CONGRESS OF THE UNITED STATES CONGRESSIONAL BUDGET OFFICE Who Went Without Health Insurance in 2019, and Why? Total Uninsured in 2019: 29.8 Million 7% Made Eligible for Medicaid by the ACA Otherwise Eligible for 10% Medicaid or CHIP Eligible for 19% Marketplace Subsidies Eligible for Subsidized Coverage 67 Percent Eligible for Subsidized 31% Employment-Based Coverage 13% Not Lawfully Present Not Eligible for Subsidized Coverage 11% Income Below Federal Poverty Level 33 Percent in a State That Did Not Expand Medicaid 9% Income Too High for Marketplace Subsidies SEPTEMBER 2020 At a Glance In 2019, about 12 percent of people under 65 were not enrolled in a health insurance plan or a government program that provides financial protection from major medical risks. In this report, the Congressional Budget Office describes that uninsured popu- lation. CBO’s analysis sheds light on groups that were not covered by comprehensive health insurance even during the strong economy and historically low unemployment that preceded the 2020 coronavirus pandemic. • Characteristics and Coverage Options. The uninsured population is heterogeneous, but some groups, including low-income people, were more likely than others to be uninsured in 2019. About two-thirds of uninsured people were eligible for some form of subsidized coverage, although the generosity of available subsidies varied on the basis of people’s family income, access to employment-based coverage, and other factors. A smaller number of uninsured people had no option for coverage except a private plan purchased at full cost. • Financial Liability and Access to Health Care. Uninsured people receive some types of health care and are often not required to pay the full billed charges for that care, but they have substantially less access to care and financial protection than insured people. Uninsured people who are eligible for Medicaid have more financial protection than others because they can enroll without waiting for an open enrollment period—in some cases, as they are seeking care in hospitals or other settings—and may receive coverage retroactively. However, they are still exposed to some financial risk and can have trouble accessing care. • Reasons for Going Without Coverage. Many uninsured people do not enroll in coverage because of the cost; others may not know that they are eligible for subsidized coverage or may be deterred by the complexity of enrolling. Although the majority of uninsured people could obtain coverage for 10 percent or less of their income, they may not view the coverage to be worth the cost. • Length of Time Without Coverage. Most people who were uninsured at a particular point in recent years went without coverage for at least one year. A smaller share lacked coverage for shorter periods. www.cbo.gov/publication/56504 Contents Summary 1 Characteristics and Coverage Options of the Uninsured 1 Financial Liability and Access to Health Care 2 Reasons for Going Without Coverage 2 Length of Time Without Coverage 2 CBO’s Analysis of the Uninsured Population After 2019 3 BOX 1. THE IMPACT OF THE CORONAVIRUS PANDEMIC ON THE UNINSURED POPULATION IN 2020 AND BEYOND 3 What Are the Demographic Characteristics of Uninsured People? 3 What Types of Coverage Are Available to Uninsured People? 5 People Eligible for Subsidized Coverage 5 People Ineligible for Subsidized Coverage 8 What Does It Mean to Be Uninsured? 8 Financial Liability 9 Access to Health Care 10 Special Considerations for People Eligible for Medicaid and CHIP 12 What Factors Deter People From Obtaining Health Insurance? 13 Premiums13 Other Factors 18 How Long Do Uninsured People Remain Without Coverage? 19 Appendix: The Data and Methods Underlying CBO’s Estimates 21 List of Tables and Figures 24 About This Document 25 Notes As referred to in this report, the Affordable Care Act comprises the Patient Protection and Affordable Care Act (Public Law 111-148), the health care provisions of the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), and the effects of subsequent judicial decisions, statutory changes, and administrative actions. Numbers in the text, tables, and figures may not add up to totals because of rounding. Estimates of health insurance coverage reflect average monthly enrollment during a calendar year and include spouses and dependents covered under family policies. Those estimates are for the civilian noninstitutionalized population under age 65. In most states, the federal poverty level in 2019 was $12,490 for a single person and increased by $4,420 for each additional person in a household. Income levels reflect modified adjusted gross income (MAGI) for the calendar year. MAGI equals gross income plus untaxed Social Security benefits, foreign earned income that is excluded from adjusted gross income, tax-exempt interest, and the income of dependent filers. The term “family” is used in this report to indicate the set of individuals who could generally be covered by a family plan if an employer offered that plan. Such a grouping is also known as a health insurance unit. This report was prepared using estimates of health insurance coverage from CBO’s baseline projections of federal spending and revenues under current law as of March 6, 2020. CBO’s estimates of the number of uninsured in 2019 did not change substantially between its March 2020 baseline and its September 2020 baseline. Who Went Without Health Insurance in 2019, and Why? Summary people into groups, CBO started with those for whom The Congressional Budget Office estimates that at any the federal subsidy would cover the greatest share of the given point in 2019, about 12 percent of the population cost, on average. under age 65, or 30 million people, were uninsured— that is, they were not enrolled in a private health insur- • Seven percent of nonelderly people without health ance plan or a government health program that provides insurance were adults who were eligible for Medicaid comprehensive major medical coverage. Examining that because they lived in a state that had expanded the uninsured population in 2019 reveals groups that were program under the terms of the Affordable Care Act often not reached by current federal programs, subsi- (ACA). (Specifically, those states extended eligibility dies, and other sources of coverage even during a strong to all adults with income up to 138 percent of the economy with historically low unemployment. Those poverty level.) insights will remain important in 2020 and beyond, even though the number of people without health insurance is • Ten percent were adults and children who were estimated to increase as a result of the novel coronavirus otherwise eligible for Medicaid or the Children’s pandemic, economic changes, and other factors. Health Insurance Program (CHIP). Characteristics and Coverage Options • Nineteen percent were eligible for subsidized coverage of the Uninsured through the health insurance marketplaces established The uninsured population in 2019 included a wide under the ACA. variety of people, but some demographic groups were more likely than others to be uninsured. CBO estimates • Thirty-one percent had access to subsidized coverage that people in low-income households were more likely through employment. to be uninsured than those with higher income, and nonelderly adults were much more likely to be uninsured CBO estimates that about one-third of uninsured people than children. Noncitizens who were not lawfully present generally did not have access to subsidized coverage. in this country were particularly likely to be uninsured, CBO categorized them into mutually exclusive groups although that group comprised just 16 percent of the on the basis of the primary reason they were not eligible uninsured population. By contrast, even though most for subsidies. nonelderly people with health insurance were covered through an employer, people in families in which no one • Thirteen percent were noncitizens who were not worked were not markedly more likely to be uninsured lawfully present in this country and did not have than people in families with a full-time worker. The vast access to coverage through an employer. They majority of uninsured people had at least one full-time were generally eligible for public coverage only for worker in their family in 2019. emergency care; otherwise, their options for coverage were limited to private insurance plans purchased CBO classified uninsured people into mutually exclu- outside of the marketplaces at full cost. sive groups on the basis of their options for subsidized coverage or the reasons they lacked those options (see • Eleven percent had income below the poverty level Figure 1). In CBO’s assessment, about two-thirds of but were ineligible for Medicaid because they lived uninsured people had access to at least one type of fully in a state that did not expand the program under the or partially subsidized coverage. To categorize those terms of the ACA. 2 Who Went Without Health Insurance in 2019, and Why? September 2020 Figure 1 . Eligibility for Subsidized Coverage Among the Uninsured in 2019 Eligible for Subsidized Coverage Not Eligible for Subsidized Coverage 20.0 Million, 67 Percent 9.8 Million, 33 Percent 2.2 2.9 5.5 9.4 4.0 3.2 2.6 Million, Million, Million, Million, Million, Million, Million, 7% 10% 19% 31% 13% 11% 9% Made Otherwise Eligible for Eligible for Subsidized Not Income Below Income Eligible for Eligible for Marketplace Employment-Based Lawfully FPL in a State Too High for Medicaid Medicaid Subsidies a Coverage b Present That Did Not Marketplace by the ACA or CHIP Expand Subsidies Medicaid Source: Congressional Budget Office. ACA = Affordable Care Act; CHIP = Children’s Health Insurance Program; FPL = federal poverty level. a. A small number of people in this group would technically be eligible for subsidies, but those subsidies would equal zero dollars. b. A small number of people in this group were self-employed and could receive a subsidy by deducting their premiums from their federal income taxes. • Nine percent had income too high to qualify for health insurance premiums. CBO estimates that roughly marketplace subsidies and did not have access to one-third of uninsured single adults would have to pay subsidized coverage through an employer; generally, more than 10 percent of their income for health insur- their only option was to buy coverage directly from ance. Uninsured people might not consider insurance insurers at full cost. to be worth the cost if it requires high deductibles, copayments, or other forms of cost sharing. Alternatively, Financial Liability and Access to Health Care they might be deterred by the complexity of enrolling Uninsured people have less financial protection and in coverage, or they might not be aware that subsidized access to health care than people with insurance, coverage is available. although the degree of those differences varies for indi- viduals in different circumstances. Uninsured people Uninsured people who are eligible for Medicaid or who are eligible for Medicaid but not enrolled have more CHIP can generally enroll without paying a premium financial protection from high medical bills than other and would have very low cost sharing in those programs. uninsured people. Medicaid allows eligible people to Again, however, unawareness of their eligibility or the enroll at any point—in some cases, at the time they seek complexity of the enrollment process may prevent them care (such as in hospital emergency departments)—and from applying or make it difficult for them to renew offers retroactive coverage for many enrollees. By con- their coverage. In addition, recent immigrants may be trast, uninsured people whose only option is to purchase discouraged from applying for Medicaid coverage for a private plan often face the full billed charges for their their citizen children because they fear it could prevent health care, although some file for bankruptcy to avoid them from becoming permanent legal residents. paying those costs or obtain discounted or charity care instead. Those high out-of-pocket costs, along with the Length of Time Without Coverage difficulty of finding providers who will see patients with- Some people