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The Uninsured: A Primer - Key Facts about Health Insurance and the Uninsured Under the Affordable Care Act

The ACA led to historic drops in the uninsured rate, with millions of previously uninsured Americans now insured and gaining access to health services and protection from catastrophic health costs. Prior to the ACA, the options for the uninsured population were limited in the individual market, as coverage was often expensive and insurers could deny coverage based on health status. Medicaid and CHIP have provided coverage to many families, but pre-2014 eligibility levels were low for parents and few states provided coverage to adults without dependent children. The ACA fills in many of these gaps by expanding Medicaid to low-income adults and providing subsidized coverage to people with incomes from 100 to 400% of poverty in the marketplaces.

Nonetheless, even with the ACA, the nation’s system of health insurance continues to have many gaps that currently leave millions of people without coverage. Nearly half (47%) of the remaining uninsured are outside the reach of the ACA either because their state did not expand Medicaid, they are subject to immigrant eligibility restrictions, or their income makes them ineligible for financial assistance. The remainder are eligible for assistance under the law but may still struggle with affordability and knowledge of options and require targeted outreach to help them gain coverage. Going without coverage can have serious health consequences for the uninsured because they receive less preventative care, and delayed care often results in serious illness or other health problems. Being uninsured can also have serious financial consequences, with many unable to pay their medical bills, resulting in medical debt.

The ACA has provided coverage to millions of people in the United States. Current debate over rolling back ACA coverage threaten these gains and may make it difficult to reach the nearly 28 million nonelderly who remain without coverage. Proposed policies to change the structure of the Medicaid program or cut back subsidies for Marketplace coverage may lead to even more uninsured individuals. On the other hand, if additional states opt to expand Medicaid as allowed under the ACA, there may be additional coverage gains as low-income individuals gain access to affordable coverage. The outcome of current debate over health coverage policy in the United States has substantial implications for people’s coverage, access, and overall health and well-being.

Julia Foutz, Ellen Squires, and Rachel Garfield are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation.

What are the financial implications of lacking insurance?

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.