¢ ASPE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION OFFICE OF DATA POINT HEALTH POLICY August 3, 2023 National Uninsured Rate Reaches an All-Time Low in Early 2023 After the Close of the ACA Open Enroliment Period The uninsured rate in early 2023 has reached an all-time low of 7.7% among all U.S. residents, indicating that 6.3 million people have gained health insurance coverage since 2020. KEY POINTS The nation's uninsured rate declined significantly in early 2023, relative to 2020, reaching an all- time low of 7.7 percent for U.S. residents of all ages in the first quarter (January-March) of 2023, based on new data from the National Health Interview Survey. Approximately 6.3 million people - including 5.5 million adults ages 18-64 and 0.7 million children ages 0-17 - have gained health coverage since 2020. These gains in health insurance coverage are concurrent with the implementation of the American Rescue Plan's enhanced Affordable Care Act (ACA) subsidies, the Inflation Reduction Act's continuation of those subsidies, the continuous enroliment condition in Medicaid, recent state Medicaid expansions, and substantial Marketplace enroliment outreach by the Biden-Harris Administration in 2021-2023. Uninsured rates among adults ages 18-64 declined from 14.5 percent in late 2020 to 11.0 percent in early 2023. The uninsured rate among children ages 0-17, which had increased during 2019 and 2020, fell from 6.4 percent in late 2020 to 4.2 percent in early 2023. Approximately 5.8 percent of adults ages 18-64 reported having ACA Marketplace coverage in early 2023 compared to 4.4 percent in 2020. Changes in uninsured rates from 2021 to Q1 2023 were largest among individuals with incomes below 100% of the Federal Poverty Level (FPL) and incomes between 200% and 400% FPL, with uninsurance rates for non-elderly individuals in both income groups decreasing 3.0 percentage points from early 2021.These gains in insurance follow record breaking sign-ups for health coverage in the ACA Marketplaces during the 2022 and 2023 Open Enrollment Periods, with the increased Marketplace enrollment contributing to the substantial growth of private coverage. These results highlight the significant gains in health insurance coverage that occurred in 2021, 2022 and early 2023 associated with the Biden-Harris Administration's policies to support health insurance expansion. These gains build on the large reductions in the uninsured rate that occurred after the implementation of the ACA in 2014, which research demonstrates produced improved health outcomes, access to care, and financial security for families. These results are likely to mark the lowest point in the uninsured rate in 2023. Each year, the first quarter of the year generally marks the lowest uninsured rate, as people transition to new sources of coverage, or periods without insurance coverage, over the remainder of the year. In August 2023 DATA POINT 1 addition, in April of 2023, the Medicaid continuous coverage condition came to an end, so some people will transition out of Medicaid coverage, including to other sources of insurance coverage over the coming months. BACKGROUND Newly-released federal survey data show the uninsured rate reached an all-time low in early 2023, and suggest that the Biden-Harris Administration's efforts to improve access to affordable health insurance coverage have helped reduce the nation's uninsured rate in 2021, 2022, and early 2023.! Previous reports indicate that health coverage related to the Affordable Care Act (ACA) - Marketplace, Medicaid expansion, and the Basic Health Program - reached an all-time high of more than 40 million people in late 2022 and early 2023.2 The 2023 Open Enrollment Period saw a record breaking 16.3 million people sign up for health coverage in ACA Marketplaces, following administrative and legislative actions such as an extended 2021 special enroliment period and implementation of expanded Marketplace subsidies under the American Rescue Plan (ARP) and Inflation Reduction Act.