent nonprofit newsroom based in New York.

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