SURVEY BRIEF FEBRUARY 2019 Health Insurance Coverage What does health insurance coverage look like for Americans today, more than eight years after the Affordable Care Act’s passage? In this brief, we present findings from the Eight Years After the ACA: Commonwealth Fund’s latest Biennial Health Insurance Survey to assess the extent and quality of coverage for U.S. working-age adults. Conducted since 2001, the survey Fewer Uninsured uses three measures to gauge the adequacy of people’s coverage: • whether or not they have insurance Americans and • if they have insurance, whether they have experienced a gap in their coverage in the prior year Shorter Coverage • whether high out-of-pocket health care costs and deductibles are causing them to be underinsured, despite having continuous coverage throughout the year. Gaps, But More As the findings highlighted below show, the greatest deterioration in the quality and comprehensiveness of coverage has occurred among people in employer plans. More than half of Americans under age 65 — about 158 million people — get their health Underinsured insurance through an employer, while about one-quarter either have a plan purchased through the individual insurance market or are enrolled in Medicaid.1 Although the ACA has expanded and improved coverage options for people without access to a job- based health plan, the law largely left the employer market alone.2 SURVEY HIGHLIGHTS Today, 45 percent of U.S. adults ages 19 to 64 are inadequately insured — nearly the same as in 2010 — though important shifts have taken place. Sara R. Collins Vice President ompared to 2010, many fewer adults are uninsured today, and the duration of C The Commonwealth Fund coverage gaps people experience has shortened significantly. Herman K. Bhupal Despite actions by the Trump administration and Congress to weaken the ACA, the Program Associate adult uninsured rate was 12.4 percent in 2018 in this survey, statistically unchanged The Commonwealth Fund from the last time we fielded the survey in 2016. Michelle M. Doty Vice President The Commonwealth Fund Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 2 ore people who have coverage are underinsured now than M in 2010, with the greatest increase occurring among those in WHO IS UNDERINSURED? employer plans. In this analysis, we use a measure of underinsurance that accounts People who are underinsured or spend any time uninsured for an insured adult’s reported out-of-pocket costs over the course report cost-related problems getting care and difficulty paying of a year, not including insurance premiums, as well as his or her plan medical bills at at higher rates than those with continuous, deductible. (The measure was first used in the Commonwealth Fund’s adequate coverage. 2003 Biennial Health Insurance Survey.*) These actual expenditures and the potential risk of expenditures, as represented by the deductible, Federal and state governments could enact policies to extend are then compared with household income. Specifically, we consider the ACA’s health coverage gains and improve the cost protection people who are insured all year to be underinsured if: provided by individual-market and employer plans. • their out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 10 percent or more of The 2018 Commonwealth Fund Biennial Heath Insurance Survey household income; or included a nationally representative sample of 4,225 adults ages 19 • their out-of-pocket costs, excluding premiums, over to 64. SSRS conducted the telephone survey between June 27 and the prior 12 months are equal to 5 percent or more of November 11, 2018. 3 (See “How We Conducted This Study” for more household income for individuals living under 200 percent detail.) of the federal poverty level ($24,120 for an individual or $49,200 for a family of four); or • their deductible constitutes 5 percent or more of household income. The out-of-pocket cost component of the measure is only triggered if a person uses his or her plan to obtain health care. The deductible component provides an indicator of the financial protection the plan offers and the risk of incurring costs before someone gets health care. The definition does not include other dimensions of someone’s health plan that might leave them potentially exposed to costs, such as copayments or uncovered services. It therefore provides a conservative measure of underinsurance in the United States. * Cathy Schoen et al., “Insured But Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, published online June 14, 2005. commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 3 Since the ACA, Fewer Adults Are Uninsured, but More Are Underinsured Since the ACA, Fewer Adults Are Uninsured, but More Are Underinsured Percent of adults ages 19–64 Compared to 2010, when the ACA became law, fewer Insured all year, not underinsured Insured all year, underinsured people today are uninsured, Insured now, had a coverage gap Uninsured now but more people are 100% underinsured. Of the 194 90% million U.S. adults ages 19 to 64 in 2018, an estimated 87 80% million, or 45 percent, were 70% 56% 54% 55% 56% 55% 65% 63% inadequately insured (see 60% Tables 1 and 2). Despite actions by the 50% Trump administration and 40% Congress to weaken the 16% 16% 17% 30% 9% 9% 22% 23% ACA, our survey found no 8% 10% statistically significant change 20% 9% 9% 13% 10% 10% in the adult uninsured rate 10% 18% 20% 19% by late 2018 compared to 17% 16% 12% 12% 2016 (Table 3). This finding 0% is consistent with recent 2003 2005 2010 2012 2014 2016 2018 federal surveys, but other Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket surveys (including private costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the time of the survey but were uninsured at any point in the 12 months prior to the survey field date. “Uninsured now” refers to adults who reported being uninsured at the time ofCommonwealth Fund other the survey. Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding surveys) have found small Data: Commonwealth Fund Biennial Healthincome; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% premiums, equaled 10% or more of Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the time of increases in uninsured rates Source: Sara R. Collins, Herman K. prior to the surveyM. Doty, Health Insurance Coverage Eight Years After thereported being the survey but were uninsured at any point in the 12 months Bhupal, and Michelle field date. “Uninsured now” refers to adults who ACA: Fewer Uninsured Americans and since 2016 (see Changes in U.S. Shorter Coverage Gaps, But More Underinsured — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, uninsured at the time of the survey. Feb. 2019). Uninsured Rates Since 2013). Data: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 4 Since the ACA, Gaps in People’s Coverage Have Been Shorter Since the ACA, Gaps in People’s Coverage Have Been Shorter Percent of adults ages 19–64 insured now but had a coverage gap in past year While there has been no change since 2010, Coverage gap of 6 months or less Coverage gap of 1 year or more statistically speaking, in 80 the proportion of people who are insured now but 70 have experienced a recent 65 time without coverage, 61 these reported gaps are 60 54 of much shorter duration 57 on average than they were 50 47 55 before the ACA. In 2018, 38 61 percent of people who 40 35 reported a coverage gap said 39 38 it has lasted for six months 30 31 or less, compared to 31 percent who said they had 20 25 been uninsured for a year or longer. This is nearly a 10 reverse of what it was like in 2012, two years before 0 2001 2010 2012 2014 2016 2018 the ACA’s major coverage expansions. In that year, Data: Commonwealth Fund Biennial Health Insurance Surveys (2001, 2010, 2012, 2014, 2016, 2018). 