The uninsured rate among U.S. adults ages 19 to 64 increased from 12.7% in 2016 to 15.5% in 2018, representing roughly four million fewer insured U.S. residents, according to the Commonwealth Fund's latest Affordable Care Act (ACA) tracking survey.
The survey is based on telephone interviews of 2,403 U.S. adults ages 19 to 64. Researchers conducted the interviews from Feb. 6 to March 30.
According to the survey, the uninsured rate among U.S. adults ages 19 to 34 increased from 18.1% in 2016 to 17% in 2018, while the uninsured rate among adults ages 35 to 64 increased from 11.3% in 2016 to 17.7% in 2018. The increases come after the U.S. uninsured rate had declined dramatically once the Affordable Care Act's (ACA) coverage expansions took effect in 2013.
The researchers found the uninsured rate among U.S. adults ages 19 to 64 who lived in households with incomes below 250% of the federal poverty level (FPL) increased from 20.9% in 2016 to 25.7% in 2018. In comparison, the uninsured rate among U.S. adults ages 19 to 64 who lived in households with incomes equaling 250% of FPL or more increased from 4.4% in 2016 to 5.8% in 2018.
In addition, the researchers found the uninsured rate rose significantly among U.S. adults ages 19 to 64 who lived in the 19 states that have not expanded Medicaid under the ACA, increasing from 16.1% in 2016 to 21.9% in 2018. In comparison, the uninsured rate among adults in the states that expanded Medicaid rose from 10.4% in 2016 to 11.4% in 2018.
The researchers also found the uninsured rate was higher among adults ages 19 to 64 who lived in southern states than in states located in the Northeast, Midwest, and West. In particular, the researchers found the U.S. adult uninsured rate increased from:
- 15.8% in 2016 to 20.7% in 2018 in the South;
- 13.4% in 2016 to 14.4% in 2018 in the West;
- 10.2% in 2016 to 11% in 2018 in the Northeast; and
- 8.2% in 2016 to 10.8% in 2018 in the Midwest.
The survey found adults who identified as Republican were more likely to become uninsured than those who identified as Democrats, with uninsured rates rising from 7.9% in 2016 to 13.9% in 2018 among Republicans and falling from 9.9% in 2016 to 9.1% in 2018 among Democrats.
The survey also suggested that the uninsured rate among U.S. adults could continue to grow. According to the survey, about 60% of respondents said they knew Republicans' recent tax reform law eliminates the individual mandate's tax penalty starting in 2019. Among insured respondents:
- 9% who were enrolled in exchange plans said they plan to drop their coverage in 2019 as a result of the change;
- 5% who were enrolled in employer-sponsored health plans said they plan to drop their coverage in 2019 as a result of the change; and
- 5% who were enrolled in Medicaid said they plan to drop their coverage in 2019 as a result of the change.
Reasons for the increases—and ways to reverse the trend
The researchers attributed the increases in the uninsured rate among U.S. adults to how Congress and the Trump administration have handled the ACA, including cuts to enrollment outreach and implementing a shorter open enrollment period.
The researchers said several policies have the potential to decrease the uninsured rate. For example, they said the uninsured rate could possibly decline if federal lawmakers reached a bipartisan agreement to:
- Ensure each exchange market has a participating insurer;
- Ensure health plans sold in the individual market are affordable; and
- Provide financial support for advertising intended to improve the awareness of health care coverage options in every state.
The researchers cited a few legislative examples that could help meet those objectives, including:
- A bill introduced by Sens. Susan Collins (R-Maine) and Bill Nelson (D-Fla.) that would create a reinsurance program for exchange insurers;
- A bill introduced by Sen. Elizabeth Warren (D-Mass.) that would expand premium and cost-sharing subsidies available under the ACA and require private insurers that participate in Medicare and Medicaid to also sell exchange plans; and
- Legislation that would expand Medicare coverage to more U.S. residents.
The researchers wrote that, "in the absence of bipartisan support for [such] federal action[s], legislative activity has shifted to the states," noting that eight states have either received or are applying for federal approval to create reinsurance programs. However, the researchers cautioned that "the shift to states carries risks, as well as potential benefits, for consumers," because although certain state proposals might make insurance more affordable, "more broadly, leaving policy innovation to states will ultimately lead to a patchwork quilt of coverage and access to health care across the country, a dynamic that will fuel inequity in overall health, productivity, and well-being." The researchers continued, "At some point, Congress will likely face pressure to step in to level the playing field" (Baker, "Vitals," Axios, 5/1; Haberkorn, "Pulse," Politico, 5/1; Collins et al., "To The Point," The Commonwealth Fund, 5/1).
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