who become uninsured are merely transi- out up-front payment, result in lower access to care. tioning between different sources of coverage, whereas others remain uninsured for longer periods. In recent Reasons for Going Without Coverage years, about 11 percent of the people who were unin- Uninsured people have different reasons for not obtain- sured at any given point in time lacked coverage for less ing health insurance. The most common is the cost of than six months altogether, whereas 80 percent went September 2020 Who Went Without Health Insurance in 2019, and Why? 3 Box 1 . The Impact of the Coronavirus Pandemic on the Uninsured Population in 2020 and Beyond Since the end of 2019, the spread of the novel coronavirus has people who lose health insurance coverage on account of the resulted in increases in unemployment, substantial changes pandemic (for example, because of a layoff or business closure) in household income, and increasing strains on the health and do not obtain alternative coverage. Therefore, understand- care delivery system. Recent legislation in response to the ing the people who lacked insurance before the pandemic pandemic has included federal funding for testing for COVID-19 remains relevant even in a rapidly changing economy. (the disease caused by the coronavirus), treatment for The increase in the uninsured population in 2020 and beyond uninsured people, and tax credits for employers that continue will be mitigated by several factors. First, although millions of contributing to the health insurance premiums of furloughed people have lost their jobs, those job losses have been concen- employees; it has also required health insurance plans to cover trated in industries—such as leisure and hospitality—that often COVID-19 testing with no cost sharing. do not offer employment-based insurance. Second, some of Against the backdrop of those changes, in the Congressional the people who lose insurance will obtain alternative coverage Budget Office’s estimation, the number of people without through Medicaid, CHIP, the health insurance marketplaces, health insurance will increase to about 31 million in 2020.1 That or a family member’s employer. Third, even among those who uninsured population in 2020 will include most of the approx- were already uninsured before the pandemic, changes in imately 30 million people who would have been uninsured household income will affect people’s eligibility for subsidized in the absence of the coronavirus pandemic, plus additional coverage. Some of those people might become eligible for and enroll in Medicaid, CHIP, or plans offered through the market- places during special enrollment periods. Fourth, some people 1. For further discussion of CBO’s estimates of the number of uninsured people will be able to continue their enrollment in Medicaid longer in 2020, see Congressional Budget Office, Federal Subsidies for Health Insurance Coverage for People Under 65: 2020 to 2030 (September 2020), than they otherwise could have, thanks to the extension of www.cbo.gov/publication/56571. continuous-­eligibility rules during the pandemic. without coverage for a year or more. People with lower and caused millions of people to lose their jobs—and, income tended to remain uninsured for longer periods, in some cases, their employment-based coverage (see and adults remained uninsured longer than children. Box 1). Information about the effects of the pandemic is changing quickly, and new developments may affect Estimating the number of people who are uninsured CBO’s assessments of the number of people without at one moment in time is only one way to measure the health insurance coverage, the composition of that uninsured population. An alternative way is to estimate population, their options for coverage, how long they the number of people who are uninsured at any point will remain uninsured, and other topics addressed in this over a given period. Although only 12 percent of people report. CBO will continue to monitor the uninsured under 65 were uninsured at a given moment in 2019, population in 2020 and how increases in that population a larger percentage went without coverage for some affect the outcomes analyzed here. amount of time over a longer period. In recent years, for example, about one-quarter of the nonelderly population What Are the Demographic Characteristics went without coverage at some point over a two-year of Uninsured People? period. CBO’s analysis of uninsured people focused on four demographic characteristics: age, family income, cit- CBO’s Analysis of the Uninsured Population izenship and legal status, and employment. Those After 2019 characteristics affect people’s options for coverage and This report reflects CBO’s analysis of the population the cost of those options. Government health insurance without health insurance coverage in 2019, based on programs and income-based subsidies for coverage are data from that year and earlier years. In 2020, the novel often available to members of low- and moderate-income coronavirus pandemic has disrupted the economy families and to children, but those options are generally 4 Who Went Without Health Insurance in 2019, and Why? September 2020 Table 1 . Characteristics of Nonelderly People Without Health Insurance, 2019 Millions of Percentage of Group Percentage of the Uninsured People Without Insurance Uninsured Population Age Less than 19 5 6 16 19 to 64 25 14 84 Family Income Relative to the Poverty Level Less than 138 percent 10 14 35 138 to 249 percent 7 14 22 250 to 399 percent 6 13 20 400 percent or more 7 8 23 Sex Male 15 12 52 Female 14 11 48 Family Size Single person 14 13 48 Two or more people 15 10 52 Family Employment Status At least one full-time worker 24 11 82 Part-time workers only 2 15 7 No work 3 12 11 Legal Status Citizens and lawfully present noncitizens 25 10 84 Noncitizens not lawfully present 5 48 16 Total Nonelderly Population 30 12 100 Source: Congressional Budget Office, using the Health Insurance Simulation Model, which incorporates survey and administrative data from a variety of sources. See Jessica Banthin and others, Sources and Preparation of Data Used in HISIM2—CBO’s Health Insurance Simulation Model, Working Paper 2019-04 (Congressional Budget Office, April 2019), www.cbo.gov/publication/55087. The term “family” is used in this report to indicate the set of individuals who could generally be covered by a family plan if an employer offered that plan. Such a grouping is also known as a health insurance unit. not available to people with higher income (who often for the individual mandate (a provision of the ACA have access to subsidized insurance through an employer) that required most people to have health insurance) or to noncitizens who are not lawfully present in the was repealed. They could change more dramatically in United States. 2020 as a result of changing economic conditions. CBO’s analysis of the relationships between demo- Although the uninsured population includes individuals graphic characteristics and coverage is based on the from all age and income groups, some groups are more agency’s estimates of those factors for 2019. Over the likely to be uninsured than others. In 2019, adults were past several years, those relationships changed somewhat more than twice as likely as children to be uninsured, as an increasing number of states expanded eligibil- and people in low-income households were more likely ity for their Medicaid programs, premiums increased to be uninsured than those with higher income (see in the nongroup market (that is, for plans purchased Table 1). CBO estimates that 14 percent of people with directly from insurance companies), and the penalty income below 250 percent of the poverty level were September 2020 Who Went Without Health Insurance in 2019, and Why? 5 uninsured in 2019, compared with 8 percent of people groups based on the primary reason they were not eligi- with income over 400 percent of the poverty level. Men ble for such coverage.1 were slightly more likely to be uninsured than women, and single people were somewhat more likely to be People Eligible for Subsidized Coverage uninsured than people in families. Legal status was also About two-thirds of uninsured people had access to sub- strongly associated with coverage: About 48 percent of sidized coverage, in CBO’s assessment. Subsidized cover- noncitizens who were not lawfully present in this coun- age was available to people with low to moderate income try were uninsured in 2019, compared with 10 percent and to those eligible for subsidized employment-based of citizens and other lawfully present residents. insurance. By contrast, employment status was not strongly linked Medicaid and CHIP. CBO estimates that 17 percent to coverage in 2019. Although most nonelderly people of uninsured people in 2019 were eligible for coverage are covered by employment-based insurance, not all through Medicaid or CHIP.2 Fewer than half were adults employers offer coverage, and people are less likely to be who were eligible for Medicaid because they lived in enrolled in Medicaid if they or their family members are states that had expanded the program under the ACA; working full time. Thus, CBO estimates that full-time the rest were adults and children who were otherwise eli- workers and their family members were nearly as likely gible for Medicaid (regardless of whether their state had to be uninsured as people in families in which no one expanded Medicaid under the ACA) or CHIP. Before the worked. People in families with only part-time workers, ACA’s enactment, Medicaid primarily covered children, who made up just 5 percent of the overall nonelderly pregnant women, disabled individuals, and parents with population, were somewhat more likely to be uninsured. very low income; income limits for the program varied somewhat by state and by eligibility category. The ACA The demographic composition of the uninsured pop- allowed states to expand Medicaid eligibility to all adults ulation reflects both the likelihood of being uninsured with family income up to 138 percent of the poverty within each demographic group and the size of each level.3 group as a share of the total nonelderly population. For example, according to CBO’s estimates, 48 percent of Because eligibility for Medicaid and CHIP is based on noncitizens who were not lawfully present were unin- income, uninsured people with low income were much sured in 2019, but only 16 percent of uninsured people more likely to have the option of enrolling. Uninsured fell into that category because it accounts for a relatively single adults were also more likely to be eligible for small share of the overall population. Although lower-­ income people were more likely to be uninsured, 23 per- 1. CBO’s estimates may differ from estimates published elsewhere cent of uninsured people had income above 400 percent for two main reasons. First, whereas many outside estimates are of the poverty level (the limit for qualifying for market- based on data from a single survey, the primary source of these place subsidies). Finally, 82 percent of uninsured people estimates is CBO’s health insurance simulation model, which were in families with at least one full-time worker, simi- begins with data from the Census Bureau’s Current Population Survey but enhances and adjusts those data to incorporate lar to the 84 percent of the overall population under age information from other sources and to match administrative data 65. However, uninsured workers were less likely to have on enrollment, income, and other details. Second, the order in jobs that offered health insurance. which CBO assigns uninsured people who may be eligible for multiple sources of coverage into mutually exclusive groups (also What Types of Coverage Are Available to known as the hierarchy) may differ from the order chosen by Uninsured People? other researchers. CBO classified uninsured people into mutually exclu- 2. Although CHIP primarily covers children, pregnant women can sive groups on the basis of their options for subsidized enroll in the program in some states. coverage or the reasons they lacked those options in 3. As originally enacted, that expansion was