57 percent of adults with a coverage gap reported Source: Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth was for a year or longer, it Fund, Feb. 2019). while one-third said it was a Data: Commonwealth Fund Biennial Health Insurance Surveys (2001, 2010, 2012, 2014, 2016, 2018). shorter gap. commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 5 There Has Been Some Improvement in Long-Term Uninsured Rates There Has Been Some Improvement in Long-Term Uninsured Rates Percent of adults ages 19–64 who are uninsured now There also has been some improvement in long-term Uninsured for 6 months or less Uninsured for more than 2 years uninsured rates. Among 80 adults who were uninsured at the time of the survey, 54 70 percent reported they had 72 been without coverage for 60 more than two years, down 62 63 64 from 72 percent before the 50 ACA coverage expansions 53 54 went into effect. The share 40 of those who had been uninsured for six months or 30 less climbed to 20 percent, nearly double the rate prior 21 20 19 to the coverage expansions. 20 12 13 11 10 0 2001 2010 2012 2014 2016 2018 Data: Commonwealth Fund Biennial Health Insurance Surveys (2001, 2010, 2012, 2014, 2016, 2018). Source: Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Surveys (2001, 2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 6 More Adults Are Underinsured, with the Greatest Growth Occurring Among Those withAdults Are Underinsured, with the Greatest Growth Occurring Among Those with More Employer Coverage Employer Coverage Percent of adults ages 19–64 insured all year who were underinsured Of people who were insured continuously throughout Total Employer-provided coverage Individual coverage^ 70 2018, an estimated 44 million were underinsured because of high out-of-pocket costs 60 and deductibles (Table 1). This is up from an estimated 50 45 44 29 million in 2010 (data 42 not shown). The most 40 37 37 likely to be underinsured are people who buy plans 29 30 28 on their own through the 22 23 23 28 individual market including 19 the marketplaces. However, 20 17 24 13 20 20 the greatest growth in the 12 17 number of underinsured 10 10 12 adults is occurring among those in employer health 0 2003 2005 2010 2012 2014 2016 2018 plans. Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. Total includes adults with coverage through Medicaid and Medicare. Respondents may have had another type of coverage at some point during the year, but had coverage for the entire previous 12 months. ^ For 2014 and 2016, includes those who get their individual coverage through the marketplace and outside of the marketplace. Notes: “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding Data: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. Total includes adultsM. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Source: Sara R. Collins, Herman K. Bhupal, and Michelle with coverage through Medicaid and Medicare. Respondents may have had another type of coverage atCoverage Gaps, But More UnderinsuredhadFindings from the Commonwealth Fund 12 months. ^ Insurance Survey, 2018 (Commonwealth Fund, Shorter some point during the year, but — coverage for the entire previous Biennial Health For 2014 and 2016, includes those who get their individual coverage through the marketplace and outside of the marketplace. Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 7 Why Are Insured Americans Spending So Much of Their Income on Health Care Costs? Several factors may be contributing to high underinsured rates among adults in individual market plans and rising rates in employer plans: 1. Although the Affordable Care Act’s reforms to the individual market coverage are somewhat more likely to have individual market have provided consumers with greater health problems than they were in 2010, which means they protection against health care costs, many moderate- also have higher costs. income Americans have not seen gains. The ACA’s essential health benefits package, cost-sharing reductions for lower- 3. While plans in the employer market historically have income families, and out-of-pocket cost limits have helped provided greater cost protection than plans in the make health care more affordable for millions of Americans. individual market, businesses have tried to hold down But while the cost-sharing reductions have been particularly premium growth by asking workers to shoulder an important in lowering deductibles and copayments for increasing share of health costs, particularly in the people with incomes under 250 percent of the poverty level form of higher deductibles. 5 While the ACA’s employer (about $62,000 for a family of four), about half of people who mandate imposed a minimum coverage requirement on large purchase marketplace plans, and all of those buying plans companies, the requirement amounts to just 60 percent of directly from insurance companies, do not have them.4 typical person’s overall costs. This leaves the potential for high plan deductibles and copayments. 2. The bans against insurers excluding people from coverage because of a preexisting condition and rating 4. Growth in Americans’ incomes has not kept pace with based on health status have meant that individuals with growth in health care costs. Even when health costs rise greater health needs, and thus higher costs, are now more slowly, they can take an increasingly larger bite out of able to get health insurance in the individual market. incomes. Not surprisingly, the survey data show that people with commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 8 Fewer Adults Report Not Getting Needed Care Because of Costs, but Gains Have Fewer Adults Report Not Getting Needed Care Because of Costs, but Gains Have Stalled in Stalled in Recent Years Recent Years Percent of adults ages 19–64 who reported any of the following It is well documented that cost-related access problems in the past year: people who gained coverage under the ACA’s expansions • Had a medical problem but did not visit doctor or clinic have better access to health • Did not fill a prescription care as a result.6 This has • Skipped recommended test, treatment, or follow-up led to overall improvement • Did not get needed specialist care in health care access, as indicated by multiple surveys.7 In 2014, the year 43 the ACA’s major coverage 41 37 37 36 expansions went into 34 35 effect, the share of adults in our survey who said that cost prevented them from getting health care that they needed, such as prescription medication, dropped significantly (Table 4). But there has been no 2003 2005 2010 2012 2014 2016 2018 significant improvement since then. Data: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). Source: Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 9 Inadequate Coverage Is Associated with More Cost-Related Problems Getting Needed Care Inadequate Coverage Is Associated with More Cost-Related Problems Getting Needed Care Percent of adults ages 19–64 who had any of four access problems in past year because of cost* The lack of continued improvement in Insured all year, not underinsured Insured all year, underinsured overall access to care Insured now, had a coverage gap Uninsured now nationally reflects the fact that coverage gains have plateaued, and underinsured rates have 59 climbed. People who 56 experience any time 49 uninsured are more likely 41 than any other group to 35 34 36 35 delay getting care because 32 29 of cost (Table 5). And among 25 27 23 24 23 people with coverage 17 all year, those who were 11 11 underinsured reported 10 7 cost-related delays in getting Did not fill prescription Skipped recommended Had a medical problem, Did not get needed At least one of four care at nearly double the test, treatment, or did not visit doctor specialist care access problems rate of those who were not follow-up or clinic because of cost underinsured. Notes: * Includes any of the following because of cost: did not fill a prescription; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor or clinic; did not see a specialist when needed. “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refersIncludes any of the followingtime of the survey but were uninsured at any point in the 12 months prior to the medical test, treatment,now” refers to adults