The Uninsured and the ACA: A Primer - Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act

The ACA led to historic drops in the uninsured rate, with millions of previously uninsured Americans gaining insurance and 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 filled 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, and recent actions to alter the ACA under the Trump Administration may limit availability of coverage. For the first time since passage of the law, the number of uninsured people increased in 2017, and 27.4 million remain uninsured. Nearly half (45%) 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 preventive 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.

Ongoing debate about altering the ACA or limiting Medicaid to populations traditionally served by the program could lead to further loss of coverage and place more people in jeopardy of facing access barriers or financial strain due to being uninsured. 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 nation and the states has substantial implications for people’s coverage, access, and overall health and well-being.

Rachel Garfield and Kendal Orgera 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? Appendix