required for states to 2019 (see Table 2). To estimate the number of people in obtain federal matching funds for any part of their Medicaid each group, CBO assigned uninsured people to the most program. The Supreme Court’s 2012 decision in National heavily subsidized option available to them (see Figure 2. Federation of Independent Business v. Sebelius allowed states to choose whether to expand eligibility for coverage under their Many uninsured people had no available options for Medicaid program under the terms of the ACA. In 2019, subsidized coverage. CBO categorized those people into 33 states and the District of Columbia had done so. 6 Who Went Without Health Insurance in 2019, and Why? September 2020 Table 2 . Eligibility for Subsidized Coverage Among the Uninsured, 2019 Percent Family Income Relative Family to the Poverty Level Size Less Than 138 to 400 More Than Single Two or Overall 138 Percent Percent 400 Percent Adults More People Eligible for Subsidized Coverage Made eligible for Medicaid by the ACA 7 16 4 0 14 1 Otherwise eligible for Medicaid or CHIP 10 16 9 1 7 11 Eligible for marketplace subsidies a 19 6 39 0 23 15 Eligible for subsidized employment-based coverage b 31 8 36 58 20 43 Not Eligible for Subsidized Coverage Not lawfully present 13 24 11 2 14 13 Income below the FPL and living in a state that has not expanded Medicaid 11 31 0 0 17 4 Income too high for marketplace subsidies 9 0 0 38 4 12 Source: Congressional Budget Office, using the Health Insurance Simulation Model, which incorporates survey and administrative data from a variety of sources. See Jessica Banthin and others, Sources and Preparation of Data Used in HISIM2—CBO’s Health Insurance Simulation Model, Working Paper 2019-04 (Congressional Budget Office, April 2019), www.cbo.gov/publication/55087. Some people may be eligible for multiple sources of coverage. CBO classified uninsured people into mutually exclusive groups (also known as the hierarchy) on the basis of the most heavily subsidized option available to them or the primary reason they were ineligible for subsidized coverage. ACA = Affordable Care Act; CHIP = Children’s Health Insurance Program; FPL = federal povery level. a. A small number of people in this group would technically be eligible for subsidies, but those subsidies would equal zero dollars. b. A small number of people in this group were self-employed and could receive a subsidy by deducting their premiums from their federal income taxes. those programs but not enrolled in them than uninsured eligible for subsidized coverage through the market- people in families. places. People who were eligible for premium tax credits were somewhat more likely to be uninsured if their Subsidized Coverage Through Health Insurance income was above 250 percent of the poverty level, Marketplaces. Another 19 percent of uninsured peo- in part because they were not eligible for cost-sharing ple were eligible for subsidized coverage through the reductions (subsidies that lower deductibles, copayments, marketplaces established under the ACA. Marketplace and coinsurance payments for lower-income people who subsidies are primarily provided through premium tax purchase silver plans) and in part because people with credits, which are generally available to people with higher income pay a larger share of their income toward income between 100 and 400 percent of the poverty marketplace coverage.4 For a small number of people in level, but only if they are lawfully present in the United areas with lower premiums, available subsidies would States, are not eligible for public coverage (such as have equaled zero dollars because their premium for a sil- Medicaid or CHIP), and do not have an affordable offer ver plan (the benchmark for calculating subsidies) would of employment­-based coverage. (In 2019, the threshold already cost less than the percentage of income they were for affordability was set at 9.86 percent of income for expected to pay. a single plan—that is, a plan that covers one person.) Eligible people can use those tax credits to lower their monthly premiums. 4. For example, in 2019, people with income between 100 and 138 percent of the poverty level were expected to pay 2.08 percent of their income toward premiums, whereas people More than one-third of uninsured people with income with income between 300 and 400 percent of the poverty level between 138 and 400 percent of the poverty level were were expected to pay 9.86 percent of their income. September 2020 Who Went Without Health Insurance in 2019, and Why? 7 Figure 2 . How CBO Categorized Uninsured People Into Groups Based on Their Options for Subsidized Coverage or the Reasons They Lacked Those Options 2.2 Million People • Adults with family income up to 138 percent of the poverty Eligible because YES level in the District of Columbia and the 33 states that Eligible for of Medicaid expanded Medicaid eligibility under the terms of the ACA YES by 2019 Medicaid or CHIP? expansions under the ACA? NO 2.9 Million People • People otherwise eligible for Medicaid or CHIP in all states: NO low-income children, pregnant women, disabled individuals, parents, and some other adults with very low income 5.5 Million People Eligible for Eligible for • Income generally between 100 and 400 percent of the Subsidized marketplace YES poverty level subsidies? a Coverage • Must be lawfully present in the United States and ineligible for public coverage (such as Medicaid), with no affordable NO offer of employment-based coverage Eligible for 9.4 Million People subsidized • Eligible regardless of income level employment- YES • Coverage subsidized through the exclusion or deduction of based insurance? b premium contributions from taxable income and through employer contributions NO 4.0 Million People • Generally not eligible for public coverage for nonemergency Noncitizens who care and not eligible for marketplace subsidies are not lawfully YES • Only option for coverage, without an offer of present? employment-based coverage, is nongroup insurance purchased outside of the marketplaces at full cost NO 3.2 Million People Not Eligible Income below • Citizens and other lawfully present residents in the for Subsidized the poverty YES 17 states that had not expanded Medicaid by 2019 Coverage level? • Would have been eligible for Medicaid if their state had expanded the program under the terms of the ACA NO 2.6 Million People Income too high • Citizens and other lawfully present residents who were not for marketplace YES eligible for any of the above sources of subsidized coverage subsidies? • Income over 400 percent of the poverty level Source: Congressional Budget Office. ACA = Affordable Care Act; CHIP = Children’s Health Insurance Program. a. A small number of people in this group would technically be eligible for subsidies, but those subsidies would equal zero dollars. b. A small number of people in this group were self-employed and could receive a subsidy by deducting their premiums from their federal income taxes. 8 Who Went Without Health Insurance in 2019, and Why? September 2020 Subsidized Employment-Based Insurance. Thirty-one insurance outside of the marketplaces at full cost.6 People percent of uninsured people had access to subsidized cov- in this group made up a large share of uninsured people erage through employment (their own or that of a family with low income and only a small share of uninsured member), in CBO’s estimation. That includes a small people with high income. number of people who were self-employed and could receive a subsidy by deducting their premiums from Income Below the Poverty Level and Not Eligible for their federal income taxes. About one-third of uninsured Medicaid. Another 11 percent of uninsured people people with income between 138 and 400 percent of the were adults who had income below the poverty level but poverty level and over half of those with higher income were ineligible for Medicaid and did not have access to fell into this group. Only a small share of uninsured peo- employment-based coverage. Those people lived in states ple with income below 138 percent of the poverty level that did not expand eligibility for Medicaid to all adults had an offer of employment-based coverage and did not with income up to 138 percent of the poverty level, fall into either of the categories above.5 as allowed under the ACA.7 In those states, although adults with income between 100 and 138 percent of the CBO estimates that 43 percent of uninsured people in poverty level are thus not typically eligible for Medicaid, families had access to coverage through an employer. they are eligible for subsidized coverage through the For workers in about one-quarter of those families, marketplaces established under the ACA. Some adults the employee contribution for a single plan would not with income below the poverty level are eligible for exceed the ACA’s standard for affordability (9.86 percent Medicaid because they meet other criteria (for example, of income), but the employee contribution for a family women who are pregnant). For the remaining adults plan would. Those workers and their family members with income below the poverty level, those options for were not eligible for subsidized coverage through the subsidized coverage are not available. Moreover, few peo- marketplaces because eligibility is based on the cost of a ple with income below the poverty level have someone in single employment-based plan. their family who is eligible for health insurance through their job. People Ineligible for Subsidized Coverage In CBO’s assessment, about one-third of the uninsured Consequently, for nearly all people in this group, the population in 2019 did not have access to any of the only option was to purchase nongroup coverage at full subsidized options above. Those people were ineligible cost. People in this category made up nearly one-third of for subsidized coverage for different reasons. uninsured people with income below 138 percent of the poverty level in 2019. Noncitizens Who Were Not Lawfully Present. CBO estimates that 13 percent of uninsured people were non- Income Too High for Marketplace Subsidies. CBO esti- citizens who were not lawfully present in this country mates that the remaining 9 percent of uninsured people and did not have access to coverage through an employer had income greater than 400 percent of the poverty level (their own or that of a family member). Without legal ($49,960 for a single person and $103,000 for a family residency, noncitizens are generally not eligible for of four) and were not eligible for subsidized coverage public coverage for nonemergency care, and they cannot through the government or an employer. Those people purchase insurance (with or without subsidies) through could obtain coverage by purchasing private nongroup health insurance marketplaces. Thus, if they lack access health insurance at full cost. to employment-based coverage, the only way for them to obtain coverage is to purchase private, or nongroup, What Does It Mean to Be Uninsured? CBO classifies people as uninsured if they are not enrolled in a private health insurance plan or a govern- ment health program that provides comprehensive major 5. About 14 percent of all uninsured people with income below 138 percent of the poverty level had an offer of employment- 6. Some uninsured people who were noncitizens and not lawfully based coverage in 2019, but more than half of those offers present had access to subsidized coverage through an employer would not meet the ACA’s standard for affordability because and are included in the 29 percent of uninsured people with the employees’ share of the premium exceeded 9.86 percent of access to employment-based coverage. their family income. About half the people in this group were eligible for Medicaid, CHIP, or subsidized coverage through the 7. In 2019, about one-third of the total population under 65 lived marketplaces. in states that did not expand Medicaid under the ACA. September 2020 Who Went Without Health Insurance in 2019, and Why? 9 medical coverage.8 People without such coverage have otherwise unable to obtain free or discounted care may less financial protection and access to health