Forward or Backward on the Uninsured?

For decades through the 1980s, ’90s and early 2000s, the health care field labored, study by study, to make the case for covering the uninsured while naysayers insisted that people without coverage could get adequate care in emergency rooms and public hospitals. The research definitively demonstrated the importance of coverage for access to care, health outcomes, and income security, as well as the necessity for subsidies or public coverage to make coverage affordable. Way back in the days of the Clinton health reform debate, when I was just starting KFF, we launched an ad campaign almost as large as the infamous Harry and Louise campaign sponsored by the insurance industry. It was called “Straight Facts on Health Reform,” and its purpose was to establish just one fact documented in the research: that insurance mattered. I am not sure how much impact we had in the middle of everything else that was going on then—probably not much—but over time, the weight of the evidence from countless studies, news reports, and personal stories won out.

(One lesson: Researchers usually aspire to break new ground. And editors often tire of seeing similar stories about the same subject over and over again. However, it was repetition among researchers and journalists pounding out studies and stories on the uninsured that eventually helped establish the facts).

Gradually, the debate shifted to how to cover the uninsured rather than whether the problem was real. Establishing the evidence on the uninsured was probably the single most important contribution made by health policy analysis and health services research (not the same things) since I have been in the field, as well as for the advocacy community, which worked tirelessly on the issue. But I don’t want to exaggerate what agreement on the evidence has meant. There is near agreement now that the uninsured is a problem, but not at all about what has been done to address the problem or should be done moving forward. Sometimes, the discussion gets ugly and turns to who is “worthy” of coverage. Debate continues about how best to expand coverage, how coverage should be structured, and whether investments in public coverage are too big or too small. Not all of the disagreement is between Democrats and Republicans. Famously, the left wing of the Democratic party would address the problem through a universal single-payer health plan rather than incremental coverage expansions building on existing programs and private coverage.

Today, less than 10% of the population is uninsured. It’s a remarkable achievement, leaving aside the fact that many who have coverage can’t afford their medical bills, a subject I write about frequently. However, the progress made leaves the question of the remaining uninsured. The uninsured have never had much political clout, even when they were a much larger group. A smaller uninsured population will have even less clout and command even less attention from policymakers and on the national agenda.

These are among the most important reasons the remaining uninsured matter:

First, the number of uninsured may be much smaller than at its high point when it approached 50 million (tracking the numbers over time can be confusing because the Census changed their survey questions), but it’s far from a small group. In 2022, the last year for which we have federal data, almost 26 million Americans were uninsured. That’s smaller, but not that much smaller than the 35 million Americans who live below the poverty line (our single biggest socio-economic problem), and it’s more than double the number of children below the poverty line.

Second, the number of uninsured is likely rising again as a result of the “Medicaid unwinding.” We don’t know by how much yet or, for technical reasons, how clearly this will show up in federal data or how soon, but potentially by millions. Enhanced ACA subsidies, which sunset at the end of 2025, could also push the numbers higher if they are not continued.

Third, the uninsured are the group who are most likely to get fleeced in our health system because, unlike the insured, who benefit from their insurance companies negotiating discounts from providers, the uninsured are on their own and often are charged full prices. Some get discounts, but many are pursued by collection agencies. Eighty-five percent of the uninsured have difficulty paying their medical bills, and 62% struggle with medical debt (more here).

Fourth, the uninsured are not one undifferentiated group. There is one sub-group that gets hit especially hard in our health system: people who are sick, who need a lot of medical care, and are uninsured. Our analysis of the National Health Interview Survey for this column showed that a striking 77% of uninsured adults in fair or poor health reported delaying or going without health or dental care due to cost in 2022. That’s compared to 28% of all adults and 57% of the uninsured generally. Analyzing a survey we did in 2023, we looked at the issue in a slightly different way but painted a similar picture. Seventy-four percent of the uninsured with a debilitating health condition (physical or mental health condition or disability that keeps them from fully participating in work, school, housework, or other activities) put off needed health care because of cost.

A sizeable share of the uninsured, as much as 60%, are eligible for current programs but either don’t know it, can’t access the coverage, or think they can’t afford it. Covering them might not require a new program but would require lots of outreach and new spending.

The Biden administration has a proposal to cover the uninsured in the coverage gap. However, except in a few states debating Medicaid expansion, the remaining uninsured are mostly now off the radar. At KFF, we have a program on Medicaid and the Uninsured and we regularly analyze, poll, and report on the subject. However, we are just one organization, and we are often stretched thin to address the issues on the policy agenda we are called to analyze, poll, and report on. A few other organizations and researchers focus on the issue as well. But most of the research enterprise has shifted attention to delivery and payment reform in recent years or, increasingly, to AI. With attention focused on the Medicaid unwinding and, depending on the outcome of the election, potentially on plans to scale back Medicaid and ACA coverage, it’s possible that maintaining current coverage levels will take priority in the near term over achieving further coverage gains.

View all of Drew’s Beyond the Data columns.

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