>* In addition, recent adoption of the ACA Medicaid expansion in several states has extended Medicaid coverage to low-income adults up to 138% of the Federal Poverty Level {FPL). Medicaid enrollment has grown during this time period as well under the continuous enrollment condition passed by Congress as part of the COVID-19 pandemic response, which has sunset as of March 31, 2023. This Data Point examines new National Health Interview Survey (NHIS) data for the first quarter of 2023 to assess changes in health insurance coverage since 2000. METHODS We analyzed newly-released NHIS data from the Centers for Disease Control and Prevention's (CDC).> Data are based on household interviews of a sample of the civilian noninstitutionalized population. The NHIS provides a reliable and consistent data source for assessing long-term changes in coverage, as indicated in a 2014 assessment by the White House Council of Economic Advisors.® NHIS results in 2020 may not be as reliable for comparisons to survey results before the pandemic, though response rates in 2021, 2022 and 2023 have more closely resembled pre-pandemic levels; more details on NHIS data collection can be found in a previous ASPE report." We analyzed changes in coverage over time by age group and income group, as well as source of health insurance coverage. We also analyzed estimates on uninsured rates by state from the American Community Survey (ACS), the largest national survey of households, since the NHIS does not have sample size to allow for state estimates for all states.* The Census Bureau surveys almost 300,000 households each month for the ACS and collects health insurance and demographic data, along with other types of information. Uninsured rates for the full state population of all ages come from the ACS's public data tables for 2013 and 2021 {the most current year of ACS data available), which we used to compare state-by-state changes in uninsured rates since the implementation of the ACA2® FINDINGS National Results Figure 1 shows the national uninsured rates for the U.S. population (all ages) from 2000 through the most recent data. The uninsured rate for Q1 2023 was 7.7 percent.'® Prior to 2023, the lowest full-year uninsured estimate in the NHIS was 9.0 percent in 2016'! and the lowest quarterly estimate was 8.0 percent in Q1 2022 (note that quarterly estimates are somewhat more volatile than full year estimates, given their smaller sample August 2023 DATA POINT 2 sizes).'?* The new results correspond to 25.3 million uninsured individuals in Q1 2023, compared to an annual estimate of 31.6 million for 2020, indicating that approximately 6.3 million people gained health care coverage during this time period.'® This is a conservative estimate of the number of people who gained coverage since 2020, since uninsured rates rose in the second half of 2020; if we compare the Q1 2023 estimate to the second half of 2020, the estimated number gaining coverage rises to 7.3 million. Figure 1 demonstrates that the recent reductions in the uninsured rate built on the large coverage gains that occurred in the first 3 years after implementation of the ACA in 2014 and reversed a temporary increase in the uninsured rate from 2017-2019. Overall, the Q1 2023 uninsured population represents a drop of nearly 23 million from the peak of 48.3 million in 2010. Figure 1. National Uninsured Rate, All Ages (2000 - Q1 2023) 20.0% 18.0% 16.0% 14.9% (48.3 M) (41.3 M) 16.0% 14.0% 12.0% ) 7.7% 10.0% (25.3 M) 8.0% 6.0% ACA ARP 4.0% Takes Takes Effect Effect 2.0% 0.0% 200020012002 2003 2004 200520062007 2008 200920102011 201220132014 201520162017 20182019202020212022 Q1 2023 Source: National Health Interview Survey's Health Insurance Coverage Reports, 2000-2022. https://www.cdc.gov/nchs/nhis/healthinsurancecoverage.htm; Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, January 2022--March 2023. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2023 Q11.pdf Note: Beginning in the third quarter of 2004, two additional questions were added to the NHIS insurance section to reduce potential errors in reporting Medicare and Medicaid status, resulting in two methods to estimate uninsurance. Beginning in 2005, all estimates were calculated using Method 2. Please see "Technical Notes" for the Early Release of Health Insurance Estimates Based on Data From the 2010 National Health Interview Survey for more information. * The NHIS underwent a survey redesign in 2019. While the questions used to assess health insurance coverage did not change, the questionnaire design and sample weighting were revised. A technical paper conducted by the National Center for Health Statistics concluded that the redesign "may have shifted upward by 0.7 percentage points due to the methodological change" the national estimate for the uninsured rate among adults. This upward shift since 2019 means that the Q1 2022 uninsured estimate of 8.0 percent likely represents a record-low by an even larger margin than the 0.6 percentage points compared to Q1 2016 and 1.1 percentage points compared to full-year 2016. See https://www.cdc.gov/nchs/data/nhis/earlyrelease/EReval202009-508.pdf for further details on the NHIS redesign. August 2023 DATAPOINT 3 Figure 2 shows quarterly changes in health insurance coverage among adults ages 18-64, for whom the uninsured rate was 11.0 percent in Q1 2023, a 3.5 percentage-point decrease from Q4 2020. Children ages 0 to 17 years also experienced a 2.2 percentage-point decrease in their uninsured rates in the same time frame. If we focus on full-year estimates for 2020 vs. Q1 2023, the change for adults ages 18-64 was -2.9 percentage points (from 13.9 percent to 11.0 percent) with approximately 5.5 million adults gaining health coverage, and the change for children was -0.9 percentage points (from 5.1 percent to 4.2 percent) with approximately 0.7 million children gaining health coverage.**° Figure 2. Uninsured Rate by Quarter, Populations Ages 18-64 and Ages 0-17 (04 2020 - Q1 2023) 16.0% 14.5% 14.2% 13.8% 14.0% o 13.1% 13.0% ' 125% 12.6% 11.8% 12.1% 12.0% 11.0% 10.0% 8.0% e 18-64 Years s 0-17 Years 6.0% 6.4% 4.0% 4.6% 4.5% 4.2% 4.2% 4.2% 4.2% 4.2% 35% 37% 2.0% 0.0% Q42020 Q12021 Q22021 Q32021 Q42021 Q12022 Q22022 Q32022 Q42022 Q12023 Source: Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2020- December 2021, https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2021 Q14.pdf; Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2021-December 2022. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2022 Q14.pdf; Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, January 2021-March 2022. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2022 Q11.pdf Figure 3 shows the growth in Marketplace coverage {(or "Exchange-based private coverage," as the NHIS refers to it} among adults 18-64 since 2019. An estimated 5.8 percent of adults ages 18-64 reported having Marketplace coverage in early 2023, compared to 4.4 percent in 2019. While survey-based information on Marketplace coverage is not as reliable as official administrative enrollment statistics, this result is consistent with the record-breaking Marketplace Open Enrollment Period for 2023%¢ and suggests that Marketplace coverage gains in 2022 and early 2023 were a substantial contributor to the reduction in the uninsured rate. August 2023 DATAPOINT 4 Figure 3. Percentage of Adults Ages 18-64 with Marketplace Coverage (Q1 2019 - Q1 2023) 7.0% 9 5.8% 6.0% 5.4% 4.9% 5.0% 4.0% 4.4% 4.0% 3.0% 2.0% 1.0% 0.0% Q1 @2 Q@3 04 a1 @2 3 a4 a1 Q@2 3 4 Qa1 Q@2 a3 o4 a 2019 2020 2021 2022 2023 Source: NHIS Interactive Quarterly Early Release Estimates. https://wwwn.cdc.gov/NHISDataQueryTool/ER_Quarterly/index_quarterly.html Figure 4 shows that uninsured rates among those under age 65 declined for all income bands since the beginning of 2021. Those with incomes below 100% FPL and between 200% FPL and 400% FPL had the greatest gains in coverage, with uninsured rates decreasing 3.0 percentage points for both groups. Uninsurance rates for individuals with incomes below 100% FPL decreased from 20.0 percent to 17.0 percent, and rates for those with incomes between 200% FPL and 400% FPL decreased from 11.7 percent to 8.7 percent. Uninsured rates for those between 100% and 200% FPL went from 16.6 to 15.8 percent, though when compared to Q2 2021, there was a larger decline from 19.0 to 15.8 percent. Those with incomes above 400% FPL had the lowest uninsured rate throughout the study period, and it declined modestly from 4.2 to 3.3 percent. In relative terms, these declines represent a 3.0 percent reduction in the uninsured rate for those below 100% FPL, a 3.2 percent reduction for those between 100% and 200% FPL (compared to Q2 2021), a 3.0 percent reduction