who reported being Notes: * to adults who were insured at the because of cost: did not fill a prescription; skipped recommended survey field date. “Uninsured or follow-up; uninsured at the time of the survey. not visit doctor or clinic; did not see a specialist when needed. “Underinsured” refers to adults who were insured had a medical problem but did Data: Commonwealth Fund Biennial Healthfollowing: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, all year but experienced one of the Insurance Survey (2018). excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the timeMichelle survey but were uninsured at any point inAfter 12 months prior to Source: Sara R. Collins, Herman K. Bhupal, and of the M. Doty, Health Insurance Coverage Eight Years the the ACA: Fewer Uninsured Americans and the survey field date. “Uninsured now” refers to adults who reported being Findings from the Commonwealthsurvey. Shorter Coverage Gaps, But More Underinsured — uninsured at the time of the Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 10 Fewer Adults Have Difficulty Paying Their Medical Bills, but the Improvement FewerStalled Has Adults Have Difficulty Paying Their Medical Bills, but the Improvement Has Stalled Percent of adults ages 19–64 who reported any of the following There was modest but medical bill or debt problems in the past year: significant improvement following the ACA’s • Had problems paying or unable to pay medical bills coverage expansions in • Contacted by a collection agency for unpaid medical bills the proportion of all U.S. • Had to change way of life to pay bills adults who reported having • Medical bills/debt being paid off over time difficulty paying their medical bills or said they were paying off medical debt 41 over time (Table 4). Federal 40 35 37 34 37 surveys have found similar improvements.8 However, those gains have stalled. 2005 2010 2012 2014 2016 2018 Data: Commonwealth Fund Biennial Health Insurance Surveys (2005, 2010, 2012, 2014, 2016, 2018). Source: Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Surveys (2005, 2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 11 Inadequate Coverage Is Associated with More Problems Paying Medical Bills Inadequate Coverage Is Associated with More Problems Paying Medical Bills Percent of adults ages 19–64 who had medical bill or debt problems in past year* Inadequate insurance coverage leaves people Insured all year, not underinsured Insured all year, underinsured exposed to high health care Insured now, had a coverage gap Uninsured now costs, and these expenses can quickly turn into medical debt. More than half of uninsured adults and 56 insured adults who have 52 had a coverage gap reported 47 47 that they had had problems 40 paying medical bills or were 33 33 paying off medical debt 30 29 26 26 26 25 over time (Table 6). Among 22 people who had continuous 19 19 16 insurance coverage, the rate 13 9 6 of medical bill and debt problems is nearly twice as Had problems paying Contacted by collection Had to change Medical bills/debt Any bill problem or or unable to pay agency for unpaid way of life to pay bills being paid over time medical debt high for the underinsured medical bills medical bills as it is for people who are not underinsured. Notes: * Includes any of the following: had problems paying or unable to pay medical bills; contacted by collection agency for unpaid medical bills; had to change way of life to pay bills; medical bills/debt being paid over time. “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the time of the survey but were uninsured at any point in the 12 months prior to the survey field date. “Uninsured now” refers to adults who reported being uninsured at the time any of the following: had problems paying or unable to pay medical bills; contacted by collection agency for unpaid medical Notes: * Includes of the survey. bills; had to change way of life to pay bills; medical bills/debt being paid over time. “Underinsured” refers to adults who were insured all year but Data: Commonwealth Fund Biennial Health Insurance Survey (2018). experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or moreSource: Sara R. Collins, Herman K. Bhupal, and Michelle M.deductiblesInsurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and of income if low-income (<200% of poverty); or Doty, Health equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the More Underinsured — Findings from the Commonwealth Fundthe 12 monthsInsurance the survey (Commonwealth Fund, Shorter Coverage Gaps, But time of the survey but were uninsured at any point in Biennial Health prior to Survey, 2018 field date. “Uninsured now” refers to adults who reported being uninsured at the time of the survey. Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 12 Continuously Insured Adults, Including Those Underinsured, Are More Likely to Get Continuously Care Adults, Including Those Underinsured, Are More Likely to Get Preventive Insured Preventive Care Percent of adults ages 19–64 Having continuous Insured all year, not underinsured Insured all year, underinsured coverage makes a significant Insured now, had a coverage gap Uninsured now difference in whether people have a regular 94 source of care, get timely 93 94 94 89 preventive care, or receive 84 recommended cancer 79 76 screenings. Adults with 72 68 coverage gaps or those who 63 were uninsured when they responded to the survey 48 44 44 were the least likely to have gotten preventive care and 30 cancer screenings in the 20 recommended time frame. Regular source Blood pressure Cholesterol Seasonal of care checked checked flu shot Notes: “Continuously insured” refers to adults who were insured for the full year up to and on the survey field date. “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10%insured of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); Notes: “Continuously insured” refers to adults who were or more for the full year up to and on the survey field date. “Underinsured” refers or deductibles equaled 5% or more of income. “Insured now, had a coveragefollowing: to adults who were insured at the time of the surveyequaled uninsured at any point in the 12 months prior to to adults who were insured all year but experienced one of the gap” refers out-of-pocket costs, excluding premiums, but were 10% or more of the survey field date. “Uninsured now” refers to adults who reported being uninsured at the time of the survey. Respondents were asked if they: had their blood pressure checked within the past two years (in past year if has hypertension or high blood pressure); had their cholesterol checked in past five years (in past (<200% of poverty); or deductibles high cholesterol); and had their income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income year if has hypertension, heart disease, or equaled seasonal flu shot within the past 12 months. had a coverage gap” refers to adults who were insured at the time of the survey but were uninsured at any 5% or more of income. “Insured now, Data: Commonwealth Fund Biennial Healthsurvey field date. “Uninsured now” refers to adults who reported being uninsured at the time of the survey. point in the 12 months prior to the Insurance Survey (2018). Respondents were asked if they: had their blood pressure checked within the past two years (in past year if has hypertension or high blood pressure); had their cholesterolSource: Sara R.past five years (in past year Michelle M. Doty, Healthheart disease, or high cholesterol); and had their checked in Collins, Herman K. Bhupal, and if has hypertension, Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and seasonal flu shot within the past 12 months. Gaps, But More Underinsured — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Shorter Coverage Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 13 Continuously Insured Adults, Including Those Underinsured, Are More Likely to Get Cancer Screenings Continuously Insured Adults, Including Those Underinsured, Are More Likely to Get Cancer Screenings Percent of adults