SURVEY BRIEF AUGUST 2019 Who Are the The Affordable Care Act (ACA) brought sweeping change to the U.S. health care system, expanding comprehensive health insurance to millions of Americans and making it possible for anyone with health problems to get coverage by banning insurers from Remaining denying coverage or charging more because of preexisting conditions. In 2018 there were 18.2 million fewer uninsured people in the U.S. than when the ACA became law.1 In addition, fewer people are forgoing health care because of cost or reporting high out-of- Uninsured, and pocket costs relative to their income.2 Yet, in 2018, an estimated 30.4 million people were uninsured, up from a low of 28.6 million in 2016. Coverage gains have stalled in most states and have even eroded in some.3 Why Do They In addition, more people have reported problems getting health care because of cost. To examine why so many people remain uninsured, we use data from the 2018 Commonwealth Fund Biennial Health Insurance Survey. Answers to the survey Lack Coverage? questions can help federal and state policymakers find solutions to help uninsured Americans gain coverage. HIGHLIGHTS 2018, uninsured working-age adults in the United States were disproportionately low In Findings from the Commonwealth income, Latino, and under age 35. Fund Biennial Health Insurance Nearly half of uninsured adults may have been eligible for subsidized insurance Survey, 2018 through the marketplace or their state’s expanded Medicaid program. Two-thirds (67%) of uninsured adults had not gone to the marketplace to examine their coverage options. Of those, one-third (36%) said they didn’t think they could afford health insurance. Following the ACA individual market subsidies and reforms, the share of adults who had tried to buy a plan in the individual market and reported difficulties finding an affordable plan fell from 60 percent to 34 percent. In 2018, 42 percent of adults reported Munira Z. Gunja Senior Researcher difficulty finding affordable coverage. The Commonwealth Fund Despite affordability concerns and changes made by Congress and the Trump administration, 62 percent of adults with individual coverage and 84 percent with Sara R. Collins Medicaid rated their coverage as “good,” “very good,” or “excellent.” Vice President The Commonwealth Fund Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 2 Uninsured Working-Age Adults Disproportionately Low-Income, Latino, and Under Age 35 Uninsured Working-Age Adults Disproportionately Low-Income, Latino, and Under Age 35 Adults ages 19–64 who were uninsured The ACA’s coverage expansions led to significant declines in uninsured rates among people Income Age who had been the most likely to be uninsured: people with Race/Ethnicity low incomes, Latinos, and 200%– 399% FPL young adults (Table 1). But in 35–49 2018, these groups remained 21% Black 30% disproportionately uninsured. 11% 19–34 400%+ FPL <200% FPL 44% 58% 8% In 2018, 58 percent of uninsured White adults had incomes below 200 DK/Refused 13% 42% Latino percent of the federal poverty 35% 50–64 24% level ($24,120 for an individual and $49,200 for a family of four). Across age groups, young Refused DK/Refused adults ages 19 to 34 made up the 2% 2% largest share of the uninsured. Asian or PI Other/Mixed More than one-third of the 6% 3% uninsured were Latino even Notes: FPL = federal poverty level. DK = don’t know. PI = Pacific Islander. though Latinos make up 18 Data: Commonwealth Fund Biennial Health Insurance Survey (2018). percent of the working-age Source: Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do they Lack Coverage?: Findings from the Commonwealth adult population (Table 1). Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019). Notes: FPL = federal poverty level. DK = don’t know. PI = Pacific Islander. Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 3 Nearly Half of Uninsured Adults May Be Eligible for Marketplace Subsidies or Medicaid Nearly Half of Uninsured Adults May Be Eligible for Marketplace Subsidies or Medicaid Adults ages 19–64 who were uninsured We examined the remaining uninsured by income status to determine whether they might be eligible for subsidized coverage. The ACA provides subsidized insurance through Eligible for unsubsidized coverage through the two sources: Medicaid for adults who earn individual market or may Eligible for expanded Medicaid or less than 138 percent of poverty ($16,643 for be eligible for traditional subsidized coverage through Above subsidy an individual or $33,948 for a family of four) in Foreign-born Latinos Medicaid the marketplace eligible range states that expanded Medicaid, and subsidized plans in the ACA marketplaces for those who earn up to 400 percent of poverty ($48,240 for an individual and $98,400 for a family of four). 