Sara R. Collins, Munira Z. Gunja, Michelle M. Doty, Sophie Beutel
S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, Who Are the Remaining Uninsured and Why Haven't They Signed Up for Coverage? Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016 The Commonwealth Fund, August 2016.
Also read a companion "To the Point": Latinos and Blacks Have Made Major Gains Under the ACA But Inequalities Remain
Issue: The number of uninsured people in the United States has declined by an estimated 20 million since the Affordable Care Act went into effect in 2010. Yet, an estimated 24 million people still lack health insurance. Goal: To examine the characteristics of the remaining uninsured adults and their reasons for not enrolling in marketplace plans or Medicaid. Methods: Analysis of the Commonwealth Fund ACA Tracking Survey, February–April 2016. Key findings and conclusions: There have been notable shifts in the demographic composition of the uninsured since the law’s major coverage expansions went into effect in 2014. Latinos have become a growing share of the uninsured, rising from 29 percent in 2013 to 40 percent in 2016. Whites have become a declining share, falling from half the uninsured in 2013 to 41 percent in 2016. The uninsured are very poor: 39 percent of uninsured adults have incomes below the federal poverty level, twice the rate of their overall representation in the adult population. Of uninsured adults who are aware of the marketplaces or who have tried to enroll for coverage, the majority point to affordability concerns as a reason for not signing up.
The number of uninsured people in the United States has declined by an estimated 20 million since the Affordable Care Act went into effect in 2010.1 The percentage of the population without health insurance has fallen to historic lows. Yet, three years into the rollout of the law’s major coverage expansions in 2014, an estimated 24 million people still lack health insurance.
This issue brief uses data from The Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016 to examine the characteristics of the remaining uninsured adults and the reasons they give for not enrolling in marketplace plans or Medicaid. We also examine how experiences differ between people who shop for health plans and complete the enrollment process and those who fail to sign up.
Prior to the Affordable Care Act, people most at risk of being uninsured were those who were least likely to have health insurance through a job. The likelihood of having job-based coverage increased with income, age, employer size, and the number of hours worked per week. Prior expansions in Medicaid and the Children’s Health Insurance Program protected children under age 19 in low-income families without employer coverage, but adults who lacked such coverage in most states had to find it in the individual market and pay the full premium. In addition, they could be charged a higher rate, have their health conditions excluded from their insurance, or be turned down because of their health. The ACA insurance reforms and expansions were thus explicitly targeted at providing access to affordable coverage for adults with low and moderate incomes, young adults, owners of small businesses and their employees, and part-time workers. Racial and ethnic minorities—particularly Latinos—comprise a large share of many of these groups.
The ACA’s insurance expansions have had a dramatic effect on these groups of adults (Exhibit 1, Table 1). The uninsured rate among 19-to-64-year-old adults with incomes under 138 percent of the federal poverty level ($16,243 for an individual, $33,465 for a family of four) dropped from 35 percent in 2013 to 24 percent in 2016; for young adults under age 35, it fell from 28 percent to 18 percent; for blacks it dropped from 21 percent to 13 percent; for Latinos, from 36 percent to 29 percent; and for adults working in small businesses, from 32 percent to 24 percent.
Despite these coverage gains, each of the groups who were most at risk of being uninsured before the ACA continues to have higher uninsured rates than their demographic counterparts. Consequently, compared with the overall working-age population, uninsured adults are disproportionately poor, young, Latino, and employed by small businesses (Table 1).
As the number of uninsured adults has declined, there have been notable shifts in their composition since 2013. Latinos have become a growing share of the uninsured among racial and ethnic groups, rising from 29 percent in 2013 to 40 percent in 2016, more than twice their representation in the overall population (Exhibit 2, Table 1). In contrast, the share of whites has declined, falling from half in 2013 to 41 percent in 2016.
As of February–April 2016, of the estimated 24 million uninsured adults, 88 percent—approximately 21 million—had incomes less than 138 percent of poverty, were young adults under age 35, were Latino, and/or were working in small firms (data not shown).