for those between 200% and 400% FPL, and a 0.9 percent reduction for those above 400% FPL. These declines in uninsured rates by income coincide with the Medicaid continuous enrollment condition, which began in March 2020 and enabled states to maintain enrollment of most individuals in Medicaid through March 31, 2023, and the implementation of the ARP and IRA subsidies, which were retroactive to January 1, 2021, and boosted the size of premium tax credits for those with incomes between 100% and 400% FPL and extended tax credits to those with incomes above 400% FPL for the first time. Previous ASPE analyses have shown the impacts of the ARP in lowering Marketplace premiums and improving plan affordability through increased access to zero- and low-premium plans on the HealthCare.gov platform.t"18 August 2023 DATAPOINT 5 Figure 4. Uninsured Rate Among U.S. Residents Under Age 65, by Income (Q1 2021 - Q1 2023) 25.0% 20.0% 20.0% 17.0% 15.0% 16.69 - ' * 15.8% <100% FPL 11.7% s 100% t0 < 200% FPL 10.0% 8.7% cmn 200% t0 <400% FPL e >400% FPL >0% M 4.2% 3.3% 0.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2021 2022 2023 Note: FPL = Federal Poverty Level. Source: Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, January 2021 March 2022. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2022 Q11.pdf; Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, October 2021-December 2022. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2022 Q14.pdf; Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview Survey, January 2022-March 2023. https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2023 Q11.pdf. State Results Turning to state specific analyses using the ACS, ASPE earlier this year reported the national uninsured rate has decreased 5.9 percentage points (from 14.5 percent to 8.6 percent in 2021) since the ACA coverage provisions were implemented in 2014.%° Table 1 presents uninsured rates before the ACA in 2013 and 2021, the most recent state uninsured data. All states experienced reductions in their uninsured rates, with 11 states - California, Kentucky, Louisiana, Michigan, Montana, New Hampshire, New York, Oregon, Rhode Island, Washington, and West Virginia, all of which expanded Medicaid - reducing their uninsured rate by at least half. The uninsured rate in 2021 varied widely across the country. Massachusetts had the lowest uninsured rate at 2.5 percent and experienced one of the smaller relative reductions under the ACA because it had already implemented large coverage expansions prior to 2014. Texas, which has not expanded Medicaid, had the highest uninsured rate in both 2013 (22.1 percent) and 2021 (18.0 percent). State decisions regarding the ACA Medicaid expansion are a main driver of variability in coverage rates across states. The Census Bureau's gold-standard estimates of the uninsured population, which come from the ACS, are not yet available for 2022. August 2023 DATAPOINT 6 Table 1. State Uninsured Rates for 2013 and 2021 California Colorado Connecticut Delaware District of Columbia Georgia Kentucky Maryland Massachusetts Nebraska Nevada New Hampshire New Jersey New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Rhode Island South Carolina Uninsured Rate %" 2013 13.6 18.5 17.1 16.0 17.2 14.1 © © b D 6.7 20.0 18.8 o N 16.2 12.7 14.0 % = 12.3 14.3 16.6 11.2 10.2 & N 11.0 o N 17.1 13.0 16.5 11.3 20.7 10.7 13.2 18.6 10.7 15.6 10.4 11.0 17.7 14.7 v N 11.6 15.8 2021 9.9 11.4 10.7 9.2 7.0 8.0 5.2 5.7 3.7 12.1 12.6 3.9 8.8 7.0 75 4.8 9.2 5.7 7.6 5.7 6.1 2.5 5.0 4.5 11.9 9.4 8.2 7.1 11.6 5.1 7.2 10.0 5.2 10.4 7.9 6.5 13.8 6.1 5.5 4.3 10.0 August 2023 DATA POINT 7 " Uninsured Rates: American Community Survey, "Health Insurance Coverage Status and Type of Coverage by State and Age for All People", 2013,2021: https://www.census.gov/data/tables/time-series/demo/health-insurance/acs- hi.2013.html. CONCLUSION The Biden-Harris Administration took administrative and legislative actions in 2021 and 2022 that have helped individuals gain and maintain health coverage, including robust outreach efforts and expanded Marketplace subsidies under the ARP and the extension of those subsidies under the IRA. These health coverage gains build on the large reductions in the uninsured rate that occurred