25% 11% 4% 3% 4% 36% 8% 9% The ACA excludes undocumented immigrants from both the marketplace subsidies and Foreign-born Latinos <100% FPL, 133%–399% FPL 400%+ FPL the Medicaid expansion: they may only buy nonexpansion coverage through the individual market outside <100% FPL, 100%–132% FPL, Undesignated the marketplaces. We use foreign-born status expansion expansion among Latinos as a rough proxy for uninsured adults who may not be eligible for subsidized 100%–132% FPL, coverage because of their immigration status.4 nonexpansion We do not have an estimate of undocumented immigrants of other ethnicities. Notes: FPL = federal poverty level. The Affordable Care Act set the top income eligibility threshold at 133% of poverty but also called for a new standardized method for calculating income. States previously had different rules about what sources of income counted for purposes of eligibility. The standardized modified adjusted gross income system automatically disregards 5% of someone's income, effectively making the threshold 138% of poverty. We use the 133% threshold in this survey. Nearly half (47%) of uninsured adults in 2018 Data: Commonwealth Fund Biennial Health Insurance Survey (2018). had incomes that may make them eligible for either expanded Medicaid or subsidized Source: Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do they Lack Coverage?: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019). marketplace plans. The remainder of uninsured adults would not qualify for either: 11 percent earn below 100 percent of poverty and live in a state that did not expand Medicaid;5 8 percent have incomes at or above 400 percent Notes: FPL = federal poverty level. The Affordable Care Act set the top income eligibility threshold at 133% of poverty but also called for a new standardized method for calculating income. States previously had different rules about what sources of income counted for of poverty and are ineligible for the tax credits; purposes of eligibility. The standardized modified adjusted gross income system automatically disregards 5% of someone's income, and 25 percent were foreign-born Latinos and effectively making the threshold 138% of poverty. We use the 133% threshold in this survey. may be ineligible for Medicaid or subsidized Data: Commonwealth Fund Biennial Health Insurance Survey (2018). plans because of their immigration status. commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 4 One-Third of Uninsured Adults Who Did Not Visit Marketplace to Get Coverage Cited Affordability Concerns One-Third of Uninsured Adults Who Did Not Visit Marketplace to Get Coverage Cited Affordability Concerns While half of adults who were Did you try to get health insurance through the marketplace? uninsured at the time of the Did you try to get health insurance survey might have been eligible through the marketplace? for subsidized health care, the Percent of adults ages 19–64 majority (67%) of uninsured who were uninsured What was the main reason you did not try to get health adults did not try to get insurance through the marketplace? health insurance through the Percent of adults ages 19–64 who were uninsured and did not visit the marketplace marketplace. When asked why, more than one-third (36%) reported it was because they 36 did not think they could afford Yes No it, 15 percent said they did not 32% 67% 28 think they needed it, 8 percent said they did not think they 15 would be eligible for insurance, 8 7 and 7 percent said they were You did not think You did not think You did not think You were not Some other not aware of the marketplace.6 you could afford you needed health you would be aware of the reason* health insurance insurance eligible for health marketplace insurance * 3% of uninsured adults ages 19 to 64 who did not visit the marketplace reported it was because they had, or will have, insurance through another source, 2% reported it was because the marketplaces were not open for enrollment when they needed coverage, and 1% reported they went someplace else to look for health insurance. Respondents who reported “some other reason” cited lack of time and citizenship status, among other reasons. Data: Commonwealth Fund Biennial Health Insurance Survey (2018). Source: Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do they Lack Coverage?: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019). * 3% of uninsured adults ages 19 to 64 who did not visit the marketplace reported it was because they had, or will have, insurance through another source, 2% reported it was because the marketplaces were not open for enrollment when they needed coverage, and 1% reported they went someplace else to look for health insurance. Respondents who reported “some other reason” cited lack of time and citizenship status, among other reasons. Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 5 One-Third of Adults Who Lost Coverage and Were Previously Covered Through the Individual Market Cited Affordability Concerns One-Third of Adults Who Lost Coverage and Were Previously Covered Through the Individual Market Cited Affordability Concerns Affordability is the top reason What was the main reason you lost or dropped your coverage? adults dropped their individual What was the main reason you lost or dropped your coverage? market coverage. One-third (34%) of adults who were either uninsured at the time of the Percent of adults ages 19–64 who were uninsured at the time of the survey or uninsured in the past 12 months survey or had a gap in coverage and were previously covered by a plan bought through the marketplace or from an insurance company in the past 12 months, and who were previously covered by either a plan they bought 34 through the marketplace or directly from an insurance company, reported they lost 20 or dropped their plan because 15 they could not afford it.7 Half of these adults were uninsured, 8 7 7 about a quarter had reenrolled You couldn’t afford Lost/changed job You didn’t pay your You missed the Your plan was no Some other reason* into the individual market, what you had to pay premium on time deadline to reenroll longer being offered 12 percent transitioned into for your health plan Medicaid, 7 percent enrolled in employer insurance, and 5 * 4% percent of adults ages 19 to 64 who were uninsured at the time of the survey or uninsured in the past 12 months and were previously covered by a plan bought on their own or through the marketplace reported they lost or dropped their marketplace coverage because they couldn’t get the health care they needed, 2% reported it was because they didn’t think they needed it, and percent enrolled into Medicare 1% reported it was because they moved. Respondents who reported “some other reason” cited lack of knowledge about their coverage options, among other reasons. (data not shown). Data: Commonwealth Fund Biennial Health Insurance Survey (2018). Source: Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do they Lack Coverage?: Findings from the Commonwealth * 4% percent of adults ages 19 to 64Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019). past 12 months and were previously covered by a Fund who were uninsured at the time of the survey or uninsured in the plan bought on their own or through the marketplace reported they lost or dropped their marketplace coverage because they couldn’t get the health care they needed, 2% reported it was because they didn’t think they needed it, and 1% reported it was because they moved. Respondents who reported “some other reason” cited lack of knowledge about their coverage options, among other reasons. Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 6 Majority of Adults Who Lost Coverage and Were Previously Covered by Medicaid Said They Were No Longer Eligible Majority of Adults Who Had Lost Coverage and Were Previously Covered by Medicaid Said They Were No Longer Eligible More than half (57%) of adults What was the main reason you lost or dropped your Medicaid coverage? who were either uninsured at What was the main reason you lost or dropped your Medicaid coverage? the time of the survey or had a gap in insurance coverage in the past 12 months and Percent of adults ages 19–64 who were uninsured at the time of the survey or uninsured in the past 12 months who were previously covered and were previously covered by Medicaid by Medicaid reported they lost their Medicaid coverage because they were no longer eligible. Fourteen percent said 57 they did not reenroll in time and 10 percent had moved.8 After losing Medicaid, about half of these adults remained uninsured, nearly one-third reenrolled in Medicaid, 14 14 14 10 percent enrolled in employer You were no longer eligible You did not reenroll in Medicaid You moved Some other reason* coverage, 3 percent gained when you needed to individual market coverage, and 3 percent gained Medicare * 4% percent of adults ages 19 to 64 who were uninsured at the time of the survey or uninsured in the past 12 months and were previously covered by Medicaid reported losing or dropping their Medicaid coverage because they couldn’t afford to pay for it and 3% reported it was because they couldn’t get the health care they needed. Respondents who reported “some other reason” cited a (data not shown). lack of knowledge about their coverage options and the complexity of the enrollment process, among other reasons. Data: Commonwealth Fund Biennial Health Insurance Survey (2018). Source: Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do they Lack Coverage?: Findings from the Commonwealth * 4% percent of adults ages 19 to 64Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. in the past 12 months and were previously covered by Fund who were uninsured at the time of the survey or uninsured 2019). Medicaid reported losing or dropping their Medicaid coverage because they couldn’t afford to pay for it and 3% reported it was because they couldn’t get the health care they needed. Respondents who reported “some other reason” cited a lack of knowledge about their coverage options and the complexity of the enrollment process, among other reasons. Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 7 More Adults Had Difficulty Finding Affordable Coverage in the Individual Market in 2018 vs. 2016 More Adults Had Difficulty Finding Affordable Coverage in the Individual Market in 2018 vs. 2016 The ACA’s subsidies and Total Health problem** <200% FPL 200%+ FPL reforms to the individual 2010 2016 2018 2010 2016 2018 2010 2016 2018 2010 2016 2018 market, such as banning preexisting condition Adults ages 19–64 with individual coverage* or 26 44 45 exclusions and premium who tried to buy it million million million setting based on health and in past three years who: gender, went into effect in 2014. Before these reforms, in 2010, Found it very difficult or impossible to find 60% 34% 42% 70% 42% 47% 64% 35% 44% 54% 32% 41% 60 percent of adults who had affordable coverage individual coverage or had tried to buy it in the past three Found it very difficult or years said it was very difficult impossible to find coverage 43% 25% 31% 53% 31% 36% 49% 26% 32% 35% 23% 31% they needed or impossible to find affordable coverage. By 2016, the share Has individual coverage* 46% 66% 61% of adults reporting difficulty or ended up buying a 12 29 27 36% 60% 59% 34% 63% 57% 57% 71% 64% finding affordable coverage in health insurance plan^ million million million the individual market fell by nearly half, to 34 percent. But Note: FPL = federal poverty level. * Bought in the past three years. ** Respondent rated their health status as fair or poor, or has any of the following chronic conditions: hypertension or high blood pressure; heart disease, including heart attack; diabetes; asthma, emphysema, or lung disease; high cholesterol. ^ Among those who ever tried buying health insurance on their own in the in 2018, this progress eroded past three years. somewhat: 42 percent of adults Data: Commonwealth Fund Biennial Health Insurance Surveys (2010, 2016, 2018). reported difficulty finding Source: Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do they Lack Coverage?: Findings from the Commonwealth affordable coverage. Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019). Note: FPL = federal poverty level. * Bought in the past three years. ** Respondent rated their health status as fair or poor, or has any of the following chronic conditions: hypertension or high blood pressure; heart disease, including heart attack; diabetes; asthma, emphysema, or lung disease; high cholesterol. ^ Among those who ever tried buying health insurance on their own in the past three years. Data: Commonwealth Fund Biennial Health Insurance Surveys (2010, 2016, 2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 8 Majority of Adults Give Their Health Insurance High Ratings Majority of Adults Give Their Health Insurance High Ratings Now thinking about your current health insurance coverage, Large majorities of insured adults continue to rate their how would you rate it? health insurance highly. In Now thinking about your current health insurance coverage, how would you rate it? 2018, 62 percent of adults with individual market plans and 84 Percent of adults ages 19–64 who were insured and viewed their health insurance as “good,” “very good,” percent with Medicaid rated or “excellent” their health coverage as “good,” Employer Medicaid Individual* “very good,” or “excellent.” Despite affordability concerns and changes made by Congress 83 84 82 82 and the Trump administration, 81 a majority of adults with 81 80 individual coverage continue 79 to give their health insurance 74 73 high marks. Significantly more 71 adults with Medicaid gave their 65 coverage high ratings in 2018 63 62 compared to 2010. 