The vast majority of uninsured adults (94%) have incomes under 400 percent of poverty ($47,080 for an individual, $97,000 for a family of four), which makes them income-eligible for either marketplace subsidies or Medicaid (Exhibit 3).
One-third (34%) of adults who were uninsured in 2016 have Medicaid-eligible incomes but live in one of the 20 states that had not yet expanded eligibility for Medicaid at the time of the survey.2 This includes adults who fall into the so-called coverage gap—that is, those with incomes under 100 percent of poverty who are neither eligible for their state’s existing Medicaid program nor marketplace subsidies (22%)—and those with incomes between 100 percent and 138 percent of poverty who are eligible for marketplace subsidies (12%).
Because young adults comprise the largest share of the uninsured across the age spectrum and because they are coveted by health insurers for their generally healthy status and lower cost risk, we took a closer look at their income profile. Like the overall adult population, the majority of uninsured young adults (96%) have incomes that make them eligible for marketplace subsidies or Medicaid. Nearly two of five (38%) uninsured young adults, an estimated 4 million, have incomes that might make them eligible for Medicaid but live in states that have not yet expanded eligibility.
Several factors, many of which emerge in the survey findings, are likely contributing to shifts in the composition of the uninsured and higher rates of uninsurance among some groups. The factors, discussed in detail below, include:
1. Undocumented Immigrants Are Not Eligible for ACA Coverage
The Affordable Care Act bars people who are not legal U.S. residents from Medicaid or marketplace coverage. This is likely a significant factor in the large number of Latinos who remain uninsured, although we do not know from the survey data what percentage of uninsured Latinos are undocumented. The Census Bureau estimates nearly half of uninsured Latinos (46%) in 2014 were noncitizens.3 Other estimates find undocumented immigrants make up about 15 percent of the remaining uninsured.4
In each of the high-risk demographic groups we examined, Latinos make up nearly half of the uninsured. Latinos make up 47 percent of uninsured adults earning less than 138 percent of poverty, 47 percent of uninsured young adults, and 46 percent of uninsured small-business workers (data not shown).
2. Nineteen States Have Not Yet Expanded Medicaid Eligibility
The 2012 Supreme Court decision made the ACA’s Medicaid expansion for people with income up to 138 percent of poverty optional for states. Currently, 19 states have not yet expanded eligibility. In these states—because Congress could not have anticipated the Court’s decision—people with incomes between 100 percent and 138 percent of poverty are eligible for subsidies for marketplace plans but those with incomes under 100 percent of poverty do not have access to the subsidies since it was assumed they would enroll in Medicaid. Nearly 3 million people are estimated to be in this so-called coverage gap.5 In addition, it is likely that many people in these states with access to subsidies remain uninsured as most plans are more expensive for enrollees, relative to Medicaid.6
The uninsured rate among adults with Medicaid-eligible income levels (under 138 percent of poverty) has fallen by half in the 30 states and the District of Columbia that had expanded Medicaid at the time of the survey, from 30 percent in 2013 to 17 percent in 2016 (Exhibit 4). The uninsured rate in this income group in nonexpansion states has declined only slightly; at 35 percent, it is twice the rate of Medicaid-eligible adults in expansion states.
A disproportionately large number of uninsured adults live in the 20 states that had not yet expanded Medicaid. Adults in these states comprise 41 percent of the overall adult population but make up 51 percent of the remaining uninsured (Table 1).7 These states, including Florida and Texas, are concentrated in the South. As a result, there is a disproportionately high number of uninsured adults in the South.
3. Less Awareness of the Marketplaces in Higher-Risk Groups
Awareness of the marketplaces has risen significantly since we first asked adults about these entities just before they opened in 2013 (see dashboard). Looking at adults who are still uninsured, 62 percent were aware of the marketplaces in 2016, compared to 79 percent of all adults (Exhibit 5 and data not shown). The demographic groups with the highest uninsured rates were least likely to know about the marketplaces.