ages 19–64 Being underinsured, Insured all year, not underinsured Insured all year, underinsured however, does not seem Insured now, had a coverage gap Uninsured now to reduce the likelihood of having a usual source of care or receiving timely preventive care or cancer screens — provided a 73 72 person has continuous 70 71 71 coverage. This is likely 63 because the ACA requires 60 53 insurers and employers 48 to cover recommended preventive care and 38 35 cancer screens without 32 cost-sharing. Even prior to the ACA, a majority of employer plans provided predeductible coverage of Received Pap test Received mammogram Received colon cancer screening preventive services.9 Notes: “Continuously insured” refers to adults who were insured for the full year up to and on the survey field date. “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income (<200% of poverty); Notes: “Continuously insured” refers to adults who were insured for the full year up to and on the survey field date. “Underinsured” refers or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the time of the survey but were uninsured at any point in the 12 months prior to the adultsfield date. “Uninsured now” refers to experienced one being uninsured at the time of the survey. Respondents were asked if they: received a Pap test within the past three years for to survey who were insured all year but adults who reported of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of females ages 21–64, received a mammogram within the past two years for females ages 40–64, and received a colon(<200% of poverty); or deductibles equaled ages 50–64. income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low-income cancer screening within the past five years for adults Data:or more of income.Biennial Health Insurance Survey (2018). refers to adults who were insured at the time of the survey but were uninsured at any 5% Commonwealth Fund “Insured now, had a coverage gap” point in the 12 months prior to the survey field date. “Uninsured now” refers to adults who reported being uninsured at the time of the survey. Respondents were asked if they: received a Pap test within the pastand Michelle M.for females ages 21–64, received a mammogram within the Source: Sara R. Collins, Herman K. Bhupal, three years Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and past two years for females agesShorter Coverage Gaps, But colon cancer screening within the past five years for adults ages 50–64. 40–64, and received a More Underinsured — Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Feb. 2019). Data: Commonwealth Fund Biennial Health Insurance Survey (2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 14 CONCLUSION AND POLICY IMPLICATIONS the ACA, potentially leaving people who enroll in them exposed U.S. working-age adults are significantly more likely to have health to high costs and insurance fraud. These plans also will draw insurance since the ACA became law in 2010. But the improvement healthier people out of the marketplaces, increasing premiums in uninsured rates has stalled. In addition, more people have health for those who remain and federal costs of premium subsidies. plans that fail to adequately protect them from health care costs, with Twenty-three states have banned or placed limits on short-term the fastest deterioration in cost protection occurring in the employer insurance policies. Some lawmakers have proposed a federal ban. market. The ACA made only minor changes to employer plans, and • Reinsurance, either state or federal. The ACA’s reinsurance the erosion in cost protection has taken a bite out of the progress program was effective in lowering marketplace premiums. After it made in Americans’ health coverage since the law’s enactment. expired in 2017, several states implemented their own reinsurance Both the federal government and the states, however, have the ability programs.12 Alaska’s program reduced premiums by 20 percent in to extend the law’s coverage gains and improve the cost protection 2018. These lower costs particularly help people whose incomes of both individual-market and employer plans. Here is a short list of are too high to qualify for ACA premium tax credits. More states policy options: are seeking federal approval to run programs in their states. Several congressional bills have proposed a federal reinsurance program. Increase Coverage • Reinstate outreach and navigator funding for the 2020 open- • Expand Medicaid without restrictions. The 2018 midterm elections enrollment period. The administration has nearly eliminated moved as many as five states closer to joining the 32 states that, funding for advertising and assistance to help people enroll in along with the District of Columbia, have expanded eligibility marketplace plans.13 Research has found that both activities for Medicaid under the ACA.10 As many as 300,000 people are effective in increasing enrollment.14 Some lawmakers have may ultimately gain coverage as a result.11 But, encouraged by proposed reinstating this funding. the Trump administration, several states are imposing work • Lift the 400-percent-of-poverty cap on eligibility for marketplace requirements on people eligible for Medicaid — a move that tax credits. This action would help people with income exceeding could reverse these coverage gains. So far, the U.S. Department $100,000 (for a family of four) better afford marketplace plans. The of Health and Human Services (HHS) has approved similar tax credits work by capping the amount people pay toward their work-requirement waivers in seven states and is considering premiums at 9.86 percent. Lifting the cap has a built in phase out: applications from at least seven more. Arkansas imposed a work as income rises, fewer people qualify, since premiums consume an requirement last June, and, to date, more than 18,000 adults have increasingly smaller share of incomes. RAND researchers estimate lost their insurance coverage as a result. that this policy change would increase enrollment by 2 million • Ban or place limits on short-term health plans and other insurance and lower marketplace premiums by as much as 4 percent as that doesn’t comply with the ACA. The Trump administration healthier people enroll. It would cost the federal government an loosened regulations on short-term plans that don’t comply with estimated $10 billion annually.15 Legislation has been introduced to lift the cap. commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 15 • Make premium contributions for individual market plans fully tax • Extend the marketplace open-enrollment period. The current deductible. People who are self-employed are already allowed to open-enrollment period lasts just 45 days. Six states that run do this.16 their own marketplaces have longer periods, some by as much • Fix the so-called family coverage glitch. People with employer as an additional 45 days. Other states, as well as the federal premium expenses that exceed 9.86 percent of their income marketplace, could extend their enrollment periods as well. are eligible for marketplace subsidies, which trigger a federal Improve Individual-Market Plans’ Cost Protections tax penalty for their employers. There’s a catch: this provision • Fund and extend the cost-sharing reduction subsidies. The Trump applies only to single-person policies, leaving many middle- administration eliminated payments to insurers for offering income families caught in the “family coverage glitch.” Congress plans with lower deductibles and copayments. Insurers, which could lower many families’ premiums by pegging unaffordable by law must still offer reduced-cost plans, are making up the coverage in employer plans to family policies instead of single lost revenue by raising premiums. But this fix, while benefiting policies.17 enrollees who are eligible for premium tax credits, has distorted both insurer pricing and consumer choice.21 In addition, it is Reduce Coverage Gaps unknown whether the administration’s support for the fix • Inform the public