57 2010 2012 2014 2016 2018 * Individual coverage includes those who purchased insurance on and off the marketplaces. Data: Commonwealth Fund Biennial Health Insurance Survey (2010, 2012, 2014, 2016, 2018). Source: Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Why Do they Lack Coverage?: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019). * Individual coverage includes those who purchased insurance on and off the marketplaces. Data: Commonwealth Fund Biennial Health Insurance Survey (2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 9 POLICY RECOMMENDATIONS Affordability remains a key reason 30 million adults remain uninsured. Our findings show more than a third of uninsured adults who did not try to get coverage through the marketplaces cited affordability concerns. One-third of adults with a coverage gap who were previously insured through the individual market dropped their plans because they could not afford them. The survey also suggests a lack of knowledge among uninsured adults about their coverage options. While the national debate about health care is focused on more sweeping reforms, such as Medicare for All, federal and state policymakers have several options to help millions of people keep or gain coverage within the existing law. • Expand Medicaid without restrictions. Seventeen states have will implement a program in 2020, and one has submitted an yet to expand eligibility for Medicaid, leaving more than 3 application to do so.13 Alaska’s program reduced premiums by million people with incomes under poverty uninsured.9 In more than 20 percent in 2018.14 These lower costs particularly addition, encouraged by the Trump administration, nine states help people with incomes too high to qualify for ACA premium have secured approval from HHS to impose work requirements tax credits. Several congressional bills have proposed a federal in their Medicaid programs; another seven have submitted reinsurance program.15 applications to do so. A federal district court judge has halted the • Reinstate outreach and navigator funding for the 2020 open- implementation of work requirements in Kentucky, Arkansas, enrollment period. The administration has nearly eliminated and New Hampshire but not before more than 18,000 poor adults funding for advertising and assistance to help people enroll in in Arkansas lost their insurance coverage as a result.10 marketplace plans.16 Survey research indicates that people who • Lift the 400-percent-of-poverty cap on eligibility for marketplace received personal assistance when they shopped for coverage tax credits. In 2019, this action would help people with incomes were more likely to enroll than those who did not.17 Some exceeding $48,560 (individuals) and $100,400 (family of four) lawmakers have proposed reinstating this funding.18 better afford marketplace plans. The tax credits work by capping • Ban or place limits on short-term health plans and other the amount people pay toward their premiums at 9.86 percent of insurance that doesn’t comply with the ACA. The Trump income. Lifting the cap has a built-in phase-out: as income rises, administration loosened regulations on short-term plans that fewer people qualify, since premiums consume an increasingly don’t have to comply with the ACA, potentially leaving people smaller share of incomes. RAND researchers estimate that this who enroll in them exposed to high costs and insurance fraud. policy change would increase insurance coverage by nearly These plans also draw healthier people out of the marketplaces, 2 million and lower silver-plan premiums by nearly 3 percent as increasing premiums for those who remain and federal costs of healthier people enroll. It would cost the federal government an premium subsidies. Twenty-three states and D.C. have banned or estimated $10 billion annually.11 Legislation has been introduced placed limits on short-term insurance policies.19 Some lawmakers to lift the cap.12 have proposed a federal ban.20 • State or federal reinsurance. The ACA’s reinsurance program was • Make premium contributions for individual market plans fully effective in lowering marketplace premiums. After it expired in tax deductible. People who are self-employed are already allowed 2017, seven states implemented their own programs, four more to do this.21 commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 10 • Fix the so-called family coverage glitch. People with employer premium expenses that exceed 9.86 percent of their income are HOW WE CONDUCTED THIS STUDY eligible for marketplace subsidies if their income falls between 100 The Commonwealth Fund Biennial points at the 95 percent confidence and 400 percent of poverty. This then triggers a federal tax penalty Health Insurance Survey, 2018, was level. The RDD landline portion of the for their employers. There’s a catch: this provision applies only to conducted by SSRS from June 27 survey achieved a 8.4 percent response single-person policies, leaving many middle-income families caught to November 11, 2018. The survey rate and the RDD cellular phone in the “family coverage glitch.” Congress could help families by consisted of telephone interviews component achieved a 5.2 percent in English and Spanish and was response rate. pegging unaffordable employer plans to family policies instead of conducted among a random, nationally single policies. In 2016, Matthew Buettgens and colleagues estimated This survey is the eighth in a series representative sample of 4,225 adults of