4. Many Uninsured Adults Cite Concerns About Affordability and Eligibility
Among uninsured adults who were aware of the marketplaces, concerns about affordability were a frequently cited factor for not visiting the marketplaces and not enrolling in a health plan after they shopped for coverage. Many people were also uncertain about their eligibility for financial assistance and many discovered that they weren’t eligible once they shopped.
Nearly two-thirds (64%) of uninsured adults who were aware of the marketplaces said they had not visited one to shop for coverage because they did not think they would be able to afford coverage (Exhibit 6). Similarly—excluding people who said they got coverage someplace else—85 percent of uninsured adults who shopped for coverage but did not enroll said it was because they could not find an affordable plan (Exhibit 7).
The majority (86%) of uninsured adults who did not enroll because they could not find affordable plans had incomes that made them eligible for tax credits or Medicaid, though these data include those who may be ineligible because of their immigration status (data not shown).8 More than half (54%) had incomes in the range that made them eligible for subsidies (i.e., from 100 percent to 400 percent of the federal poverty level, or $11,770 to $47,080 annual income for an individual).9 About one-third (32%) had incomes under 100 percent of poverty. An estimated 27 percent—and thus nearly all of those with incomes under 100 percent of poverty—were likely in the Medicaid coverage gap. About 14 percent had incomes that exceeded the threshold that made them eligible for subsidies (i.e., 400 percent of poverty).
5. Adults Who Do Not Enroll in Coverage Have Greater Difficulty Comparing Health Plans
We compared the shopping experiences of enrollees and nonenrollees who were eligible for marketplace plans.10 We excluded those who told us they had enrolled in another source of coverage.
We asked people who visited the marketplaces how difficult or easy it was to compare health plans on the basis of premium costs, benefits covered, out-of-pocket costs, and provider networks.11 Those who enrolled in plans were more likely than those who did not enroll to report an easy time identifying differences among plans (Exhibit 8).12
Similarly, adults who enrolled in marketplace plans were significantly more likely to report they had an easy time finding an affordable health plan and/or a plan with the type of coverage they needed than those who did not enroll (Exhibit 9).13
Overall, people who ultimately enrolled in either Medicaid or a marketplace plan were significantly more likely than those who did not enroll to give high ratings to their overall experience. (Exhibit 10).14
6. Adults Who Do Not Enroll Are Less Likely to Have Received Personal Assistance
Receiving personal assistance during the enrollment process appears to make a significant difference in whether a person signs up for coverage. People with incomes in the range that made them eligible for Medicaid or marketplace subsidies, those who are part of racial and ethnic minority groups, those with a high school education or less, and older adults were the most likely to report they had received personal assistance from a telephone hotline, insurance broker, navigator, or other source (Table 2). When we controlled for demographic differences, 77 percent of adults who said they had received assistance enrolled in a marketplace plan or Medicaid (Exhibit 11).15 In contrast, 60 percent of those who did not receive personal assistance ultimately enrolled.
The health insurance reforms of the Affordable Care Act have been successful on key measures: substantial declines in the number of uninsured Americans and nationwide declines in people’s out-of-pocket spending growth, cost-related problems getting care, and medical bill problems.16 The majority of enrollees in both marketplace plans and Medicaid are satisfied with their health plans and doctors.17 And the law’s subsidies have made premiums and cost-sharing for low- and moderate-income adults enrolled in coverage through the marketplaces comparable to what people pay in employer plans.18
However, millions of people who would benefit from these reforms remain uninsured. This analysis finds that the vast majority have low incomes, are young, are Latino, and/or are working in a small firm. They are also less aware of the marketplaces than most Americans. Among those who are aware of the coverage options, or have tried to enroll, the majority point to affordability concerns as a reason for not signing up.