about their options. People who lose coverage will continue in the future, creating uncertainty for insurers.22 during the year are eligible for special enrollment periods for Congress could reinstate the payments to insurers and consider ACA marketplace coverage. Those eligible for Medicaid can sign making the plans available to people with higher earnings. up at any time. But research indicates that many people who • Increase the number of services excluded from the deductible. lose employer coverage do not use these options.18 The federal Most plans sold in the individual market exclude certain government, the states, and employers could increase awareness services from the deductible, such as primary care visits and of insurance options outside the open-enrollment periods certain prescriptions.23 As the survey data suggest, these types through advertising and education. of exclusions appear to be important in ensuring access to • Reduce churn in Medicaid. Research shows that over a two-year preventive care among people who have coverage but are period, one-quarter of Medicaid beneficiaries leave the program underinsured. In 2016, HHS provided a standardized plan and become uninsured.19 Many do so because of administrative option for insurers that excluded eight health services — barriers.20 By imposing work requirements, as some states are including mental health and substance-use disorder outpatient doing, this involuntary disenrollment is likely to get worse. To visits and most prescription drugs — from the deductible at the help people stay continuously covered, the federal government silver and gold level.24 The Trump administration eliminated and the states could consider simplifying and streamlining the the option in 2018. Congress could make these exceptions enrollment and reenrollment processes. mandatory for all plans. commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 16 Improve Employer Plans’ Cost Protections • Protect consumers from surprise medical bills. Several states • Increase the ACA’s minimum level of coverage. Under the ACA, have passed laws that protect patients and their families from people in employer plans may become eligible for marketplace unexpected medical bills, generally from out-of-network tax credits if the actuarial value of their plan is less than 60 providers.27 A bipartisan group of U.S. senators has proposed percent, meaning that under 60 percent of health care costs, federal legislation to protect consumers, including people on average, are covered. Congress could increase this to the 70 enrolled in employer and individual-market plans. percent standard of silver-level marketplace plans, or even higher. Health care costs are primarily what’s driving growth in premiums • Require deductible exclusions. Congress could require employers across all health insurance markets. Employers and insurers to increase the number of services that are covered before someone have kept premiums down by increasing consumers’ deductibles meets their deductible. Most employer plans exclude at least and other cost-sharing, which in turn is making more people some services from their deductibles.25 Congress could specify a underinsured. This means that policy options like the ones we’ve minimum set of exclusions for employer plans that might resemble highlighted above will need to be paired with efforts to slow medical the standardized-choice options that once existed for ACA plans. spending. These could include changing how health care is organized • Refundable tax credits for high out-of-pocket costs. Congress could and providers are paid to achieve greater value for health care dollars make refundable tax credits available to help insured Americans and better health outcomes.28 The government also could tackle pay for qualifying out-of-pocket costs that exceed a certain rising prescription drug costs29 and use antitrust laws to combat the percentage of their income.26 growing concentration of insurer and provider markets.30 commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 17 HOW WE CONDUCTED THIS STUDY error of +/– 1.9 percentage points at the 95 percent confidence level. The The Commonwealth Fund Biennial Health Insurance Survey, 2018, was RDD landline portion of the survey achieved a 8.4 percent response rate and conducted by SSRS from June 27 to November 11, 2018. The survey the RDD cellular phone component achieved a 5.2 percent response rate. consisted of telephone interviews in English and Spanish and was conducted We also report estimates from the 2001, 2003, 2005, 2010, 2012, 2014, and among a random, nationally representative sample of 4,225 adults ages 19 2016 Commonwealth Fund Biennial Health Insurance Surveys. These surveys to 64 living in the continental United States. A combination of landline and were conducted by Princeton Survey Research Associates International cellular phone random-digit dial samples was used to reach people. In all, 725 using the same stratified sampling strategy that was used in 2018, except the interviews were conducted with respondents on landline telephones and 2001, 2003, and 2005 surveys did not include a cellular phone random-digit 3,500 interviews were conducted on cellular phones. dial sample. In 2001, the survey was conducted from April 27 through July The sample was designed to generalize to the U.S. adult population and to 29, 2001, and included 2,829 adults ages 19 to 64; in 2003, the survey was allow separate analyses of responses of low-income households. Statistical conducted from September 3, 2003, through January 4, 2004, and included results are weighted to correct for the stratified sample design, the 3,293 adults ages 19 to 64; in 2005, the survey was conducted from August overlapping landline and cellular phone sample frames, and disproportionate 18, 2005, to January 5, 2006, among 3,352 adults ages 19 to 64; in 2010, the nonresponse that might bias results. The data are weighted to the U.S. adult survey was conducted from July 14 to November 30, 2010, among 3,033 population by age, sex, race/ethnicity, education, household size, geographic adults ages 19 to 64; in 2012, the survey was conducted from April 26 to region, population density, and household telephone use, using the U.S. August 19, 2012, among 3,393 adults ages 19 to 64; in 2014, the survey was Census Bureau’s 2017 Annual Social and Economic Supplement. conducted from July 22 to December 14, 2014, among 4,251 adults ages 19 The resulting weighted sample is representative of the approximately 193.9 to 64; and in 2016, the survey was conducted from July 12 to November 20, million U.S. adults ages 19 to 64. The survey has an overall margin of sampling 2016, among 4,186 adults ages 19 to 64. commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 18 CHANGES IN U.S. UNINSURED RATES SINCE 2013 Uninsured Rate for Adults Compared to Other Surveys Since 2013 Preimplementation uninsured rate (%) Lowest uninsured rate (%) Current uninsured rate (%) Survey [95% CI] [95% CI] [95% CI] Commonwealth Fund Biennial Health Insurance Surveya 19.3% [17.5%–21.3%] 12.0% [10.7%–13.52%] (July–Nov. 2016) 12.4% [11.2%–13.7%] Commonwealth Fund Affordable Care Act Tracking Survey b 19.9% [18.5%–21.4%] 12.7% [11.5%–14.0%] (Feb.–Apr. 2016) 15.5% [13.7%–17.5%] National Health Interview Survey (NHIS) (2016)c 20.4% [19.7%–21.1.%] 12.4% [11.7%–13.1%] (2016) 12.5% [11.6%–13.4%] Current Population Survey (CPS) d 18.3% 11.9% (2016) 12.1% Gallup Healthways Well-Being Indexe,f 20.8% 13.1% (Q4 2016) 16.3% Urban Institute Health Reform Monitoring Survey g 17.4% 9.8% (Q1 2016) 10.8% Methodological Differences Between Surveys Survey Population Time Frame Sample Frame Response Rate Commonwealth Fund Biennial Health 2012: 22% landline, 19% cell; U.S. adults ages 19–64 Apr.–Aug. 2012 to June–Nov. 2018 Dual-frame, RDD telephone survey Insurance Survey 2018: 8.4% landline, 5.2% cell Commonwealth Fund Affordable Care 2013: 20.1%; U.S. adults ages 19–64 July–Sept. 2013 to Feb.