care than face the providers’ full charges, which are typically higher people who are enrolled in coverage. People who are than the discounted rates paid by private insurers. eligible for Medicaid or CHIP but are not enrolled have more financial protection than other uninsured people Second, uninsured people can avoid paying for care they because they can enroll at any time and may receive receive by not paying some or all of their medical bills, retroactive coverage for services rendered before their which may not be fully collected by providers and can enrollment. Still, uninsured people who are eligible for be discharged through bankruptcy.11 However, leaving those programs have less financial protection than they medical bills unpaid can reduce people’s access to credit would if they were enrolled, and they may have difficul- and disrupt other aspects of their lives.12 For example, ties accessing health care. medical bills can be a source of stress and lead people to cut back on other types of spending.13 Research shows Financial Liability that people without health insurance have more unpaid Uninsured people generally face much more exposure to medical bills, more bills in collection, and higher rates financial risk from using health care than insured people. of bankruptcy.14 The financial cost of unpaid medical Several types of protection reduce uninsured people’s out-of-pocket costs for health care, but those protec- Garfield, Kendal Orgera, and Anthony Damico, The Uninsured tions often provide only a modest reduction in financial and the ACA: A Primer—Key Facts About Health Insurance exposure. and the Uninsured Amidst Changes to the Affordable Care Act (Kaiser Family Foundation, January 2019), https://tinyurl.com/ First, some uninsured patients receive services for free or yb4fdk8p. at highly discounted prices through safety-net providers, 11. For a discussion of the role bankruptcy plays in protecting people such as community health centers and free clinics, or from large medical expenses, see Neale Mahoney, “Bankruptcy as through other sources of charity care.9 Highly discounted Implicit Health Insurance,” American Economic Review, vol. 105, care is typically targeted toward low-income people, and no. 2 (February 2015), pp. 710–746, https://doi.org/10.1257/ aer.20131408. sources of such care have limited funding and capaci- ty.10 Uninsured people who are not qualified for or are 12. One study found that uninsured people who were admitted to a hospital experienced a substantial increase in unpaid medical bills, a small increase in the probability of bankruptcy, and 8. CBO considers such people to be uninsured even if they are a small decline in borrowing limits. See Carlos Dobkin and eligible to immediately enroll in a plan or government program others, “The Economic Consequences of Hospital Admissions,” that would retroactively pay for previously incurred health care American Economic Review, vol. 108, no. 2 (February 2018), expenses. In CBO’s view, that definition of being uninsured pp. 308–352, https://doi.org/10.1257/aer.20161038. aligns with the concept underlying data from the National 13. In one survey, 53 percent of uninsured households reported Center for Health Statistics, which relies on individuals to report that they had problems paying medical bills. Within that group, their insurance status in surveys. CBO’s definition of coverage 39 percent said they were unable to pay for basic necessities such includes all plans that are compliant with the ACA and some as food, heat, or housing as a result. See Liz Hamel and others, that are not compliant but still provide coverage for high-cost The Burden of Medical Debt: Results From the Kaiser Family physician and hospital care. For more details, see Congressional Foundation/New York Times Medical Bills Survey (Kaiser Family Budget Office, Health Insurance Coverage for People Under Age 65: Foundation, January 2016), https://tinyurl.com/yb4sqxl6. Definitions and Estimates for 2015 to 2018 (April 2019), www. cbo.gov/publication/55094. 14. For an example of how insurance coverage affects patients’ unpaid medical bills and bills in collection, see Luojia Hu 9. Community health centers, many of which are funded in part by and others, “The Effect of the Affordable Care Act Medicaid federal grants, provide comprehensive primary care services and Expansions on Financial Wellbeing,” Journal of Public Economics, use a sliding scale based on income to set patients’ fees. Free and vol. 163 (July 2018), pp. 99–112, https://doi.org/10.1016/j. charitable clinics, which are generally funded through private jpubeco.2018.04.009. Other studies have found that expanding donations and grants and are primarily staffed by volunteers, health insurance reduces rates of consumer bankruptcy. See also provide free or highly discounted care to uninsured patients. Tal Gross and Matthew J. Notowidigdo, “Health Insurance Safety-net hospitals are another major source of charity care, and and the Consumer Bankruptcy Decision: Evidence From the nearly all other hospitals provide charity care to some degree. Expansion of Medicaid,” Journal of Public Economics, vol. 95, Various other sources, including local health departments and no. 7–8 (August 2011), pp. 767–778, https://doi.org/10.1016/j. other public and private clinics, also provide free or discounted jpubeco.2011.01.012; and Bhashkar Mazumder and Sarah care to uninsured patients. Some private, office-based providers Miller, “The Effects of the Massachusetts Health Reform on also provide a limited amount of charity care. Household Financial Distress,” American Economic Journal: 10. One survey found that 27 percent of uninsured adults received at Economic Policy, vol. 8, no. 3 (August 2016), pp. 284–313, least some care for free or at a reduced cost in 2015. See Rachel http://dx.doi.org/10.1257/pol.20150045. 10 Who Went Without Health Insurance in 2019, and Why? September 2020 bills, referred to as bad debt, is predominantly borne by coverage often applied for only 60 days, this hospitals.15 option was available to only a small segment of the uninsured population in 2019. Third, some of the people CBO classifies as uninsured have partial protection against high-cost medical events Uninsured people who are eligible for Medicaid or CHIP because they are enrolled in a noncomprehensive health coverage have an even greater degree of partial protection plan or are eligible for coverage under a plan offered by against high-cost medical events and are discussed in their previous employer. more detail below. • Enrollment in noncomprehensive health plans. Finally, uninsured people may put off seeking care when Some health plans cover a limited set of services doing so is feasible and have that care covered later, by and, in most cases, a limited amount of total costs, enrolling in a plan during the next open enrollment which means that participants who receive costly period.18 However, the ability to enroll in coverage in the medical care may be responsible for very large bills.16 future does not protect uninsured people from high costs CBO estimates that in 2019, about 5 percent of associated with unexpected and urgent health events. people without comprehensive health coverage (roughly 1.5 million people) were enrolled in a Access to Health Care noncomprehensive plan. More than half of those Even people with insurance may have trouble accessing people were enrolled in health care sharing ministries, health care, but in general, uninsured people face more which act as cooperatives through which members barriers.19 People tend to be less willing to seek care when pay one another’s bills. they face high out-of-pocket costs, and uninsured patients who cannot pay the full billed charges for care often have • Eligibility for COBRA coverage. Workers separating difficulty finding a provider who will see them. Although from a job where they had employment-based some types of subsidized care are available to uninsured coverage typically have at least 60 days to enroll people, the providers often have limited capacity, which in COBRA coverage (named for the Consolidated can result in long wait times for uninsured patients. Some Omnibus Budget Reconciliation Act, which providers may be unwilling to treat uninsured people who established it) and can receive retroactive coverage cannot pay the full price up front, or they may see only a for any health care expenses incurred during that limited number of those patients. period.17 Because the ability to obtain retroactive 15. See Craig Garthwaite, Tal Gross, and Matthew J. Notowidigdo, “Hospitals as Insurers of Last Resort,” American Economic Journal: Applied Economics, vol. 10, no. 1 (January 2018), pp. 1–39, to 18 months. The deadline for enrolling in COBRA coverage https://doi.org/10.1257/app.20150581; and David Dranove, was extended in 2020 because of the coronavirus pandemic; Craig Garthwaite, and Christopher Ody, “Uncompensated Care see Extension of Certain Timeframes for Employee Benefit Decreased at Hospitals in Medicaid Expansion States but Not Plans, Participants, and Beneficiaries Affected by the COVID- at Hospitals in Nonexpansion States,” Health Affairs, vol. 35, 19 Outbreak, 85 Fed. Reg. 26351 (May 4, 2020), no. 8 (August 2016), pp. 1471–1479, https://doi.org/10.1377/ https://go.usa.gov/xwHua. hlthaff.2015.1344. 18. Under current law, most comprehensive health plans are required 16. Such plans include policies with limited insurance benefits to accept all eligible applicants regardless of preexisting health (known as mini-med plans); some types of short-term, limited- conditions. As a result, delaying care for such conditions, when duration policies; “dread disease” policies, which cover only feasible, would not prevent applicants from enrolling in a plan specific diseases; supplemental plans that pay for medical and having much of the cost of their treatment covered. expenses another policy does not cover; fixed-dollar indemnity 19. In a 2018 survey of nonelderly adults, 26 percent with Medicaid plans, which pay a predetermined lump sum in the event of or CHIP coverage, 18 percent with private coverage, and an illness or hospitalization; health care sharing ministries; and 36 percent who were uninsured reported delaying medical care single-service plans, such as dental- or vision-only policies. because of barriers to access. Cost was much more likely to be 17. COBRA protections apply to workers separating from private- such a barrier for those who were uninsured than those who sector employers with at least 20 employees or from state and were insured. See Medicaid and CHIP Payment and Access local government employers. COBRA also guarantees that those Commission, “Measures of Access to Care Among Non- workers can continue to purchase their employment-based Institutionalized Individuals Age 19–64 by Primary Source of coverage at full cost (paying both the employee and employer Health Coverage,” Exhibit 46 in MACStats: Medicaid and CHIP shares of the premium, plus a small administrative fee) for up Data Book (December 2019), www.macpac.gov/macstats/. September 2020 Who Went Without Health Insurance in 2019, and Why? 11 As a result of those factors, uninsured people receive less evidence for effects on specific health conditions has health care than they would if they were insured. Research been less consistent. Those inconsistent results might shows that people substantially increase their use of health imply that health insurance improves some aspects of care services after gaining health insurance.20 Additionally, health but not others or that its effects on certain aspects uninsured people report going without care and delaying of health (particularly those relevant to only a subset of care at much higher rates than insured people.21 And even the population) are more challenging to measure.24 when they do obtain care, uninsured people may not receive the same level of treatment as insured people.22 Uninsured people’s access to care may depend on the type of care and the provider. Hospital emergency For those reasons, it is likely that being uninsured results departments usually present the lowest barriers to care in worse health