Commonwealth Fund surveys to more than 6 million people were affected by the glitch and fixing ages 19 to 64 living in the continental measure access to affordable health it would lower their spending on premiums from an average 12 United States. A combination of landline care over time. The previous surveys and cellular phone random-digit-dial percent of income to 6.3 percent, at a cost to the federal government were conducted by Princeton Survey (RDD) samples was used to reach of $3.7 billion to $6.5 billion.22 people. In all, 725 interviews were Research Associates International using the same stratified sampling conducted with respondents on • Inform people about their options. People who lose coverage landline telephones and 3,500 interviews strategy that was used in 2018, except during the year are eligible for special enrollment periods for ACA were conducted on cellular phones. the 2001, 2003, and 2005 surveys did not include a cellular phone random- marketplace coverage. Those eligible for Medicaid can sign up at any The sample was designed to generalize digit-dial sample. In 2001, the survey time. But research indicates that many people who lose employer to the U.S. adult population and to allow was conducted from April 27 through coverage do not use these options.23 The federal government, the separate analyses of responses of low- July 29, 2001, and included 2,829 adults states, and employers could increase awareness through advertising income households. Statistical results ages 19 to 64; in 2003, the survey was and education. are weighted to correct for the stratified conducted from September 3, 2003, sample design, the overlapping landline through January 4, 2004, and included • Reduce churn in Medicaid. Research shows that over a two-year and cellular phone sample frames, 3,293 adults ages 19 to 64; in 2005, the and disproportionate nonresponse survey was conducted from August period, one-quarter of Medicaid beneficiaries leave the program and that might bias results. The data are 18, 2005, to January 5, 2006, among become uninsured.24 Many do so because of administrative barriers, weighted to the U.S. adult population 3,352 adults ages 19 to 64; in 2010, the particularly the renewal process.25 By imposing work requirements, by age, sex, race/ethnicity, education, survey was conducted from July 14 as some states are doing, this involuntary disenrollment will household size, geographic region, to November 30, 2010, among 3,033 likely get worse. To help people stay continuously covered, the population density, and household adults ages 19 to 64; in 2012, the survey telephone use, using the U.S. Census federal government and the states could consider simplifying and Bureau’s 2017 Annual Social and was conducted from April 26 to August 19, 2012, among 3,393 adults ages 19 to streamlining the enrollment and reenrollment processes. Economic Supplement. 64; in 2014, the survey was conducted • Extend the marketplace open-enrollment period. The current open- The resulting weighted sample is from July 22 to December 14, 2014, representative of the approximately among 4,251 adults ages 19 to 64; and enrollment period lasts just 45 days. In 2019, eight states that run 193.9 million U.S. adults ages 19 to 64. in 2016, the survey was conducted from their own marketplaces have longer periods, some by as much as an The survey has an overall margin of July 12 to November 20, 2016, among additional 45 days.26 Other states, as well as the federal marketplace, sampling error of +/– 1.9 percentage 4,186 adults ages 19 to 64. could extend their enrollment periods as well. commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 11 Table 1. Uninsured Rates by Demographics Total (ages 19–64) Uninsured (rate) Uninsured (distribution) 2010 2018 2010 2018 2010 2018 Percent distribution 100% 100% 20% 12% 20% 12% Unweighted n 3065 4225 593 555 593 555 Millions 185.0 193.9 37.2 24.0 37.2 24.0 NOTES Age 19–34 34 32 27 17 46 44 * Respondent said health 35–49 33 30 20 12 34 30 status was fair or poor or 50–64 32 35 13 8 20 24 said they had at least one of the following chronic Gender Male 49 48 20 14 49 54 diseases: hypertension or Female 51 52 20 11 51 46 high blood pressure; heart Base: Young adults Male 51 51 29 19 54 58 disease; diabetes; asthma, (ages 19–34) Female 49 49 25 15 46 42 emphysema, or lung disease; high cholesterol; Race/Ethnicity White 64 59 15 9 47 42 depression or anxiety. African American 12 12 24 11 15 11 ** The following states Latino 16 18 39 24 31 35 have state-based Asian 3 4 9 10 1 3 marketplaces: CA, CO, CT, Other/Mixed 4 5 29 14 5 6 ID, MA, MD, MN, NY, RI, VT, WA, and the District Poverty status Less than 100% poverty 20 18 41 19 41 27 of Columbia. All other 100%–132% poverty 7 7 31 18 11 10 states were considered to 133%–249% poverty 18 19 26 17 23 26 have federally facilitated marketplaces. 