There are various ways more universal coverage in the United States might be achieved under the Affordable Care Act. First and foremost, all states can accept the federal dollars available to them and expand eligibility for their Medicaid programs. Second, the survey findings and other research indicate that outreach and assistance can help reach uninsured people and facilitate enrollment.19 Widespread concerns about affordability suggest that additional education is needed to inform people about their options and available subsidies.20 For some eligible uninsured people, enhanced subsidies and lower cost-sharing in marketplace plans may be required to facilitate enrollment, particularly for moderate-income households and those near the income-eligibility thresholds. Finally, the growing share of Latinos in the shrinking number of uninsured people reflects both the growth of this population in the United States in general and the explicit exclusion of undocumented immigrants from the law’s coverage expansions. Immigration reform would help increase the numbers of people who are eligible for coverage, as would a loosening of the law’s restrictions on the eligibility of undocumented immigrants.
Table 1. Uninsured Rates by Demographics, July–September 2013 and February–April 2016
|Total adults (% ages 19–64)||Uninsured (rate)||Uninsured (distribution)|
|July–Sept. 2013||Feb.–April 2016||July–Sept. 2013||Feb.–April 2016||July–Sept. 2013||Feb.–April 2016|
|Current insurance status|
| (base: young adults
| Below 100%
| 400% poverty
| Below 250%
| 250% poverty
| Fair/Poor health
status, or any
| Did not expand
|Adult work status|
|Not working||33||33||25||17||42||43||Employer sized|
| 500 or more
— Not applicable.
a Respondent said health status was fair or poor or said they had at least one of the following chronic diseases: hypertension or high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease; high cholesterol; depression or anxiety.
b The following states have state-based marketplaces: CA, CO, CT, ID, KY, MA, MD, MN, NY, RI, VT, WA, and the District of Columbia. All other states were considered to have federally facilitated marketplaces.
c Thirty states (AK, AR, AZ, CA, CO, CT, DE, HI, IA, IN, IL, KY, MA, MD, MI, MN, MT, ND, NH, NJ, NM, NV, NY, OH, OR, PA, RI, VT, WA, WV) and the District of Columbia expanded their Medicaid program and began enrolling individuals in February 2016 or earlier. All other states were considered to have not expanded.
d Base: Full- and part-time employed adults ages 19–64. Distributions may not sum to 100 percent because of “don’t know” responses or refusal to respond.
Source: The Commonwealth Fund Affordable Care Act Tracking Surveys, July–September 2013 and February–April 2016.
Table 2. Demographics of Adults Who Visited the Marketplace and Received Personal Assistance
|Percent of adults ages 19–64 who visited the
marketplace and received personal assistancea
|Below 100% poverty||56|
|400% poverty or more||37|
|High school or less||59|
|College graduate or higher||41|
|Fair/Poor health status, or any chronic condition or disabilityb||52|
|No health problem||46|
a Personal assistance includes calling a telephone hotline, or getting help from an insurance broker, navigator, or in some other way.
b Respondent said health status was fair or poor or said they had at least one of the following chronic diseases: hypertension or high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease; high cholesterol; depression or anxiety.
Source: The Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016.
1 B. W. Ward, T. C. Clark, C. N. Nugent et al., Early Release of Selected Estimates Based on Data from the 2015 National Health Interview Survey (National Center for Health Statistics, May 2016); and N. Uberoi, K. Finegold, and E. Gee, Health Insurance Coverage and the Affordable Care Act, 2010–2016, ASPE Issue Brief (Office of the Assistant Secretary for Planning and Evaluation, March 3, 2016).
2 Louisiana Governor John Bel Edwards issued an executive order to expand eligibility for Medicaid on January 12, 2016. Enrollment began on June 1 and coverage took effect on July 1. See N. N. Levey, “In Louisiana, the Rush to Sign Up for Obamacare Highlights a ‘Long Overdue’ Demand for Health Insurance,” Los Angeles Times, Aug. 4, 2016.
3 Authors’ analysis of Pew Research Center’s Statistical Portrait of Hispanics in the United States using the 2014 American Community Survey. J. M. Krogstad, and M. H. Lopez, “Hispanic Immigrants More Likely to Lack Health Insurance Than U.S.-Born” (Pew Research Center, Sept. 26, 2014).