–Mar. 2018 Dual-frame, RDD telephone survey Act Tracking Survey 2018: 7.5% National Health Interview Survey U.S. adults ages 18–64 2013 to Jan.–June 2018 Multistage area probability design 70% (NHIS) (2016)h,i Probability-selected sample; personal and 2018: 85%k; Current Population Survey (CPS)d U.S. adults ages 18–64 Mar. 2013–2017 telephone interviewsj 2014: 79.6%l Before 2018: dual-frame RDD telephone survey; Gallup Healthways Well-Being Indexm U.S. adults ages 18–64 2013 to Oct.–Dec. 2018 2018: address-based sampling frame with web survey Urban Institute Health Reform KnowledgePanel-probability-based internet U.S. adults ages 18–64 July–Sept. 2013 to Jan.–Mar. 2018 ~5% Monitoring Surveyn panel of 55,000 households a Commonwealth Fund Biennial Health Insurance Survey, Apr.–Aug. 2012, July–Nov. 2016, June–Nov. 2018. b Commonwealth Fund Affordable Care Act Tracking Survey, July–Sept. 2013, Feb.–Apr. 2016, Feb.–Mar. 2018. c Emily P. Zammitti, Robin A. Cohen, and Michael E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, Jan.–June 2017 (National Center for Health Statistics, Nov. 2017); and Michael E. Martinez, Emily P. Zammitti, and Robin A. Cohen, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, Jan.–June 2018 (National Center for Health Statistics, Nov. 2018). d U.S. Census Bureau, 2013, 2016, and 2017 Current Population Reports; for 2013, see https://www.census.gov/cps/data/cpstablecreator.html. e Stephanie Marken, “U.S. Uninsured Rate at 11.4% in Second Quarter,” Gallup News, July 10, 2015. f Dan Witters, “U.S. Uninsured Rate Rises to Four-Year High,” Gallup News, Jan. 23, 2019. g Jennifer Haley et al., “Adults’ Uninsurance Rates Increased by 2018, Especially in States That Did Not Expand Medicaid — Leaving Gaps in Coverage, Access, and Affordability,” Health Affairs Blog, Sept. 26, 2018. h Martinez, Zammitti, and Cohen, Health Insurance Coverage, 2018. i National Center for Health Statistics, “About the National Health Interview Survey,” fact sheet (NCHS, last updated Jan. 19, 2019). j U.S. Census Bureau, “Current Population Survey (CPS): Methodology,” Census Bureau, n.d. k U.S. Census Bureau, “Current Population Survey (CPS): Non-Response Rates,” Census Bureau, n.d. l U.S. Census Bureau, “Current Population Survey, 2014 ASEC Technical Documentation,” Census Bureau, 2014. m Gallup, “How Does the Gallup National Health and Well-Being Index Work?,” Gallup, n.d. n Urban Institute Health Policy Center, “Health Reform Monitoring Survey: HRMS Frequently Asked Questions,” Urban, n.d. commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 19 Table 1. Insurance Status by Demographics, 2018 (base: adults ages 19–64) Total Insured Insured all year, Insured all year, Insured now, had Uninsured (19–64) all year not underinsured underinsured a coverage gap now Total (millions) 193.9 150.6 106.8 43.8 19.3 24.0 Percent distribution 100.0% 77.7% 55.1% 22.6% 10.0% 12.4% Unweighted n 4225 3254 2272 982 416 555 Gender Female 52 78 56 22 11 11 Male 48 77 54 23 9 14 Age 19–34 32 69 48 21 14 17 NOTES 35–49 30 79 58 21 9 12 “Underinsured” refers to adults who were insured all 50–64 35 84 59 26 7 8 year but experienced one of Race/Ethnicity the following: out-of-pocket costs, excluding premiums, Non-Hispanic White 59 83 58 25 8 9 equaled 10% or more of Black 12 73 56 18 16 11 income; out-of-pocket costs, Latino 18 62 45 17 14 24 excluding premiums, equaled 5% or more of income if low- Asian/Pacific Islander 4 81 61 21 8 10 income (<200% of poverty); Other/Mixed 5 77 51 26 9 14 or deductibles equaled 5% or more of income. “Insured Poverty status now, had a coverage gap” Below 133% poverty 25 68 37 31 14 18 refers to adults who were insured at the time of the 133%–249% poverty 19 69 45 24 14 17 survey but were uninsured at 250%–399% poverty 19 80 57 23 10 10 any point in the 12 months prior to the survey field date. 400% poverty or more 29 91 75 16 5 3 “Uninsured now” refers to Below 200% poverty 39 67 39 28 15 18 adults who reported being uninsured at the time of the 200% poverty or more 53 86 67 19 7 7 survey. Fair/Poor health status, 50 78 54 24 10 12 * At least one of the or any chronic condition* following chronic conditions: Adult work status hypertension or high blood pressure; heart Full-time 53 81 59 22 9 10 disease; diabetes; asthma, Part-time 14 67 47 20 16 17 emphysema, or lung disease; or high cholesterol. Not currently employed 33 77 52 25 9 14 ** Base: Full- and part-time Employer size** employed adults ages 19–64. 1–19 employees 23 66 44 21 10 24 20–49 employees 11 79 59 20 9 13 DATA 50–99 employees 8 74 57 17 14 13 Commonwealth Fund Biennial Health Insurance 100 or more employees 56 85 62 22 10 6 Survey (2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 20 Table 2. Insurance Status, 2003–2018 (base: adults ages 19–64) 2003 2005 2010 2012 2014 2016 2018 Total (millions) 172.0 172.5 183.6 183.9 182.8 187.4 193.9 Percent distribution 100% 100% 100% 100% 100% 100% 100% Unweighted n 3293 3352 3033 3393 4251 4186 4225 Insured all year 74 72 72 70 72 78 78 Insured all year, not underinsured 65 63 56 54 55 56 55 Insured all year, underinsured 9 9 16 16 17 22 23 Insured now, had a coverage gap 9 9 8 10 13 10 10 Uninsured now 17 18 20 19 16 12 12 NOTES “Underinsured” refers to adults who were insured all year but experienced one of the following: out-of-pocket costs, excluding premiums, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low- income (<200% of poverty); or deductibles equaled 5% or more of income. “Insured now, had a coverage gap” refers to adults who were insured at the time of the survey but were uninsured at any point in the 12 months prior to the survey field date. “Uninsured now” refers to adults who reported being uninsured at the time of the survey. DATA Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 21 Table 3. Uninsured Rate by Demographics, 2003–2018 (base: adults ages 19–64) 2003 2005 2010 2012 2014 2016 2018 Total (millions uninsured) 29.8 31.6 37.1 35.5 28.7 22.6 24.0 Percent distribution 17% 18% 20% 19% 16% 12% 12% Unweighted n 643 716 590 650 685 520 555 Gender Female 17 18 20 17 13 11 11 Male 17 18 20 22 19 13 14 Age 19–34 24 26 27 23 19 15 17 35–49 15 19 20 22 17 14 12 50–64 11 10 13 13 11 8 8 Race/Ethnicity Non-Hispanic White 13 13 15 14 10 7 9 Black 23 19 24 20 18 12 11 Latino 37 48 39 40 34 28 24 Asian/Pacific Islander 14 9 9 8 7 4 10 Other/Mixed 17 18 29 29 22 16 14 Poverty status Below 133% poverty — — 38 35 26 21 18 133%–249% poverty — — 26 22 19 14 17 250%–399% poverty — — 8 11 11 6 10 400% poverty or more — — 4 5 3 3 3 Below 200% poverty 34 39 36 32 24 19 18 NOTES 200% poverty or more 7 9 7 9 7 4 7 “Uninsured” refers to Fair/Poor health status, or adults who reported being 17 22 22 20 15 13 12 any chronic condition* uninsured at the time of the survey. Adult work status — Data not collected or Full-time 11 14 12 12 11 9 10 collected differently for that Part-time 26 22 32 26 23 16 17 year. Not currently employed 26 27 28 27 19 15 14 ** Base: Full- and part-time employed adults ages 19–64. Employer size** 1–19 employees 28 27 — 25 28 24 24 DATA 20–49 employees 17 26 — 30 22 14 13 Commonwealth Fund Biennial 50–99 employees 14 19 13 12 15 12 13 Health Insurance Surveys (2003, 2005, 2010, 2012, 100 or more employees 7 6 8 9 5 4 6 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 22 Table 4. Cost-Related Access Problems and Medical Bill Problems by Year (base: adults ages 19–64) Percent Estimated millions 2003 2005 2010 2012 2014 2016 2018 2003 2005 2010 2012 2014 2016 2018 Total (adults ages 19–64) 100% 100% 100% 100% 100% 100% 100% 172.0 172.5 183.6 183.9 182.8 187.4 189.7 Access problems in past year Went without needed care in past year because of cost: Did not fill prescription 23 25 26 27 19 19 19 39 43 48 50 35 36 37 Skipped recommended test, 19 20 25 27 19 18 19 32 34 47 49 35 34 36 treatment, or follow-up Had a medical problem, did not visit 22 24 26 29 23 20 21 38 41 49 53 42 37 40 doctor or clinic Did not get needed specialist care 13 17 18 20 13 13 14 22 30 34 37 23 25 27 At least one of four access problems 37 37 41 43 