outcomes, at least for some people. because they are required to assess and stabilize all Determining how going without coverage affects health patients regardless of their insurance status.25 However, is challenging, however, because insured and uninsured emergency departments cannot provide all types of people differ along many other dimensions that affect care, and the care they do provide often results in large health outcomes. To overcome those challenges, research- medical bills for uninsured people (many of which go ers have tried to study what happens when people lose unpaid). In particular, emergency departments are not or gain insurance for reasons unrelated to their health. likely to offer a stable supply of medication or ongoing Those studies have found that gaining insurance leads treatment for chronic diseases. to improvements in some measures of overall health, including self-reported health and mortality.23 However, Many uninsured people receive primary care through community health centers, which charge highly dis- 20. For example, see Amy Finkelstein and others, “The Oregon counted rates for low-income patients, or through Health Insurance Experiment: Evidence From the First Year,” other safety-net clinics or local health departments.26 Quarterly Journal of Economics, vol. 127, no. 3 (August 2012), pp. 1057–1106, https://doi.org/10.1093/qje/qjs020. Working Paper 26081 (National Bureau of Economic Research, 21. For example, 25 percent of nonelderly U.S. residents without August 2020), https://www.nber.org/papers/w26081. For a insurance reported delaying medical care because of the cost in detailed review of the evidence from recent Medicaid expansions, 2018, compared with 6 percent of those with private insurance see Madeline Guth, Rachel Garfield, and Robin Rudowitz, and 5 percent of those with Medicaid or other public coverage. The Effects of Medicaid Expansion Under the ACA: Updated Similarly, forgoing medical care because of the cost was reported Findings From a Literature Review (Kaiser Family Foundation, by far more uninsured people (19 percent) than people with March 2020), https://tinyurl.com/y9xb6ylg. private insurance (3 percent) or public coverage (4 percent). See Centers for Disease Control, National Center for Health 24. For example, a study of the Oregon Health Insurance Experiment Statistics, Summary Health Statistics: National Health Interview showed that participants who gained Medicaid coverage had Survey, 2018, Table P-9c (accessed July 12, 2020), www.cdc.gov/ reduced rates of depression, but it did not detect statistically nchs/nhis/shs/tables.htm. significant improvements in measures of hypertension or high cholesterol; however, the lack of statistically significant 22. One study found that uninsured patients who were hospitalized improvements in those measures was due in part to the small after severe auto accidents received less intensive care than number of participants who had those conditions. See Katherine insured patients and had higher mortality rates. See Joseph J. Baicker and others, “The Oregon Experiment—Effects of Doyle Jr., “Health Insurance, Treatment, and Outcomes: Using Medicaid on Clinical Outcomes,” The New England Journal of Auto Accidents as Health Shocks,” Review of Economics and Medicine, vol. 368, no. 18 (May 2013), pp. 1713–1722, https:// Statistics, vol. 87, no. 2 (May 2005), pp. 256–270, doi.org/10.1056/NEJMsa1212321. Another study did detect https://doi.org/10.1162/0034653053970348. improved control of hypertension in federally funded community 23. For a recent review of the literature, see Benjamin Sommers, Atul health centers after expansions of Medicaid. See Megan B. Cole Gawande, and Katherine Baicker, “Health Insurance Coverage and others, “At Federally Funded Health Centers, Medicaid and Health—What the Recent Evidence Tells Us,” The New Expansion Was Associated With Improved Quality of Care,” England Journal of Medicine, vol. 377, no. 6 (August 2017), Health Affairs, vol. 36, no. 1 (January 2017), pp. 40–48, pp. 586–593, https://doi.org/10.1056/nejmsb1706645. For https://doi.org/10.1377/hlthaff.2016.0804. more recent evidence that gaining insurance reduces mortality, 25. Those requirements were established by the Emergency Medical see Jacob Goldin, Ithai Z. Lurie, and Janet McCubbin, Health Treatment and Labor Act in 1986. Insurance and Mortality: Experimental Evidence From Taxpayer Outreach, Working Paper 26533 (National Bureau of Economic 26. More than 6 million uninsured patients received care at a Research, December 2019), https://www.nber.org/papers/ community health center in 2018. See Kaiser Family Foundation, w26533; and Sarah Miller and others, Medicaid and Mortality: “Community Health Center Patients by Payer Source” (accessed New Evidence From Linked Survey and Administrative Data, July 12, 2020), https://tinyurl.com/ybzg86mv. 12 Who Went Without Health Insurance in 2019, and Why? September 2020 Other types of care are generally less accessible for period. That flexibility in enrollment is a major distinc- uninsured people who cannot afford to pay the full tion between those programs and private health insur- price of treatment. For example, one study found that ance, in which people can typically enroll only during in 2016, 85 percent of uninsured patients were not able open enrollment periods that occur once per year. to schedule an appointment with a private, office-based primary care provider unless they could pay the full price Medicaid and some states’ CHIP programs also offer of the visit up front.27 Specialty care, including cardiac additional protections for some people who are eligible and orthopedic procedures, is not often offered through but not enrolled. Hospitals and some other providers community health centers and is described as difficult to are authorized to presumptively enroll individuals in access by uninsured patients who report a need for it.28 Medicaid at the point of service on the basis of a simpli- fied income screen that indicates whether they appear to Finally, prescription drugs can be difficult for uninsured be eligible.30 And in many states, people who enroll in patients to obtain. Many community health centers Medicaid can receive retroactive coverage for any med- provide subsidized prescription drugs to their patients, ical expenses incurred up to three months before they and prescription drug manufacturers offer a limited applied.31 Such retroactive coverage allows providers to number of subsidized drugs to low-income patients receive payment for services that are rendered before without insurance through patient-assistance programs.29 their patients can submit a complete application for the However, not all uninsured people are able to fill their program. The presumptive-eligibility and retroactive-­ prescriptions through those channels; as a result, many coverage rules of states’ Medicaid programs also apply uninsured people are unable to fill their prescriptions at to CHIP programs that were implemented through all (or can fill them only sporadically). Medicaid expansions, which include the entire CHIP program in 8 states and a portion of the CHIP program Special Considerations for People Eligible for (for example, coverage for enrollees below a particular Medicaid and CHIP age or income level) in an additional 41 states. Some People who are eligible for Medicaid or CHIP but not states also allow additional providers and entities to make enrolled have a greater degree of financial protection presumptive-eligibility determinations for CHIP. than other uninsured people, but they can still have difficulties accessing care. However, even for people covered by the presumptive-­ eligibility and retroactive-coverage rules, those rules do Eligible people can enroll in Medicaid or CHIP through- not provide complete protection. Individuals are not out the year, without waiting for an open enrollment always presumptively enrolled, particularly when they are seeking care outside of a hospital, and they may not 27. See Brendan Saloner and others, “Most Primary Care Physicians be aware that they can apply for retroactive coverage. Provide Appointments, but Affordability Remains a Barrier Moreover, many providers do not accept patients who for the Uninsured,” Health Affairs, vol. 37, no. 4 (April 2018), cannot present proof of enrollment or pay the full cost pp. 627–634, https://doi.org/10.1377/hlthaff.2017.0959. out of pocket. 28. For evidence on the availability of specialty care for community health center patients, see Michael K. Gusmano, Gerry Fairbrother, and Heidi Park, “Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured,” 30. Under the ACA, all states are required to allow hospitals to Health Affairs, vol. 21, no. 6 (November 2002), pp. 188–194, conduct presumptive eligibility determinations for Medicaid. https://doi.org/10.1377/hlthaff.21.6.188. For a comparison of Some states also allow other providers and entities to make uninsured and insured patients’ reported difficulties in accessing those determinations. For more details on specific state policies, specialty care for chronic conditions, see Anita Soni, Specialist see Tricia Brooks and others, Medicaid and CHIP Eligibility, Need and Access Among Adults With Multiple Chronic Conditions, Enrollment, and Cost Sharing Policies as of January 2020: Findings U.S. Civilian Noninstitutionalized Population, 2012, Statistical From a 50-State Survey (Kaiser Family Foundation, March 2020), Brief 482 (Agency for Healthcare Research and Quality, https://tinyurl.com/ya5sa3y7. Department of Health and Human Services, November 2015), 31. In recent years, an increasing number of states have received https://go.usa.gov/xw654. approvals for waivers to limit retroactive coverage. See Medicaid 29. Community health centers and other safety-net providers receive and CHIP Payment and Access Commission, Medicaid discounted prescription drugs through the federal 340B drug Retroactive Eligibility: Changes Under Section 1115 Waivers pricing program. (August 2019), https://go.usa.gov/xw65W (PDF, 275 KB). September 2020 Who Went Without Health Insurance in 2019, and Why? 13 People who are eligible for but not enrolled in Medicaid However, most uninsured people had lower-cost options or CHIP are also probably less likely to seek health care because they were eligible for premium tax credits, than enrollees, for several reasons: They may be unaware employment-based coverage, or public programs.33 Using that they are eligible for those programs and could have its health insurance simulation model, CBO determined the cost of treatment covered; they are less likely to have the average price of the lowest-cost option for health insur- a usual source of care; and they do not have a connection ance for people with access to various subsidized sources of to a health plan and network of providers. As a result, coverage as well as those without access to subsidies. (See they probably have more difficulties accessing care than the appendix for more details on CBO’s methods.) people who are actually enrolled in those programs. The generosity of coverage provided by the lowest-cost What Factors Deter People From Obtaining option varied for different people. Medicaid, CHIP, and Health Insurance? the plans offered through most employers would have People may forgo coverage for various reasons. The most covered a larger share of health care costs than most common is the high out-of-pocket cost of health insur- plans available through the nongroup market. People ance premiums; others include a lack of awareness of purchasing plans in the nongroup market would face program eligibility, the hassle of enrolling in coverage, even higher premiums if those plans were as generous as and high cost sharing required by some health plans. the average employment-based plan. Premiums Premiums for Single Adults. For some groups of Higher out-of-pocket premiums tend to reduce people’s uninsured single adults, the cheapest available coverage willingness to purchase health insurance. Research has in 2019 would have cost zero dollars; for other groups, shown that the likelihood of enrolling in insurance falls it would have cost more than $7,000, on