4 R. Garfield, A. Damico, C. Cox et al., New Estimates of Eligibility for ACA Coverage Among the Uninsured (Henry J. Kaiser Family Foundation, Jan. 2016). See also State Health Access Data Assistance Center (SHADAC), State Estimates of the Low-Income Uninsured Not Eligible for the ACA Medicaid Expansion (Robert Wood Johnson Foundation, March 2013).
5 R. Garfield and A. Damico, Kaiser Commission on Medicaid and the Uninsured, The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid—An Update (Henry J. Kaiser Family Foundation, Jan. 2016).
6 S. Beutel, M. Z. Gunja, and S. R. Collins, How Much Financial Protection Do Marketplace Plans Provide in States Not Expanding Medicaid? (The Commonwealth Fund, June 2016).
7 Thirty states (AK, AR, AZ, CA, CO, CT, DE, HI, IA, IN, IL, KY, MA, MD, MI, MN, MT, ND, NH, NJ, NM, NV, NY, OH, OR, PA, RI, VT, WA, WV) and the District of Columbia had expanded their Medicaid program and began enrolling individuals before this survey went into the field in February 2016. All other states were considered to have not expanded their program. For more information, see: http://www.commonwealthfund.org/interactives-and-data/maps-and-data/medicaid-expansion-map.
8 Using 2009 data, SHADAC estimated that among uninsured adults with incomes under 138 percent of poverty, 17 percent were undocumented immigrants or recently arrived legal immigrants (because the latter group falls into the five-year waiting period for Medicaid under federal law, the ACA made these individuals eligible for subsidized coverage through the marketplaces even if their income is under 100 percent of poverty). State Health Access Data Assistance Center (SHADAC), State Estimates of the Low-Income Uninsured Not Eligible for the ACA Medicaid Expansion (Robert Wood Johnson Foundation, March 2013).
9 Breaking this down further, 35 percent had incomes that made them eligible for the most generous subsidies (between 100 percent and 249 percent of poverty) and 19 percent had incomes between 250 percent and 399 percent of poverty (data not shown).
10 Eligible adults were those with incomes of 138 percent of poverty or more in Medicaid expansion states and 100 percent of poverty or more in nonexpansion states.
11 For trend data on this question from October 2013 to March–April 2015, see our interactive survey data tool at http://acatracking.commonwealthfund.org/.
12 Differences between those who obtained coverage and those who did not are significant on benefits covered and providers covered, but differences are not significant on premiums and out-of-pocket costs.
13 For trend data over 2013–2015, see our interactive survey data tool at http://acatracking.commonwealthfund.org/.
14 For trend data over 2013–2015, see our interactive survey data tool at http://acatracking.commonwealthfund.org/.
15 Adjusted percentages were estimated based on a logistic regression model that controlled for race, education, poverty, age, and health status.
16 B. D. Sommers, R. J. Blendon, E. J. Orav et al., “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance,” JAMA Internal Medicine, published online Aug. 8, 2016; and S. R. Collins, Consumer Experiences in the ACA Marketplaces, Marketplace Stability, and Remaining Challenges to Covering the Uninsured, Invited testimony, U.S. House of Representatives, Committee on Energy and Commerce, Subcommittee on Health, Hearing on “Advancing Patient Solutions of Lower Costs and Better Care,” June 10, 2016.
17 S. R. Collins, M. Z. Gunja, M. M. Doty, and S. Beutel, Americans’ Experiences with ACA Marketplace and Medicaid Coverage: Access to Care and Satisfaction (The Commonwealth Fund, May 2016).
18 M. Z. Gunja, S. R. Collins, M. M. Doty, and S. Beutel, Americans’ Experiences with ACA Marketplace Coverage: Affordability and Provider Network Satisfaction (The Commonwealth Fund, July 2016).
19 B. D. Sommers, B. Maylone, K. H. Nguyen et al., “The Impact of State Policies on ACA Applications and Enrollment Among Low-Income Adults in Arkansas, Kentucky, and Texas,” Health Affairs, June 2015 34(6):1010–18; and A. G. Mosqueira and B. D. Sommers, “Better Outreach Critical to ACA Enrollment, Particularly for Latinos,” To the Point, The Commonwealth Fund, Jan. 14, 2016.