36 34 35 63 64 75 80 66 63 68 because of cost Delayed or did not get dental care 27 — 38 39 32 31 33 46 — 69 72 58 57 65 Medical bill problems in past year Had problems paying or unable to pay 23 23 29 30 23 23 24 40 39 53 55 43 43 46 medical bills Contacted by collection agency 21 21 23 22 20 21 22 35 36 42 41 37 38 42 Contacted by collection agency for — 13 16 18 15 14 15 — 22 30 32 27 25 30 unpaid medical bills Contacted by collection agency — 7 5 4 4 5 5 — 11 9 7 8 9 10 because of billing mistake NOTES — Data not collected for Had to change way of life to pay bills 15 14 17 16 14 14 13 26 24 31 29 26 26 26 that year. * Does not include adults who Any bill problem* — 28 34 34 29 29 29 — 48 62 63 53 53 57 reported being contacted by a collection agency because Medical bills/debt being paid off over — 21 24 26 22 24 23 — 37 44 48 40 46 45 of a billing mistake.. time Any bill problem or medical debt* — 34 40 41 35 37 37 — 58 73 75 64 70 71 DATA Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, 2014, 2016, 2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 23 Table 5. Cost-Related Access Problems and Preventive Care by Insurance Continuity, Insurance Status, and Poverty (base: adults ages 19–64) Insurance status Insurance type** Federal poverty level NOTES “Underinsured” refers to had a coverage gap Insured all year adults who were insured all age 65, disabled) Medicare (under Insured all year Uninsured now year but experienced one of 400% poverty underinsured underinsured Insured now, 133%– 249% 250%– 399% the following: out-of-pocket Below 133% Total 19–64 Individual* Insured all costs, excluding premiums, Employer Medicaid year, not poverty poverty poverty or more Insured all year, equaled 10% or more of income; out-of-pocket costs, excluding premiums, equaled 5% or more of income if low- Total (millions) 193.9 150.6 106.8 43.8 19.3 24.0 102.6 15.8 22.5 15.8 47.8 37.5 37.4 57.1 income (<200% of poverty); or deductibles equaled 5% or Percent distribution 100% 78% 55% 23% 10% 12% 53% 8% 12% 8% 25% 19% 19% 29% more of income. “Insured now, Unweighted n 4225 3254 2272 982 416 555 2016 360 523 479 1212 796 783 1138 had a coverage gap” refers to adults who were insured at the Access problems in past year time of the survey but were Went without needed care in past year because of cost: uninsured at any point in the 12 months prior to the survey Did not fill prescription 19 15 11 25 35 32 16 21 22 20 24 22 19 13 field date. “Uninsured now” Skipped recommended test, refers to adults who reported 19 14 10 23 34 36 16 25 14 14 18 25 20 14 being uninsured at the time of treatment, or follow-up the survey. Had a medical problem, 21 15 11 24 35 49 16 24 16 14 24 28 23 13 * Individual includes adults did not visit doctor or clinic who are enrolled in either Did not get needed specialist care 14 10 7 17 27 29 11 17 12 12 16 19 15 8 marketplace plans or purchased directly off the At least one of four access marketplace. 35 29 23 41 56 59 31 42 32 32 39 43 38 26 problems because of cost ** Insurance type at time of Delayed or did not get dental care 33 28 23 41 49 56 26 38 38 35 39 45 38 21 survey. Preventive care ¥ In past year if respondent has hypertension or high Regular source of care 89 93 93 94 84 68 92 86 93 96 88 88 88 93 blood pressure. Blood pressure checked in past two years¥ 91 94 94 94 89 72 94 94 89 96 88 89 90 96 ¥¥ In past year if respondent Dental exam in past year 60 67 67 67 40 32 72 59 49 40 43 49 61 79 has hypertension or high blood pressure, heart disease, Received mammogram in past two years or high cholesterol. 65 71 71 71 48 32 75 60 55 64 56 48 70 75 (females age 40+) ^ Base: Respondents with Received Pap test in past three years at least one of the following 70 72 73 70 72 53 77 64 71 58 67 63 72 78 (females ages 21–64) health problems: hypertension or high blood pressure, heart Received colon cancer screening in 58 62 63 60 38 35 62 52 51 63 50 51 64 63 disease, diabetes, asthma, past five years (age 50+) emphysema, lung disease, high Cholesterol checked in past five years¥¥ 72 78 79 76 63 44 80 70 69 77 63 63 71 87 cholesterol, depression, kidney disease, cancer, or stroke. Seasonal flu shot in past year 42 47 48 44 30 20 48 36 39 55 40 36 38 51 ^^ Insufficient sample. Access problems for people with health conditions Unweighted n 474 276 118 158 ^^ 115 143 ^^ ^^ ^^ 198 125 ^^ ^^ DATA Skipped doses or did not fill a prescription Commonwealth Fund for medications for the health condition(s) 19 14 10 23 ^^ 45 14 ^^ ^^ ^^ 22 30 ^^ ^^ Biennial Health Insurance because of the cost of the medicines^ Survey (2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 24 Table 6. Medical Bill Problems, by Insurance Continuity, Insurance Status, and Poverty (base: adults ages 19–64) Insurance status Insurance type** Federal poverty level had a coverage gap Insured all year age 65, disabled) Medicare (under Insured all year Uninsured now 400% poverty underinsured underinsured Insured now, 133%– 249% 250%– 399% Below 133% Total 19–64 Individual* Insured all Employer Medicaid year, not poverty poverty poverty or more Insured all year, Total (millions) 193.9 150.6 106.8 43.8 19.3 24.0 102.6 15.8 22.5 15.8 47.8 37.5 37.4 57.1 Percent distribution 100% 78% 55% 23% 10% 12% 53% 8% 12% 8% 25% 19% 19% 29% Unweighted n 4225 3254 2272 982 416 555 2016 360 523 479 1212 796 783 1138 Medical bill problems in past year Went without needed care in past year because of cost: Had problems paying or unable to pay NOTES 24 18 13 30 47 40 19 28 23 35 28 35 28 12 medical bills “Underinsured” refers to adults who were insured all Contacted by collection agency for unpaid 15 12 9 19 29 26 12 14 15 29 21 27 14 5 year but experienced one of medical bills the following: out-of-pocket Had to change way of life to pay bills 13 10 6 19 26 22 10 16 11 25 16 20 14 7 costs, excluding premiums, equaled 10% or more of Any bill problem 29 24 18 38 52 47 23 35 30 46 36 43 32 14 income; out-of-pocket costs, Medical bills/debt being paid off over time 23 21 16 33 33 26 24 22 19 28 21 30 27 19 excluding premiums, equaled 5% or more of income if low- Any bill problem or medical debt 37 32 25 47 56 52 32 42 35 53 42 48 40 24 income (<200% of poverty); or deductibles equaled 5% Base: Any medical debt or more of income. “Insured How much are the medical bills that are now, had a coverage gap” being paid off over time? refers to adults who were insured at the time of the Less than $2,000 43 46 51 40 35 36 46 52 36 35 46 40 46 39 survey but were uninsured at $2,000 to less than $4,000 22 23 21 26 18 17 22 24 27 15 20 20 22 27 any point in the 12 months prior to the survey field date. $4,000 to less than $8,000 17 14 9 21 23 22 18 8 9 18 10 21 16 22 “Uninsured now” refers to adults who reported being $8,000 to less than $10,000 4 4 3 4 5 7 2 6 9 4 6 5 4 3 uninsured at the time of the $10,000 or more 12 10 11 8 16 18 10 6 17 14 14 11 13 9 survey. * Individual includes adults Was this for care received in past year or earlier? who are enrolled in either Past year 47 50 53 48 38 35 53 54 34 37 38 41 49 57 marketplace plans or purchased directly off the Earlier year 46 43 42 43 49 58 39 38 63 55 56 51 39 38 marketplace. Both 7 6 5 9 11 7 8 5 1 8 5 8 11 5 ** Insurance type at time of Were these bills for someone who was insured survey. at the time the care was provided or was the person uninsured then? DATA Insured at time care was provided 65 77 77 79 42 30 81 73 45 63 49 55 74 86 Commonwealth Fund Biennial Health Insurance Uninsured at time care was provided 28 16 15 17 46 64 13 19 47 29 43 37 21 7 Survey (2018). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 25 NOTES 1. Analysis of the 2018 U.S. Current Population Survey by Ougni Chakraborty 10. In three states — Idaho, Nebraska, and Utah — voters approved ballot and Sherry Glied of New York University for the Commonwealth Fund. initiatives to expand eligibility for Medicaid; Kansas elected a Democratic governor who has pledged to expand; Maine’s newly elected Democratic 2. One of the ACA’s most notable provisions aimed at employers was the governor is expanding Medicaid one year after voters approved a ballot initiative so-called employer mandate — the requirement that large firms offer affordable to expand. See Donald Moulds et al., “The Midterm Election Results Have Big coverage to full-time employees or pay penalties. Implications for Health Care,” To the Point (blog), Commonwealth Fund, Nov. 7. 