average (see as out-of-pocket premiums increase, particularly among Figure 3). Those who were eligible for Medicaid or low-income populations.32 CHIP would have been responsible for no or nearly no premiums if they enrolled.34 At the other end of the CBO estimated how expensive it would be for different spectrum, CBO estimates that people with income too types of uninsured people to enroll in coverage, focus- high for marketplace subsidies and no other option but ing first on the estimated cost of obtaining coverage for to purchase nongroup coverage at full cost would have single adults. Determining the cost of obtaining health faced an average cost of $7,500 to enroll in the least insurance for families is more complex because members expensive (and least generous) plan available to them. of the same family may be eligible for different types of Adults below the poverty level who were ineligible for coverage. For example, CBO estimates that in 28 percent Medicaid would have faced costs that were nearly as high of uninsured families, at least one member is eligible to enroll in a nongroup plan. For uninsured people who for Medicaid or CHIP but at least one other member were eligible for subsidized coverage through the market- is not and would have to purchase a private plan. (Such places, the average cost of enrolling in the least expensive situations often arise when a program’s income threshold option would have been about $1,500 per year; for those for eligibility is higher for children than for parents.) The gross premium for a family plan (that is, the cost before 33. CBO estimates that the average gross premium for a bronze plan taxes and subsidies) is generally higher than that for a was about $8,300 in 2019. Younger people’s premiums would single plan because family plans cover more people. generally be lower than that average, and older people’s premiums would generally be higher. In some states, other types of plans with lower premiums are available, but they may cover fewer CBO estimates that for people who were uninsured in types of health care services, exclude coverage for pre-existing 2019, the average gross premium for the least generous conditions, be priced on the basis of people’s health care status, or type of single plan in the private nongroup market (a deny coverage to people with high expected health care costs. bronze plan, which on average pays for about 60 per- 34. Most state programs do not charge premiums for adults or cent of covered benefits) would have been about $7,700. children, but a small number of states charge a small premium to enroll in Medicaid, and more than half of states charge a 32. For example, see Amy Finkelstein, Nathaniel Hendren, and Mark modest premium to enroll in CHIP. For more details, see Tricia Shepard, “Subsidizing Health Insurance for Low-Income Adults: Brooks, Lauren Roygardner, and Samantha Artiga, Medicaid Evidence From Massachusetts,” American Economic Review, and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of vol. 109, no. 4 (April 2019), pp. 1530-–567, January 2019: Findings From a 50-State Survey (Kaiser Family https://doi.org/10.1257/aer.20171455. Foundation, March 2019), https://tinyurl.com/yc7b3dg2. 14 Who Went Without Health Insurance in 2019, and Why? September 2020 Figure 3 . Annual Out-of-Pocket Cost of Premiums for Uninsured Single Adults’ Least Expensive Option for Health Insurance, 2019 Eligible for Subsidized Coverage Not Eligible for Subsidized Coverage $8,000 $7,500 $6,500 $6,000 $5,400 $4,000 $2,000 $1,700 $1,500 $0 0 Eligible Eligible for Eligible for Subsidized Not Income Below FPL Income for Medicaid Marketplace Employment-Based Lawfully in a State Too High for or CHIP a Subsidies b Coverage c,d Present That Did Not Marketplace Expand Medicaid Subsidies Percentage for Whom the Cost Would Be... 5 Percent of Income More Than 5 Percent, More Than 10 Percent or Less Up to 10 Percent of Income of Income 2% 1% 5% 14% 16% 42% 56% 18% 40% 100% 100% 68% 95% 45% Source: Congressional Budget Office. ACA = Affordable Care Act; CHIP = Children’s Health Insurance Program; FPL = federal poverty level. CBO classified people with zero income who were eligible for Medicaid and CHIP as having an option that would cost 0 to 5 percent of income. (Such people generally face zero or very small premiums.) Other people with zero income (or negative income) were classified as having an option that would cost more than 10 percent of income. a. Most state Medicaid programs do not charge premiums for adults or children, but a small number of states do charge a small premium. Over half of states charge a modest premium to enroll in CHIP. On average, the costs of premiums for those programs still round to zero dollars. b. A small number of people in this group would technically be eligible for subsidies, but those subsidies would equal zero dollars. c. A small number of people in this group were self-employed and could receive a subsidy by deducting their premiums from their federal income taxes. d. CBO imputes health insurance premiums with a simplified representation of how premiums are actually constructed by firms and group insurers, which slightly underestimates the fraction of workers with large out-of-pocket premiums. September 2020 Who Went Without Health Insurance in 2019, and Why? 15 with access to subsidized employment-based coverage, income too high for marketplace subsidies and no offer it would have been about $1,700 per year.35 (For subsi- of employment-based coverage, more than half could dized marketplace coverage, that amount reflects the cost purchase coverage for 10 percent or less of their income, of a bronze plan; for employment-based coverage, that but fewer than one-fifth could purchase coverage for amount reflects the cost of a plan that is typically more 5 percent or less of their income. generous.) Those figures are averages; the actual cost faced by individuals for their cheapest coverage option Among those who were not eligible for subsidized cover- could vary widely depending on their age, location, fam- age, premiums for plans through the nongroup market ily size, income, and tobacco use.36 tended to be lower and more affordable for younger adults than older adults. The largest age-based discrepan- The affordability of premiums depends not only on cies were for people with income too high to qualify for their absolute cost but on how that cost compares to marketplace subsidies. Because older adults are generally one’s family income. CBO estimated the percentage of subject to higher premiums, their out-of-pocket costs uninsured people who could have obtained coverage for jump significantly once their income exceeds the cutoff no more than 10 percent or 5 percent of their income. for subsidies.37 CBO estimates that 19- to 49-year-olds Although those thresholds are one indication of afford- over that cutoff would have paid an average of $4,900 ability, some people, particularly those with low income, to enroll in their least expensive option, whereas 50- to may find it difficult to spend even 5 percent of their 64-year-olds would have paid an average of $9,800.38 income on health insurance because they have competing Those costs were also lower in relation to income for financial obligations (such as housing or other bills). younger adults than for older adults. CBO estimates that 91 percent of the same 19- to 49-year-olds could have CBO estimates that 64 percent of single adults who were obtained coverage for 10 percent or less of their income, uninsured in 2019 could have obtained coverage for compared with only 34 percent of the 50- to 64-year- 10 percent or less of their income, and 49 percent could olds. A much smaller share of adults in either group have obtained coverage for 5 percent or less of their could have purchased unsubsidized private coverage for income (see Table 3). Of the people eligible for some 5 percent or less of their income. form of subsidized coverage, the vast majority could have enrolled at a cost of 10 percent or less of their income, Finally, some uninsured people have the option of enroll- and a large share could have enrolled for 5 percent or ing in coverage for free—zero dollars paid out of pocket. less of their income. By contrast, people ineligible for That includes nearly all people eligible for Medicaid, subsidized coverage were far less likely to have affordable many people eligible for CHIP, and the majority of options—particularly noncitizens who were not lawfully people eligible for subsidized marketplace coverage.39 present and were not offered employment-based coverage Although people in the last group could enroll in a plan and people with income below the poverty line in states that had not expanded Medicaid. Among those with 37. For more information about the so-called subsidy cliff, see Rachel Fehr and others, How Affordable Are 2019 ACA Premiums for Middle-Income People? (Kaiser Family Foundation, March 2019), 35. Some people eligible for subsidized employment-based coverage https://tinyurl.com/y2lvvmkh. are self-employed and have enough self-employment income to deduct health insurance premiums from their federal income 38. Age-rating regulations limit the extent to which premiums for taxes. The value of that deduction is much smaller than the younger adults in the nongroup market can differ from those for combined value of the exclusion of premiums from income and older adults to reflect their lower underlying health risk. payroll taxes and the employer contributions available to people 39. Zero-premium options for marketplace plans became more offered coverage through an employer. prevalent after the federal government terminated payments 36. Some of those differences in characteristics also help to explain to insurers for cost-sharing reductions in October 2017. Most why different groups of uninsured people face different average insurers responded by increasing their premiums for silver gross premiums through the nongroup market. People who are plans. The second-lowest-cost silver plan is the benchmark for eligible for marketplace subsidies, who are not lawfully present calculating subsidies, so increasing those premiums increased and not eligible for employment-based coverage, who have federal subsidy levels. The higher subsidies enabled more people income below the poverty level and are not eligible for Medicaid, to purchase a bronze plan—and, in some cases, the lowest-cost and who have income too high for marketplace subsidies and no silver plan—for zero dollars out of pocket. For more details, see offer of employment-based coverage all would purchase coverage Rachel Fehr, Cynthia Cox, and Matthew Rae, How Many of the through the nongroup market; however, because those groups Uninsured Can Purchase a Marketplace Plan for Free in 2020? have different distributions of ages, locations, and other factors, (Kaiser Family Foundation, December 2019), their average gross premiums range from $5,400 to $7,500. https://tinyurl.com/v6wqn9f. 16 Who Went Without Health Insurance in 2019, and Why? September 2020 Table 3 . Annual Out-of-Pocket Cost of Premiums for Uninsured Single Adults’ Least Expensive Option for Health Insurance, by Age Group, 2019 Average Cost Percentage of Individuals for Whom the (In 2019 dollars) Cost Would Be... Before Taxes and After Taxes and 10 Percent​ 5 Percent Subsidies Subsidies of Income or Less f of Income or Less f Single Adults Under Age 65 3,900 2,900 64 49 Eligible for subsidized coverage Made eligible for Medicaid by the ACA 0e 0e 100 100 Otherwise eligible for Medicaid or CHIP 0e 0e 100 100 Eligible for marketplace subsidies a,b 5,500 1,500 98 56 Eligible for subsidized employment-based coverage c,d 2,200 1,700 86 68 Ineligible for subsidized coverage Not lawfully present a 5,400 5,400 5 1 Income below the FPL and living in a state that has not expanded Medicaid a 6,500 6,500 0 0 Income too high for marketplace subsidies a 7,500 7,500 60 16 Single Adults Ages 19 to 49 3,000 2,300 66 50 Eligible for subsidized coverage Made eligible for Medicaid by the ACA 0e 0e 100 100 Otherwise eligible for Medicaid or CHIP 0e 0e 100 100 Eligible for marketplace subsidies a,b 4,400 1,500 98 56 Eligible for