250%–399% poverty 19 19 8 10 8 16 400% poverty or more 25 29 4 3 4 8 *** The following states expanded their Medicaid Don't know/Refused 11 7 23 22 12 13 program and began Health status No health problem 50 50 19 13 46 53 enrolling individuals in July Fair/Poor health status, or any chronic condition* 50 50 22 12 54 47 2018 or earlier: AK, AR, AZ, CA, CO, CT, DE, HI, IA, IL, Political affiliation Republican 23 22 14 9 16 16 IN, KY, LA, MA, MD, ME, MI, Democrat 32 28 19 8 31 18 MN, MT, ND, NH, NJ, NM, NV, Independent 23 23 16 11 19 21 NY, OH, OR, PA, RI, VA, VT, Something else 12 18 27 15 16 22 WA, WV, and the District of Columbia. All other states Marketplace type** State-based marketplace — 29 — 10 — 22 were considered to have Federally run marketplace — 71 — 13 — 76 not expanded. Medicaid expansion*** Expanded Medicaid — 64 — 9 — 48 ^^ Base: Full- and part-time Did not expand Medicaid — 35 — 18 — 51 employed adults ages Region Northeast 19 19 13 8 13 12 19–64. Distributions may not sum to 100 percent Midwest 22 21 16 11 17 18 because of "don't know" or South 37 37 24 16 44 47 refusal to respond. West 22 23 23 12 25 23 — Not applicable. Adult work status Full time 52 53 12 10 30 42 Part time 12 14 32 17 19 19 DATA Not working 36 33 28 14 50 38 Commonwealth Fund Employer size^^ Less than 100 employees 40 41 26 19 67 68 Biennial Health Insurance 100 or more employees 57 56 8 6 29 28 Surveys (2010 and 2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 12 NOTES 1. Robin A. Cohen, Emily P. Terlizzi, and Michael E. Martinez, Health Insurance 8. Four percent of adults ages 19 to 64 who were uninsured at the time of the Coverage: Early Release of Estimates from the National Health Interview survey or uninsured in the past 12 months and were previously covered by Survey, 2018 (National Center for Health Statistics, Centers for Disease Control Medicaid reported losing or dropping their Medicaid coverage because they and Prevention, May 2019). couldn’t afford to pay for it and 3% reported it was because they couldn’t get the health care they needed. Respondents who reported “some other reason” 2. David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on State cited a lack of knowledge about their coverage options and the complexity of Health System Performance: Deaths from Suicide, Alcohol, Drugs on the Rise; the enrollment process, among other reasons. Progress Expanding Health Care Coverage Stalls; Health Costs Are a Growing Burden (Commonwealth Fund, June 2019). 9. Estimate includes three states (Idaho, Nebraska, Utah) that passed ballot initiatives in 2018 to expand Medicaid but have not yet done so. See 3. Radley, Collins, and Hayes, 2019 Scorecard, 2019. Commonwealth Fund, “Status of Medicaid Expansion and Work Requirement Waivers,” interactive map, updated July 31, 2019; Rachel Garfield, Kendal 4. Research has found that nearly half of foreign-born Latinos are Orgera, and Anthony Damico, The Coverage Gap: Uninsured Poor Adults in undocumented immigrants. See Jens M. Krogstad and Mark H. Lopez, Hispanic States that Do Not Expand Medicaid (Henry J. Kaiser Family Foundation, June Immigrants More Likely to Lack Health Insurance than U.S.-Born (Pew Research 2018 and May 2019); and Matthew Buettgens, The Implications of Medicaid Center, Sept. 2014). Expansion in the Remaining States (Urban Institute, May 2018). 5. These adults would only be eligible for their state’s existing Medicaid 10. Benjamin D. Sommers et al., “Medicaid Work Requirements – Results from program, which is usually only available to children and very poor parents, or the First Year in Arkansas,” New England Journal of Medicine, published online unsubsidized plans in the marketplaces. June 19, 2019. 6. Three percent of uninsured adults ages 19 to 64 who did not visit the 11. Jodi Liu and Christine Eibner, Expanding Enrollment Without the marketplace reported it was because they had, or will have, insurance through Individual Mandate: Options to Bring More People into the Individual Market another source, 2% reported it was because the marketplaces were not open (Commonwealth Fund, Aug. 2018). for enrollment when they needed coverage, and 1% reported they went someplace else to look for health insurance. Respondents who reported “some 12. U.S. Senator for California, Dianne Feinstein, “Senators Introduce other reason” cited lack of time and citizenship status, among other reasons. Legislation to Improve Affordable Care Act, Make Coverage More Affordable for Middle-Class Families,” Press release, June 7, 2017. 