3. Princeton Survey Research Associates International conducted the prior-year 2018. Biennial Surveys analyzed in this brief. 11. Matthew Buettgens, The Implications of Medicaid Expansion in the Remaining 4. Centers for Medicare and Medicaid Services, “Effectuated Enrollment for the States: 2018 Update (Urban Institute, May 2018); and Rachel Garfield, Anthony First Half of 2018,” fact sheet, Nov. 28, 2018. Damico, and Kendal Orgera, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid (Henry J. Kaiser Family Foundation, June 2018). 5. Sara R. Collins and David C. Radley, The Cost of Employer Insurance Is a Growing Burden for Middle-Income Families (Commonwealth Fund, Dec. 2018). 12. American Academy of Actuaries, Drivers of 2016 Health Insurance Premium Changes (AAA, Aug. 2015). 6. Benjamin D. Sommers et al.,“Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults,” Health Affairs 13. Sara R. Collins, “Consumers Shopping for Health Plans Are Left in the Dark by Web First, published online May 17, 2017; and Munira Z. Gunja, Sara R. Collins, Trump Administration,” To the Point (blog), Commonwealth Fund, July 19, 2018. and Herman K. Bhupal, Is the Affordable Care Act Helping Consumers Get Health 14. Sara R. Collins, Munira Z. Gunja, and Michelle M. Doty, Following the ACA Care? Findings from the Commonwealth Fund Affordable Care Act Tracking Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? Survey, March–June 2017 (Commonwealth Fund, Dec. 2017). Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, 7. Tainya C. Clarke, Tina Norris, and Jeannine S. Schiller, Early Release of Selected March–June 2017 (Commonwealth Fund, Sept. 2017). Estimates Based on Data From the 2016 National Health Interview Survey 15. Jodi Liu and Christine Eibner, Expanding Enrollment Without the (National Center for Health Statistics, May 2017). Individual Mandate: Options to Bring More People into the Individual Market 8. Robin A. Cohen and Jeannine S. Schiller, Problems Paying Medical Bills Among (Commonwealth Fund, Aug. 2018). Persons Under Age 65: Early Release of Estimates from the National Health 16. Timothy S. Jost, “Fixing Our Most Pressing Health Insurance Problems: A Interview Survey, 2011–June 2016 (National Center for Health Statistics, Dec. Bipartisan Path Forward,” To the Point (blog), Commonwealth Fund, July 13, 2015). 2017. 9. “Interim Final Rules for Group Health Plans and Health Insurance Issuers 17. Christine Eibner, Sarah Nowak, and Jodi Liu, Hillary Clinton’s Health Care Re- Relating to Coverage of Preventive Services Under the Patient Protection and form Proposals: Anticipated Effects on Insurance Coverage, Out-of-Pocket Costs, Affordable Care Act,” Federal Register 75, no. 137 (July 19, 2010): 41726–60. and the Federal Deficit (Commonwealth Fund, Sept. 2016). commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 26 18. Matthew Buettgens, Stan Dorn, and Hannah Recht, More Than 10 Million 25. Jon R. Gabel et al., Consumer Cost-Sharing in Marketplace vs. Employer Health Uninsured Could Obtain Marketplace Coverage Through Special Enrollment Insurance Plans, 2015 (Commonwealth Fund, Dec. 2015). Periods (Robert Wood Johnson Foundation and Urban Institute, Nov. 2015). 26. Christine Eibner, Sarah Nowak, and Jodi Liu, Hillary Clinton’s Health Care 19. Sara R. Collins, Sherry A. Glied, and Adlan Jackson, The Potential Implications Reform Proposals: Anticipated Effects on Insurance Coverage, Out-of-Pocket of Work Requirements for the Insurance Coverage of Medicaid Beneficiaries: The Costs, and the Federal Deficit (Commonwealth Fund, Sept. 2016). Case of Kentucky (Commonwealth Fund, Oct. 2018). 27. Jack Hoadley, Kevin Lucia, and Maanasa Kona, “State Efforts to Protect 20. Benjamin D. Sommers, “Loss of Health Insurance Among Non-Elderly Adults Consumers from Balance Billing,” To the Point (blog), Commonwealth Fund, Jan. in Medicaid,” Journal of General Internal Medicine 24, no. 1 (Jan. 2009): 1–7. 18, 2019. 21. Christina Cousart, How Elimination of Cost-Sharing Reduction Payments 28. David Blumenthal, Lovisa Gustafsson, and Shawn Bishop, “To Control Changed Consumer Enrollment in State-Based Marketplaces (National Academy Health Care Costs, U.S. Employers Should Form Purchasing Alliances,” Harvard for State Health Policy, March 20, 2018). Business Review, published online Nov. 2, 2018. 22. Centers for Medicare and Medicaid Services, “CMS Issues the Proposed 29. Henry Waxman et al., Getting to the Root of High Prescription Drug Prices Payment Notice for the 2020 Coverage Year,” news release, Jan. 17, 2019. (Commonwealth Fund, July 2017). 23. Munira Z. Gunja, Sara R. Collins, and Sophie Beutel, How Deductible 30. Richard M. Scheffler, Daniel R. Arnold, and Christopher M. Whaley, Exclusions in Marketplace Plans Improve Access to Many Health Care Services “Consolidation Trends in California’s Health Care System: Impacts on ACA (Commonwealth Fund, Mar. 2016). Premiums and Outpatient Visit Prices,” Health Affairs 37, no. 9 (Sept. 2018): 1409–16. 24. Sara R. Collins, “The Trump Administration’s New Marketplace Rules: Regulatory Simplification or More Complexity for Consumers?” To the Point (blog), Commonwealth Fund, Apr. 13, 2018. commonwealthfund.org Survey Brief, February 2019 Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured 27 ABOUT THE AUTHORS ACKNOWLEDGMENTS Sara R. Collins, Ph.D., is vice president for Health Care Coverage and The authors thank Robyn Rapoport, Rob Manley, and Erin Czyzewicz Access at the Commonwealth Fund. An economist, Dr. Collins joined the of SSRS, and David Blumenthal, Donald Moulds, Kathleen Regan, Fund in 2002 and has led the Fund’s national program on health insurance Chris Hollander, Deborah Lorber, Paul Frame, Jen Wilson, Susan since 2005. Since joining the Fund, she has led several national surveys on Hayes, Corinne Lewis, and Arnav Shah of the Commonwealth Fund. health insurance and authored numerous reports, issue briefs, and journal articles on health insurance coverage and policy. She has provided invited Editorial support was provided by Christopher Hollander. 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 For more information about this brief, please contact: was an associate editor at U.S. News & World Report, a senior economist Sara R. Collins, Ph.D. at Health Economics Research, and a senior health policy analyst in the Vice President, Health Care Coverage and Access New York City Office of the Public Advocate. Dr. Collins holds a Ph.D. in The Commonwealth Fund economics from George Washington University. srccmwf.org Herman K. Bhupal is program associate in the Health Care Coverage and Access program at the Commonwealth Fund, joining the staff in June 2017. She is responsible for providing daily support for the program, with responsibilities ranging from daily administrative and grants management tasks to writing and research. Prior to joining the Fund, Ms. Bhupal was an associate at PwC Strategy&, where she served several health care clients in a strategy consulting role. She graduated with a B.A. in economics with honors from Harvard University in May 2016. Michelle McEvoy Doty, Ph.D., is vice president of survey research and evaluation for the Commonwealth Fund. She has authored numerous publications on cross-national comparisons of health system performance, access to quality health care among vulnerable populations, and the extent to which lack of health insurance contributes to inequities in quality of care. Dr. Doty holds an M.P.H. and a Ph.D. in public health from the University of California, Los Angeles. commonwealthfund.org Survey Brief, February 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.