subsidized employment-based coverage c,d 1,800 1,400 87 69 Ineligible for subsidized coverage Not lawfully present a 4,800 4,800 6 1 Income below the FPL and living in a state that has not expanded Medicaid a 4,700 4,700 0 0 Income too high for marketplace subsidiesa 4,900 4,900 91 22 Continued for free on the basis of their yearly income, they might marketplace, whereas others would have had to purchase be reluctant to sign up for coverage if they are unsure a family plan through the nongroup market at full cost. whether future increases in their income could result in their having to repay some or all of the subsidies. In any • Thirty percent were eligible for employment-based case, premiums are not the primary barrier to enrollment coverage. CBO estimates that their average cost for for people in any of those groups, which means that family coverage would have been about $4,000, other factors explain why they do not enroll in coverage. amounting to less than 10 percent of income for about 80 percent of those families and less than Premiums for Families. To illustrate the cost of obtain- 5 percent of income for about 60 percent of those ing coverage for families, CBO focused on families in families. which all members were eligible for the same type of private coverage and none were eligible for public cover- • Eight percent were eligible to purchase subsidized age. Those families accounted for 64 percent of unin- coverage through the marketplaces. CBO estimates sured families in 2019. In some cases, different family that their average cost for family coverage under members might have access to different types of private a bronze plan would have been about $3,500, coverage, but they would typically all enroll in the same amounting to less than 10 percent of income for plan. Some had the option to purchase a subsidized nearly all of those families and less than 5 percent of family plan through an employer or a health insurance income for about half. September 2020 Who Went Without Health Insurance in 2019, and Why? 17 Table 3. Continued Annual Out-of-Pocket Cost of Premiums for Uninsured Single Adults’ Least Expensive Option for Health Insurance, by Age Group, 2019 Average Cost Percentage of Individuals for Whom the (In 2019 dollars) Cost Would Be... Before Taxes and After Taxes and 10 Percent​ 5 Percent Subsidies Subsidies of Income or Less f of Income or Less f Single Adults Ages 50 to 64 6,700 4,800 60 44 Eligible for subsidized coverage Made eligible for Medicaid by the ACA 0e 0e 100 100 Otherwise eligible for Medicaid or CHIP 0e 0e 100 100 Eligible for marketplace subsidies a,b 8,700 1,700 97 58 Eligible for subsidized employment-based coverage c,d 3,300 2,500 84 64 Ineligible for subsidized coverage Not lawfully present a 8,700 8,700 4 1 Income below the FPL and living in a state that has not expanded Medicaid a 10,400 10,400 0 0 Income too high for marketplace subsidies a 9,800 9,800 34 10 Source: Congressional Budget Office, using the Health Insurance Simulation Model, which incorporates survey and administrative data from a variety of sources. See Jessica Banthin and others, Sources and Preparation of Data Used in HISIM2—CBO’s Health Insurance Simulation Model, Working Paper 2019-04 (Congressional Budget Office, April 2019), www.cbo.gov/publication/55087. Some people may be eligible for multiple sources of coverage. CBO classified uninsured people into mutually exclusive groups (also known as the hierarchy) on the basis of the most heavily subsidized option available to them or the primary reason they were ineligible for subsidized coverage. Estimates of premiums are rounded to the nearest hundred dollars. Premiums before taxes and subsidies account for employer contributions. Premiums after taxes and subsidies reflect out-of-pocket costs after applying all relevant federal subsidies (including premium tax credits and premium tax exclusions). Estimates of premiums as a share of income reflect those out-of-pocket costs divided by pre-tax income. ACA = Affordable Care Act; CHIP = Children’s Health Insurance Program; FPL = federal poverty level. a. Premiums reflect the cost of purchasing the least expensive bronze plan available. b. A small number of people in this group would technically be eligible for subsidies, but those subsidies would equal zero dollars. c. A small number of people in this group were self-employed and could receive a subsidy by deducting their premiums from their federal income taxes. d. CBO imputes health insurance premiums with a simplified representation of how premiums are actually constructed by firms and group insurers, which slightly underestimates the fraction of workers with large out-of-pocket premiums. e. Most state Medicaid programs do not charge premiums, but a small number charge a small premium to some enrollees. Over half of states charge a modest premium to enroll in CHIP. On average, the costs of premiums for those programs still round to zero dollars. f. Includes people eligible for Medicaid and CHIP but not enrolled, who generally face zero or very small premiums. Other people with zero income (or negative income) were classified as having an option costing more than 10 percent of income. • Twenty-seven percent could have purchased family In the remaining families, at least some members were coverage only through the nongroup market at eligible for public coverage or different members were full cost. CBO estimates that their average cost for eligible for different types of private coverage. Families family coverage under a bronze plan would have been in which all members were eligible for public coverage about $14,000, amounting to less than 10 percent made up only about 5 percent of uninsured families in of income for about 30 percent of those families and 2019, and their cost to obtain coverage would have been less than 5 percent of income for about 10 percent of close to zero. Families in which some, but not all, mem- those families. bers were eligible for public coverage made up about 28 percent of uninsured families in 2019. Estimating 18 Who Went Without Health Insurance in 2019, and Why? September 2020 their cost to cover all members of the family is more dif- provide no more financial protection than bankruptcy.)43 ficult because the lowest-cost option might be to enroll Many people do not have sufficient savings to pay those different members of the family in different types of costs before their care will be covered by insurance.44 In coverage.40 In the remaining 2 percent of uninsured fam- one survey, about one-third of insured people and nearly ilies, only some members of the family were eligible for half of those earning less than $40,000 per year said they premium tax credits, and estimating their cost to obtain had trouble affording their deductibles in 2019.45 Faced coverage is challenging for the same reason. with the prospect of paying thousands of dollars per year for coverage under which they still might not be able Other Factors to afford care, many people decide that enrolling is not Although premiums are the most important factor in worth the cost. many people’s decision to forgo insurance, other factors also play a role.41 For example, lack of information, con- Even people who are eligible to enroll in subsidized fusion, and the complexity of applying for coverage are coverage for a zero-dollar or very small premium— common barriers to enrollment. including all people who are eligible for Medicaid and CHIP and more than half of people eligible for market- In some cases, people may simply place a low value on place subsidies—do not always enroll. Their reasons may health insurance. For example, some people believe that include lack of awareness of the programs, uncertainty they do not need health insurance, particularly if they are about their eligibility, administrative hurdles in apply- healthy. And in areas where free or highly subsidized care ing for coverage or renewing eligibility, or resistance to is readily available, low-income people may be accus- reliance on government programs.46 Among immigrant tomed to obtaining care through those channels and see parents who are seeking citizenship, concerns about the little value in spending their limited resources on health 2019 Medicaid public charge rule appear to be reducing insurance premiums.42 willingness to enroll eligible children in Medicaid and CHIP, even if those children are citizens.47 Uninsured people also may not believe that a plan is worth the cost if it includes a high degree of cost shar- 43. Neale Mahoney, “Bankruptcy as Implicit Health Insurance,” ing. Such plans offer very limited protection against American Economic Review, vol. 105, no. 2, pp. 710–746, expensive medical events for people who are unable to https://doi.org/10.1257/aer.20131408. pay the associated deductibles, copayments, or other 44. One recent study found that 37 percent of people would not charges, which may total hundreds or thousands of have been able to pay for an unexpected expense of $400 without dollars. (Research has suggested that for people with low borrowing money in 2019. See Board of Governors of the to moderate income, plans with high deductibles may Federal Reserve System, Report on the Economic Well-Being of U.S. Households in 2019, Featuring Supplemental Data From April 2020 (May 2020), https://go.usa.gov/xw6PZ (PDF, 3.2 MB). 45. Ashley Kirzinger and others, Data Note: Americans’ Challenges 40. For most of the families in this group, children were eligible for With Health Care Costs (Kaiser Family Foundation, June 2019), public coverage but their parents were not. That is because the https://tinyurl.com/y2oa4rjf. family income limit for Medicaid and CHIP is generally higher 46. See Jennifer M. Haley and Genevieve M. Kenney, Why Aren’t for children than for adults. More Uninsured Children Enrolled in Medicaid or SCHIP? (Urban 41. See, for example, Sara R. Collins and others, Who Are the Institute, May 2001), https://tinyurl.com/y96n8rbc. Remaining Uninsured and Why Haven’t They Signed Up for 47. Legal immigrants seeking admission or an update in status must Coverage? Findings From the Commonwealth Fund Affordable Care demonstrate that they are not financially dependent on the Act Tracking Survey, February–April 2016 (The Commonwealth government. Under previous policy, only enrollment in Medicaid Fund, August 2016), https://tinyurl.com/ydyrp5l4. to cover nursing home or long-term institutional care would 42. Some researchers have argued that the availability of charity care result in inadmissibility under that “public charge rule.” In 2019, could explain why many low-income people do not purchase the federal government expanded that definition to include even highly subsidized insurance. See Amy Finkelstein, Nathaniel more categories of Medicaid enrollment. See Joan Alker and Hendren, and Mark Shepard, “Subsidizing Health Insurance for Lauren Roygardner, The Number of Uninsured Children Is on the Low-Income Adults: Evidence From Massachusetts,” American Rise (Georgetown University Health Policy Institute Center for Economic Review, vol. 109, no. 4, pp. 1530–1567, Children and Families, October 2019), p. 6, https://tinyurl.com/ https://doi.org/10.1257/aer.20171455. y26nogwe. September 2020 Who Went Without Health Insurance in 2019, and Why? 19 Table 4 . Length of Time Without Coverage for People Who Are Uninsured at a Particular Point in Time Percent Family Income Age Relative to the Federal Poverty Level Less Than 138 to 400 More Than Overall Less Than 19 19 to 64 138 Percent Percent 400 Percent 1 to 5 Months 11 24 9 8 11 n.a. 6 to 11 Months 9 13 8 9 8 n.a. 12 Months or More 80 62 83 83 81 73 Source: Congressional Budget Office, using longitudinal data from the Medical Expenditure Panel Survey. The estimates measure the total length of time without coverage for people who were uninsured as of the middle of the 2015–2016 and 2016–2017 panels of the Medical Expenditure Panel Survey. Results for some groups are not applicable because the sample sizes are very small, which makes it difficult to produce precise estimates. n.a. = not applicable. How Long Do Uninsured People Remain individuals changed jobs and moved from one employer’s