7. Four percent of adults ages 19 to 64 who were uninsured at the time of the survey or uninsured in the past 12 months and were previously covered by a 13. Commonwealth Fund, “What Is Your State Doing to Affect Access to plan bought on their own or through the marketplace reported they lost or Adequate Health Insurance?,” interactive map, updated Aug. 22, 2019. dropped their marketplace coverage because they couldn’t get the health care they needed, 2% reported it was because they didn’t think they needed it, and 14. Rachel Schwab, Emily Curran, and Sabrina Corlette, Assessing the 1% reported it was because they moved. Respondents who reported “some Effectiveness of State-Based Reinsurance: Case Studies of Three States’ Efforts other reason” cited lack of knowledge about their coverage options, among to Bolster Their Individual Markets (Robert Wood Johnson Foundation, Nov. other reasons. 2018). commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 13 15. Sara R. Collins and Roosa Tikkanen, “The Many Varieties of Universal 22. Matthew Buettgens, Lisa Dubay, and Genevieve M. Kenney, “Marketplace Coverage,” interactive, Mar. 6, 2019. Subsidies: Changing The ‘Family Glitch’ Reduces Family Health Spending But Increases Government Costs,” Health Affairs 35, no. 7 (July 2016): 1167–75. 16. Sara R. Collins, “Consumers Shopping for Health Plans Are Left in the Dark by Trump Administration,” To the Point (blog), Commonwealth Fund, July 19, 23. Matthew Buettgens, Stan Dorn, and Hannah Recht, More Than 10 Million 2018. Uninsured Could Obtain Marketplace Coverage Through Special Enrollment Periods (Robert Wood Johnson Foundation and Urban Institute, Nov. 2015). 17. Sara R. Collins, Munira Z. Gunja, and Michelle M. Doty, Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? 24. Sara R. Collins, Sherry A. Glied, and Adlan Jackson, The Potential Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, Implications of Work Requirements for the Insurance Coverage of Medicaid March–June 2017 (Commonwealth Fund, Sept. 2017). Beneficiaries: The Case of Kentucky (Commonwealth Fund, Oct. 2018). 18. Collins and Tikkanen, “Many Varieties of Universal Coverage,” 2019. 25. Benjamin D. Sommers, “Loss of Health Insurance Among Non-Elderly Adults in Medicaid,” Journal of General Internal Medicine 24, no. 1 (Jan. 2009): 19. Commonwealth Fund, “What Is Your State Doing?,” 2019. 1–7. 20. Collins and Tikkanen, “Many Varieties of Universal Coverage,” 2019. 26. Commonwealth Fund, “What Is Your State Doing?,” 2019. 21. Timothy S. Jost, “Fixing Our Most Pressing Health Insurance Problems: A Bipartisan Path Forward,” To the Point (blog), Commonwealth Fund, July 13, 2017. commonwealthfund.org Survey Brief, August 2019 Who Are the Remaining Uninsured, and Why Do They Lack Coverage? 14 ABOUT THE AUTHORS ACKNOWLEDGMENTS Munira Z. Gunja, M.P.H., is senior researcher in the Health Care The authors thank Robyn Rapoport, Rob Manley, and Erin Czyzewicz Coverage and Access program at the Commonwealth Fund. Ms. Gunja of SSRS, and David Blumenthal, Elizabeth Fowler, Chris Hollander, joined the Fund from the U.S. Department of Health and Human Deborah Lorber, Paul Frame, Jen Wilson, Gabriella Aboulafia, Corinne Services in the office of the Assistant Secretary for Planning and Lewis, and Roosa Tikkanen of the Commonwealth Fund. Evaluation (ASPE), Division of Health Care Access and Coverage, where she received the Secretary’s Award for Distinguished Service. Before joining ASPE, Ms. Gunja worked for the National Cancer Institute where Editorial support was provided by Deborah Lorber. she conducted data analysis for numerous studies featured in scientific journals. She graduated from Tulane University with a B.S. in public For more information about this brief, please contact: health and international development and an M.P.H. in epidemiology. Munira Z. Gunja, M.P.H. Senior Researcher, Health Care Coverage and Access Sara R. Collins, Ph.D., is vice president for Health Care Coverage and The Commonwealth Fund Access at the Commonwealth Fund. An economist, Dr. Collins joined mgcmwf.org the Fund in 2002 and has led the Fund’s national program on health insurance since 2005. She also directs the Fund’s research initiative on Tracking Health System Performance. Since joining the Fund, she has led several national surveys on health insurance and authored numerous reports, issue briefs, and journal articles on health insurance coverage and policy. She has provided invited testimony before several Congressional committees and subcommittees. Prior to joining the Fund, Dr. Collins was associate director/senior research associate at the New York Academy of Medicine. Earlier in her career, she was an associate editor at U.S. News & World Report, a senior economist at Health Economics Research, and a senior health policy analyst in the New York City Office of the Public Advocate. Dr. Collins holds a Ph.D. in economics from George Washington University. commonwealthfund.org Survey Brief, August 2019 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.