The U.S. residents who will remain uninsured under the ACA

Most of the uninsured residents will be citizens, researchers say

Topics: Access to Care, Quality, Performance Improvement, Appropriateness, Outcomes, Care Coordination, Methodologies, Accountable Care, Market Trends, Strategy

June 10, 2013

The Affordable Care Act is extending insurance to millions of Americans, but about 30 million U.S. residents will remain uninsured after the law's full rollout next year, according to research published last week in Health Affairs.

  • Meet the ACA's newly insured residents. We explain what the millions of Americans who will gain insurance in 2014 have in common.

For the study, Harvard researchers sought to estimate the number of U.S. resident who will be uninsured in 2016 and determine their characteristics.

Using the Advisory Board's Medicaid Map, they identified states that were unlikely to participate in the Medicaid expansion. In those states, they projected that 90% of uninsured individuals below 138% of the federal poverty level (FPL)—the eligibility level for Medicaid expansion—would remain uninsured after 2014, as well as 75% of the uninsured individuals above the eligibility level.

In states expected to expand Medicaid under the ACA, researchers assumed that 40% of Medicaid-eligible residents who are currently uninsured will remain uninsured, as well as 60% of uninsured individuals above the eligibility level.

Based on those expectations and assuming undecided states decide to participate in the expansion, the researchers estimated that 29.8 million U.S. residents will remain uninsured. (If all undecided states opt out, 31 million U.S. residents will remain uninsured, per their analysis.)

  • How can your hospital help patients get insured? Read our latest white paper on the insurance exchanges to learn how providers can take patient outreach and education into their own hands.

Who will be uninsured

Assuming that all currently undecided states opt into the expansion, then in 2016:

  • 26.9% of uninsured residents will be below 100% of the FPL;
  • 29.9% will be between 100% and 199% of the FPL;
  • 29.5% will be between 200% and 399% of the FPL; and
  • 13.7% will be above 399% of the FPL.

Assuming that all currently undecided states opt out of the expansion, then in 2016:

  • 27.5% of uninsured residents will be below 100% of the FPL;
  • 30.0% will be between 100% and 199% of the FPL;
  • 29.0% will be between 200% and 399% of the FPL; and
  • 13.4% will be above 399% of the FPL.

In either scenario, about 59% of the uninsured residents will be employed, and nearly 60% will be between ages 18 and 44.

Moreover, the study shows that more than 70% of uninsured residents will be U.S.-born citizens and another 7% will be foreign-born citizens. The researchers say this finding runs contrary to the assumption that the ACA will extend insurance to most legal residents (Nardin et al., "Health Affairs Blog," Health Affairs, 6/6; Kliff, "Wonkblog," Washington Post, 6/7).

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