Without Coverage? plan to another, or if they cycled into and out of public The length of time individuals remain uninsured has coverage as a result of changes in income. implications for their exposure to financial risk and access to health care. A short spell without insurance CBO estimated durations without coverage by taking exposes individuals to the financial risk of unexpected a snapshot of the uninsured population at a particular health events that could occur during that period, but it moment and measuring how long those people were has a more limited effect on their access to routine and uninsured. That definition of the uninsured population anticipated care. corresponds to the definition CBO used to examine the characteristics and coverage options of uninsured people Overall, CBO estimates that in recent years, 80 percent in 2019. However, the uninsured population could also of people who were uninsured at a given point went be defined to include anyone who lost coverage at any without coverage for 12 months or longer (see Table 4). point over a particular period. For example, whereas Adults ages 19 to 64 and people with income below 12 percent of people under 65 were uninsured at a given 138 percent of the poverty level were the most likely point in 2019, roughly 25 percent spent some time with- to fall into this group. By contrast, children and mem- out coverage over a two-year period in recent years. The bers of families with income above 400 percent of the latter group includes more people who were uninsured poverty level tended to be uninsured for shorter spells. for short periods, which means the average length of Altogether, about 11 percent of the uninsured popula- time without coverage is shorter for that group than for tion lacked coverage for periods of 1 to 5 months, and people uninsured at a given moment. For more details another 9 percent lacked coverage for 6 to 11 months. on CBO’s methods and that alternative measure of time Those shorter gaps in coverage could have occurred if without coverage, see the appendix. Appendix: The Data and Methods Underlying CBO’s Estimates This appendix describes the data and methods the CBO also includes variables that are not available in Congressional Budget Office used to produce the esti- the CPS data. In some cases, CBO does so by matching mates in this report. The methods used in this analysis records to observations from other surveys and admin- are consistent with those used to construct CBO’s base- istrative sources. For example, premiums for nongroup line projections of coverage as of March 6, 2020. (The (non-employment-based) coverage are developed using baseline is CBO’s best estimate of how the budget would administrative data on actual premiums from federal evolve if existing laws generally remained in place. CBO’s and state health insurance marketplaces. In other cases, estimates of the number of uninsured in 2019 did not variables are developed endogenously (that is, on the change substantially between its March 2020 baseline basis of the values of other variables) within the model. and its September 2020 baseline.) Premiums for employment-based insurance fall into that category: In the model, those premiums are calculated Characteristics and Coverage Options of the on the basis of plans’ characteristics, which are imputed Uninsured Population in 2019 to observations using data from the Medical Expenditure Many of the estimates in this report are drawn from the Panel Survey—Insurance Component, and on the basis CBO’s health insurance simulation model, HISIM2, of distributions of households’ spending on health care, which CBO uses to estimate the major sources of health which are imputed to observations using data from insurance coverage and associated premiums for non- the Medical Expenditure Panel Survey—Household institutionalized U.S. residents under age 65.1 Most of Component (MEPS-HC). the data in HISIM2 come from the Annual Social and Economic Supplement of the Current Population Survey Lowest-Cost Options for Coverage (CPS). Those data provide reliable, timely, and detailed CBO uses income and other factors in its HISIM2 information on many of the key variables needed to model to calculate each individual’s eligibility for public model health insurance coverage—including income, coverage (such as Medicaid or CHIP) and for premium employment, and self-reported health status. tax credits for nongroup coverage purchased through the marketplaces. CBO also simulates which workers will To improve the accuracy of the CPS data, CBO adjusts have an offer of employment-based coverage and the cost variables that are likely to be reported with some error, of that single or family coverage after any relevant tax such as the number of people enrolled in Medicaid subsidies and employer contributions. In addition, CBO and the amount of income reported on tax returns, so simulates the value of the tax deduction for health insur- that the distributions of characteristics of people in the ance available to self-employed people without access to HISIM2 sample match those found in administrative group coverage through an employer. data. Using the model, CBO estimated the minimum amount that uninsured people eligible for different types of sub- 1. For more information about how CBO prepares data for sidized coverage would have to pay to enroll in coverage. HISIM2, see Jessica Banthin and others, Sources and Preparation To do so, CBO first estimated the net out-of-pocket of Data Used in HISIM2—CBO’s Health Insurance Simulation premium each uninsured person would pay for each of Model, Working Paper 2019-04 (Congressional Budget Office, his or her coverage options. The net premium reflects the April 2019), www.cbo.gov/publication/55087. For additional information about HISIM2, see Congressional Budget Office, out-of-pocket cost to households after applying all rele- “Methods for Analyzing Health Insurance Coverage” (accessed vant federal subsidies (including the reduced tax liability September 17, 2020), https://go.usa.gov/xGQcM. from premium tax credits, tax deductions for nongroup 22 Who Went Without Health Insurance in 2019, and Why? September 2020 Figure A-1 . Measuring the Length of Time Without Coverage for People Who Are Uninsured at a Particular Point in Time Person E Person D 15 Person C Point in Time Person B Person A Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Source: Congressional Budget Office. The Congressional Budget Office measured how long uninsured people usually go without coverage using the duration of uninsured spells that were in progress at a particular point in time. Consider five people who become uninsured at some point during a two-year period. Person A becomes uninsured in January of the first year and remains uninsured for the entire period. The other four people are each uninsured for six months—Person B from January through June of the first year, Person C from July through December of the first year, and so on. Using CBO’s point-in-time measure, the uninsured population in December of the first year consisted of two people (Person A and Person C); of that uninsured population, 50 percent (one of two) was uninsured for a year or more and 50 percent was uninsured for six months. If, instead, the length of time uninsured people go without coverage was measured by including all people who were uninsured at some point over the period, then 20 percent (one of five) went without coverage for a year or more and 80 percent (four of five) went without coverage for six months. The first approach characterizes the length of time without coverage for the population that is uninsured at a particular point in time, whereas the second approach does so for a broader definition of the uninsured population. insurance, and tax exclusions for employment-based Although most of the estimates in this report that are insurance premiums) and employer contributions. Then, based on the HISIM2 model describe the uninsured CBO determined the least expensive of those options population in 2019, CBO used data from the 2015– and used its cost as each person’s lowest-cost option for 2016 and the 2016–2017 panels of the MEPS-HC obtaining health insurance coverage. To demonstrate because those were the most recent data available. CBO how federal subsidies lower the cost of health insurance, pooled the data from those two panels to improve the CBO also estimated the gross premiums for the least precision of its estimates, but the length of time unin- expensive options—that is, the cost after any employer sured people went without coverage in each panel was contributions but before subsidies. very similar. Length of Time Without Coverage CBO measured durations without coverage for peo- CBO’s estimates of the length of time uninsured people ple who were uninsured at a particular point in time. go without coverage were produced using data from the Specifically, CBO identified the people who were unin- MEPS-HC. The MEPS-HC surveys the same house- sured in December of 2015 and 2016 and estimated how holds five times over a two-year period and reports each long they went without coverage, looking backward and person’s coverage status for each month of that period. forward 12 months (see Figure A-1). Those data allowed CBO to follow the same uninsured people over time to measure how long they remained An alternative approach would be to measure the length without coverage. of time without coverage for a broader definition of the uninsured population: people who were without APPENDIX Who Went Without Health Insurance in 2019, and Why? 23 coverage at any point over a longer period. Defined approach would reflect a shorter average length of time in that way, the uninsured population would include without coverage. Although many people go without more people who transitioned into and out of coverage coverage for relatively short periods, most people who relatively quickly over the course of a year. Compared are uninsured at a given moment will remain without with the point-in-time approach that CBO used, that coverage for at least a year. List of Tables and Figures Tables 1. Characteristics of Nonelderly People Without Health Insurance, 2019 4 2. Eligibility for Subsidized Coverage Among the Uninsured, 2019 6 3. Annual Out-of-Pocket Cost of Premiums for Uninsured Single Adults’ Least Expensive Option for Health Insurance, by Age Group, 2019 16 4. Length of Time Without Coverage for People Who Are Uninsured at a Particular Point in Time 19 Figures 1. Eligibility for Subsidized Coverage Among the Uninsured in 2019 2 2. How CBO Categorized Uninsured People Into Groups Based on Their Options for Subsidized Coverage or the Reasons They Lacked Those Options 7 3. Annual Out-of-Pocket Cost of Premiums for Uninsured Single Adults’ Least Expensive Option for Health Insurance, 2019 14 A-1. Measuring the Length of Time Without Coverage for People Who Are Uninsured at a Particular Point in Time 22 About This Document This report was prepared at the request of the Chairman of the House Budget Committee. In keeping with the Congressional Budget Office’s mandate to provide objective, impartial analysis, the report makes no recommendations. Allison Percy and Karen Stockley wrote the report, with guidance from Alexandra Minicozzi and Julie Topoleski. Geena Kim contributed to the analysis. Alice Burns, Sarah Masi, Robert Stewart, Emily Vreeland, and Chapin White provided useful comments. Katherine Feinerman and Christian Henry fact-checked the report. Matthew Fiedler of the Brookings Institution, Craig Garthwaite of Northwestern University, Sherry Glied of New York University, and Mark Shepard of Harvard University provided helpful comments. The assistance of external reviewers implies no responsibility for the final product, which rests solely with CBO. Jeffrey Kling and Robert Sunshine reviewed the report. Christine Browne was the editor, and Jorge Salazar was the graphics editor. An electronic version is available on CBO’s website (www.cbo.gov/publication/56504). CBO continually seeks feedback to make its work as useful as possible. Please send any comments to communications@cbo.gov. Phillip L. Swagel Director September 2020