The Uninsured: A Primer - Key Facts about Health Insurance and the Uninsured in the Wake of National Health Reform
Who remains uninsured after the ACA and why do they lack coverage?
Even after the ACA, over 28 million nonelderly people in the United States were uninsured as of the end of 2015.1 Despite coverage gains, groups with historically high uninsured rates continue to be at highest risk of being uninsured, including low-income individuals, adults, and people of color. Cost continues to pose a major barrier to coverage with nearly half (46%) of the uninsured in 2015 saying that the main reason they lacked coverage was because it was too expensive.2
Though provisions in the ACA aim to make coverage more affordable for low and moderate-income families, these income groups still make up the vast majority of the uninsured. More than half of the remaining uninsured population (53%) has family income at or below 200% of poverty ($19,078 for a family with two adults and one child in 2015)3 and another 28% has family income between 200 and 399% of poverty (Figure 7). Low-income individuals are at the highest risk of being uninsured.4
A majority of the remaining uninsured population is in a family with at least one worker, and many uninsured workers continue to lack access to coverage through their job. As of the end of 2015, over seven in ten (74%) of the uninsured have at least one full time worker in their family, and an additional 11% have a part-time worker in their family (Figure 7).5 As in the past, low-income workers and those who work in blue-collar jobs (versus white-collar jobs) are more likely than other workers to be uninsured.6 Uninsured adults report that access to coverage through a job remains limited or unaffordable.7 While the ACA’s employer offer requirements may help many uninsured individuals with a worker in their family, nearly half (49%) of uninsured workers in 2015 worked in firms with fewer than 50 employees, which are not required to offer affordable insurance coverage.8
People of color are at higher risk of being uninsured than Whites. While a plurality (45%) of the uninsured are non-Hispanic Whites, people of color are disproportionately likely to be uninsured: they make up 41% of the overall U.S. population but account for over half of the total uninsured population (Figure 7). Hispanics account for nearly a third (32%) of the uninsured, and non-Hispanic Blacks account for 15%.9 Differences in coverage by race/ethnicity likely reflect a combination of factors, including language and immigration barriers, income and work status, and state of residence.
Adults are still more likely than children to be uninsured. Nonelderly adults were more than twice as likely as children (13% vs. 5%) to be uninsured in 2015.10 This disparity reflects ongoing differences in eligibility for public coverage. While the ACA has increased Medicaid eligibility levels for adults, states have expanded coverage for children even higher through CHIP, while adults without children are excluded from Medicaid in all but one non-expansion state.11
Uninsured rates for children are low, and most uninsured children are eligible for Medicaid or CHIP. Largely due to expanded eligibility for public coverage under Medicaid and CHIP, the uninsured rate for children is relatively low: in 2015, 5% of children nationwide were uninsured.12 Two-thirds (66%) of uninsured children are eligible for Medicaid, CHIP, or other public programs.13 Some of these children may be reached by covering their parents, as research has found that parent coverage in public programs is associated with higher enrollment of eligible children.14,15
Insurance coverage continues to vary by state and region, with individuals living in the South and West the most likely to be uninsured (Figure 8). In 2014, the 16 states with the highest uninsured rates were all in the South and West,16 reflecting state Medicaid expansion status, demographic characteristics, economic conditions, availability of employer-based coverage, and state outreach efforts under the ACA.
While most of the uninsured are U.S. citizens, non-citizens continue to be at much higher risk of being uninsured. In 2015, nearly three out of four (73%) uninsured nonelderly individuals were citizens. However, non-citizens (including those who are lawfully present and those who are undocumented) are more likely than citizens to be uninsured in 2015. Among citizens, 9% were uninsured in 2015, compared to 28% of non-citizens.17
Cost still poses a major barrier to coverage for the uninsured. Nearly half (46%) of uninsured adults in 2015 said that the main reason they lacked coverage was because it was too expensive.18 Though financial assistance is available to many of the remaining uninsured under the ACA,19 not everyone who is uninsured is eligible for free or subsidized coverage. In addition, affordability of ACA Marketplace coverage remains a concern for some people. In 2016, 40% of people with Marketplace coverage said they were dissatisfied with their monthly premium and nearly half (46%) were dissatisfied with their deductible.
Some individuals may remain uninsured because they are not aware of coverage options or face barriers to enrollment, even though they may be eligible for financial assistance under the ACA. In 2015, about one in five uninsured nonelderly adults said they remained uninsured because they didn’t know about the requirement to have health insurance (7%) or didn’t think the requirement applied to them (13%) (some in fact may be exempt under specific provisions of the law). About one in ten said they tried to get coverage but were unable (11%),20 though many enrollment barriers encountered in the first year of ACA coverage have been addressed.
Most people who remained uninsured in 2015 were uninsured for more than a year. Though the share of uninsured who lacked coverage for more than a year decreased from 81% in 2013 to 76% in 2015,21 the vast majority of uninsured people were still long-term uninsured. People who have been without coverage for long periods may be particularly hard to reach through outreach and enrollment efforts.