20 J. Giovannelli and E. Curran, Factors Affecting Health Insurance Enrollment Through the State Marketplaces: Observations on the ACA’s Third Open Enrollment Period (The Commonwealth Fund, July 2016).
The Commonwealth Fund Affordable Care Act (ACA) Tracking Survey, February–April 2016, was conducted by SSRS from February 2 to April 5, 2016. The survey consisted of 15-minute telephone interviews in English or Spanish, conducted among a random, nationally representative sample of 4,802 adults ages 19 to 64 living in the United States. Overall, 1,496 interviews were conducted on landline telephones and 3,306 interviews on cell phones.
This survey is the fourth in a series of Commonwealth Fund surveys to track the implementation and impact of the ACA. The first was conducted by SSRS from July 15 to September 8, 2013, by telephone among a random, nationally representative U.S. sample of 6,132 adults ages 19 to 64. The survey had an overall margin of sampling error of +/– 1.8 percentage points at the 95 percent confidence level.
The second survey in the series was conducted by SSRS from April 9 to June 2, 2014, by telephone among a random, nationally representative U.S. sample of 4,425 adults ages 19 to 64. The survey had an overall margin of sampling error of +/– 2.1 percentage points at the 95 percent confidence level. The sample for the April–June 2014 survey was designed to increase the likelihood of surveying respondents who were most likely eligible for new coverage options under the ACA. As such, respondents in the July–September 2013 survey who said they were uninsured or had individual coverage were asked if they could be recontacted for the April–June 2014 survey. SSRS also recontacted households reached through their omnibus survey of adults who were uninsured or had individual coverage prior to the first open enrollment period for 2014 marketplace coverage.
The third survey in the series was conducted by SSRS from March 9 to May 3, 2015, by telephone among a random, nationally representative U.S. sample of 4,881 adults ages 19 to 64. The March–May 2015 sample also was designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. SSRS recontacted households reached through their omnibus survey of adults between November 5, 2014, and February 1, 2015, who were uninsured, had individual coverage, had a marketplace plan, or had public insurance. The survey had an overall margin of sampling error of +/– 2.1 percentage points at the 95 percent confidence level.
The February–April 2016 sample also was designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. Interviews in wave 4 were obtained through two sources: stratified random-digit-dialing sample, using the same methodology as in waves 1, 2 and 3; and households reached through the SSRS omnibus survey, where interviews were previously completed with respondents ages 19 to 64 who were uninsured, had individual coverage, had a marketplace plan, or had public insurance.
As in all waves of the survey, SSRS oversampled adults with incomes under 250 percent of poverty to further increase the likelihood of surveying respondents eligible for the coverage options as well as allow separate analyses of responses of low-income households.
The data are weighted to correct for the stratified sample design, the use of recontacted respondents from the omnibus survey, the overlapping landline and cell phone sample frames, and disproportionate nonresponse that might bias results. The data are weighted to the U.S. 19-to-64 adult population by age, gender, race/ethnicity, education, household size, geographic division, and population density using the U.S. Census Bureau’s 2014 American Community Survey, and weighted by household telephone use using the U.S. Centers for Disease Control and Prevention’s 2014 National Health Interview Survey.
The resulting weighted sample is representative of the approximately 189 million U.S. adults ages 19 to 64. Data for income, and subsequently for federal poverty level, were imputed for cases with missing data, utilizing a standard regression imputation procedure. The survey has an overall margin of sampling error of +/– 2.0 percentage points at the 95 percent confidence level. The landline portion of the main-sample survey achieved a 22.6 percent response rate and the cellular phone main-sample component achieved a 13.9 percent response rate. The overall response rate, including the prescreened sample, was 13.9 percent.
The authors thank Robyn Rapoport and Arina Goyle of SSRS; and David Blumenthal, Don Moulds, Kathy Regan, Eric Schneider, Deborah Lorber, Chris Hollander, Paul Frame, Jen Wilson, Jamie Ryan, and Dana Sarnak of The Commonwealth Fund.