after the implementation of the ACA in 2014. Medicaid enrollment has grown under several states' recent Medicaid expansions, as well as the continuous enrollment condition passed by Congress as part of the COVID-19 pandemic response, which has sunset as of March 31, 2023. With these policies in effect, the U.S. uninsured rate declined since 2021, reaching an all-time low of 7.7percent by the first quarter of 2023. Updated 2022 ACS data on state-level changes in health insurance coverage will be available later this year after the release of annual ACS data. Research over the past decade demonstrates that the ACA has produced improved health outcomes, access to care, and financial security for families.?>?%?? Understanding the full nature of these historic gains in health insurance coverage as a result of the ACA, the ARP, and the IRA will be critical to maintaining high health coverage rates, assessing their impact on population health, and building on recent progress to make health insurance affordable and available to all Americans. As states return to standard Medicaid and CHIP eligibility renewal processes with the end of the Medicaid continuous enrollment condition, some transitions in health insurance coverage are expected over the coming months. The Biden-Harris Administration is working with states and other stakeholders to successfully facilitate these transitions to support individuals' enrollment in the coverage for which they are eligible. August 2023 DATAPOINT 8 REFERENCES ! Cohen RA, Martinez ME. 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Access to Marketplace Plans with Low Premiums on the Federal Platform, Part Il: Availability Among Uninsured Non-Elderly Adults Under the American Rescue Plan (Issue Brief No. HP-2021-08). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. April 1, 2021. Available at: https://aspe.hhs.gov/reports/accessmarketplace-plans-low-premiums-uninsured-american-rescue-plan 18 Branham DK, Conmy AB, Deleire T, Musen J, Xiao X, Chu RC, Peters C, and Sommers BD. Access to Marketplace Plans with Low Premiums on the Federal Platform, Part lll: Availability Among Current HealthCare.gov Enrollees Under the American Rescue Plan (Issue Brief No. HP-2021-09). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. April 13, 2021. Available at: https://aspe.hhs.gov/reports/access-marketplace-plans-low-premiums-federal-platform 19 Office of the Assistant Secretary for Planning and Evaluation, U.S.Department of Health and Human Services. Health Coverage Changes Under the Affordable Care Act: Current Enrollment and State Estimates. (Issue Brief No. HP-2023-08). March 2023. Accessed at https://www.aspe.hhs.gov/reports/current-health-coverage-under-affordable-care-act 20 Gruber J, Sommers BD. The Affordable Care Act's Effects on Patients, Providers, and the Economy: What We Know So Far. Journal of Policy Analysis and Management. 2019; 38(4): 1028-1052. 2! Mazurenko O, Balio CP, Agarwal R, Carroll AE, Menachemi N. The Effects Of Medicaid Expansion Under The ACA: A Systematic Review. Health Aff (Millwood). 2018 Jun;37(6):944-950. doi: 10.1377/hlthaff.2017.1491. PMID: 29863941. 22 Creedon TB, Zuvekas SH, Hill SC, Ali MM, McClellan C, Dey JG. Effects of Medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for Medicaid. Health Serv Res. 2022 Jul 10. doi: 10.1111/1475-6773.14034. Epub ahead of print. PMID: 35811358. August 2023 DATA POINT 10 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretary for Planning and Evaluation 200 Independence Avenue SW, Mailstop 447D Washington, D.C. 20201 For more ASPE briefs and other publications, visit: aspe.hhs.gov/reports EiE SUGGESTED CITATION National Uninsured Rate Reaches an All-Time Low in Early 2023 After Close of ACA Open Enroliment Period (Issue Brief No. HP-2023-20). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. August 2023. COPYRIGHT INFORMATION All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. DISCLOSURE This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. Subscribe to ASPE mailing list to receive email updates on new publications: https://list.nih.gov/cgi-bin/wa.exe?SUBED1=ASPE-HEALTH-POLICY&A=1 For general questions or general information about ASPE: aspe.hhs.gov/about August 2023 DATA POINT 11