Who's still uninsured under the ACA?

Latinos make up 40 percent of uninsured population

Low-income and Latino individuals are among the Americans most likely to still be uninsured six years after the passage of the Affordable Care Act (ACA), according to a Commonwealth Fund report released last week.

The report is based on results from the Commonwealth Fund Affordable Care Act Tracking Survey conducted between February and April.

CDC: Uninsured rate falls to record low

Uninsurance risk varies by age, demographics

The report said that about 20 million U.S. residents have gained coverage since the ACA passed in 2010.

However, about 24 million U.S. adults have remained uninsured, and demographic groups that disproportionately lacked insurance before the ACA took effect remained at a higher risk of being uninsured during the study period.

The report found that 88 percent of uninsured U.S. adults:

  • Had incomes below 138 percent of the federal poverty level;
  • Were younger than 35;
  • Were Latino; or
  • Worked for small businesses.

According to the report, Latinos accounted for 40 percent of the United States' remaining uninsured adult population, up from 29 percent in 2013.

Meanwhile, whites in 2016 accounted for 41 percent of the uninsured adult population, down from about 50 percent in 2013.

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Divergence between expansion, non-expansion states

Uninsured rates for low-income adults have diverged sharply between states that did and did not expand Medicaid under the ACA, the report found.

In states that had expanded Medicaid, the uninsured rate among low-income adults fell sharply from 30 to 17 percent from 2013 to 2016. In non-expansion states, the rate fell more modestly from 41 percent to 35 percent.

All told, 34 percent of the uninsured had incomes low enough to qualify for the ACA's Medicaid expansions but lived in states that had not expanded Medicaid.

According to the report, the vast majority of the uninsured were eligible for some form of assistance to pay for health insurance. For instance, the report found that 94 percent had incomes that would make them eligible for Medicaid or for subsidies if they purchased exchange plans.

Reasons why US adults remain uninsured

The report cited several factors for why people remain uninsured, including that:

  • Consumers had concerns about plan costs and their eligibility for subsidies;
  • Consumers had difficulty selecting health plans during open enrollment periods;
  • Consumers did not receive assistance with selecting plans;
  • Some demographic groups were disproportionately unlikely to be aware of the ACA's exchanges;
  • Some states had not expanded Medicaid under the ACA; and
  • Undocumented immigrants are not eligible for the ACA's coverage expansions.

According to the report, about 38 percent of uninsured adults said they had not heard of the exchanges, compared with 21 percent of the total U.S. population. Nearly two-thirds of uninsured adults who said they had heard of the exchanges also said they had not used them "because they did not think they would be able to afford coverage."

Recommendations

To help lower the uninsured rate, the report recommended that:

  • More states expand Medicaid;
  • Policymakers consider immigration reform; and
  • States bolster ACA-related outreach and assistance programs (Mershon, CQ HealthBeat, 8/18 [subscription required]; McIntire, Morning Consult, 8/18; Mangan, CNBC, 8/18).

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