Key Facts about the Uninsured Population | KFF

The economic downturn caused by the coronavirus pandemic has brought renewed attention to health insurance coverage, as millions have lost their jobs and possibly their health coverage. The Affordable Care Act (ACA) sought to address the gaps in our health care system that leave millions of people without health insurance by extending Medicaid coverage to many low-income people and providing subsidies for health insurance. market coverage for people below 400% of the poverty level. After the ACA law, the number of uninsured non-elderly Americans decreased by 20 million, falling to an all-time low in 2016. However, as of 2017, the number of uninsured non-elderly Americans increased for three years in a row, growing by 2.2 million from 26.7 million in 2016 to 28.9 million in 2019, and the uninsured rate increased from 10.0% in 2016 to 10.9% in 2019.

the future of the aca is again before the supreme court in california vs. texas, a case supported by the trump administration seeking to repeal the aca in its entirety. A court decision to invalidate the ACA would eliminate the avenues of coverage created by the ACA, leading to significant coverage losses.

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Although the number of uninsured is likely to have increased further in 2020, the 2019 data provides an important baseline for understanding the changes in health coverage that led to the pandemic. This briefing outlines trends in health coverage before the pandemic, examines the characteristics of the uninsured population in 2019, and summarizes access and the financial implications of being uninsured.

how many people do not have insurance?

After several years of improvements in coverage following the implementation of the ACA, the rate of uninsured increased from 2017 to 2019 amid efforts to alter the availability and affordability of coverage. Coverage losses in 2019 were driven by declines in Medicaid and non-group coverage and were greatest among non-elderly Hispanics and Native Hawaiians and other Pacific Islanders. the number of uninsured children also grew significantly.

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Despite recent increases, the number of uninsured remains well below pre-ACA levels. the number of non-elderly people without insurance fell from more than 46.5 million in 2010 to less than 26.7 million in 2016 before rising to 28.9 million in 2019. we focus on coverage among non-elderly people, as Medicare offers near-universal coverage for seniors, with only 407,000, or less than 1%, of people age 65 and older uninsured.

key details:

• The uninsured rate increased in 2019, continuing a steady climb that began in 2017. The 2019 uninsured rate increased to 10.9% from 10.4% in 2018 and the 10.0% in 2016, and the number of people who were uninsured in 2019 grew by more than one million from 2018 and by 2.2 million since 2016 (figure 1). Despite these increases, the uninsured rate in 2019 remained significantly below pre-ACA levels.
• after the aca was enacted in 2010, when coverage for young adults under 26 and the early expansion of medicaid went into effect, the number of uninsured and the uninsured rate began decrease. When the main coverage provisions of ACA took effect in 2014, the number of uninsured people and the rate of uninsured people dropped dramatically and continued to fall until 2016, when just under 27 million people (10.0% of the non-elderly population) lacked coverage (figure 1).
• In 2019, increases in employer-sponsored insurance were offset by decreases in non-group and Medicaid coverage, resulting in an increase in the number of uninsured non-seniors. While the number of people covered by employer-sponsored insurance increased by 929,000, or 0.5 percentage point, from 2018 to 2019, the number of non-elderly Medicaid enrollees decreased by more than double that amount, or 1.9 million people (0.7 percentage points). The drop in Medicaid coverage was greater for children (0.9 percentage points) compared to non-elderly adults (0.5 percentage points). in addition, the number of non-elderly people covered in the non-group market also fell by 879,000 from 2018 to 2019 (figure 2).
• Hispanics and Native Hawaiians and other Pacific Islanders experienced the largest increases in uninsured in 2019. The uninsured rate increased one percentage point, from 19.0% in 2018 to 20.0% in 2019 for Hispanics and 3.4% in 2019. points, from 9.3% in 2018 to 12.7% in 2019 for Native Hawaiians and Pacific Islanders (Figure 3). while uninsured rates also increased for whites and Asians, uninsured rates for blacks and American Indians/Alaskan Natives did not change significantly.
• Hispanics accounted for more than half (57%) of the increase in uninsured older people in 2019, accounting for more than 612,000 people. Among these uninsured non-elderly Hispanics, more than one-third (35%) were children.
• The number of uninsured children increased by more than 327,000 from 2018 to 2019 and the rate of uninsured children increased nearly 0.5 percentage point, from just under 5.1% in 2018 to 5.6% in 2019 (figure 3). While the rate of uninsured increased for children of all races and ethnicities, the increase was greatest for Hispanic children, from 8.1% in 2018 to 9.2% in 2019.
• Changes in the number of uninsured people varied among states in 2019. A total of 13 states experienced increases in the number of non-elderly uninsured people, including nine states with Medicaid expansion and four states without expansion . however, the uninsured rate for the group of expanding states was almost half that of the non-expanding states (8.3% vs. 15.5%). two states, california and texas, accounted for 45% of the increase in the number of uninsured from 2018 to 2019. virginia was the only state to see a statistically significant decrease in the number of uninsured in 2019; the state expanded its medicaid program that year (appendix table a).

who are the uninsured?

Most uninsured people are non-elderly adults from working families. low-income families are more likely to be uninsured. In general, people of color are more likely to be uninsured than white people. Reflecting geographic variation in income and the availability of public coverage, people living in the South or West are more likely to be uninsured. most of those without insurance have been without coverage for long periods of time. (See Appendix Table B for detailed information on the characteristics of the uninsured population.)

key details:

• In 2019, more than seven in ten of the uninsured (73.2%) had at least one full-time worker in their family, and an additional 11.5% had a part-time worker in their family. his family (figure 4).
• People with incomes below 200% of the Federal Poverty Level (FPL)1 are at greatest risk of being uninsured (Appendix Table B). overall, more than eight in ten (82.6%) of the uninsured were in families with incomes below 400% of poverty in 2019 (figure 4).
• the majority (85.4%) of the uninsured are non-elderly adults. The uninsured rate among children was 5.6% in 2019, less than half the rate among non-seniors (12.9%), largely due to increased availability of Medicaid and chip coverage for children than for adults (figure 5).
• While a plurality (41.1%) of the uninsured are non-Hispanic white, people of color are generally at higher risk of being uninsured than white people. People of color make up 43.1% of America’s age-old people. but they represent more than half of the total non-elderly uninsured population (figure 4). Hispanics, blacks, American Indians/Alaskan Natives, and Native Hawaiians and other Pacific Islanders have significantly higher rates of uninsured than whites (7.8%) (Figure 5). however, as in previous years, Asians have the lowest rate of uninsured at 7.2%.
• Most of the uninsured (77.0%) are American. citizens and 23.0% are non-citizens. however, non-citizens are more likely to be uninsured than citizens. the uninsured rate for recent immigrants, those who have been in the us uu. for less than five years was 29.6% in 2019, while the uninsured rate for immigrants who have lived in the us. uu. for more than five years it was 36.3% (appendix table b).
• Uninsured rates vary by state and region; people who live in states that are not expanding are more likely to be uninsured (figure 5). Fifteen of the twenty states with the highest uninsured rates in 2019 were states with no expansion as of that year (Figure 6 and Appendix Table A). Economic conditions, the availability of employer-sponsored coverage, and demographics are other factors that contribute to variation in uninsured rates across states.
• nearly seven in ten (69.5%) of adults without health insurance in 2019 have been without coverage for more than a year. enrollment efforts.

why don’t people have insurance?

most non-elderly people in the us. uu. obtain health insurance through an employer, but not all workers are offered employer-sponsored coverage or, if offered, can pay their share of the premiums. Medicaid covers many low-income people; however, adult medicaid eligibility remains limited in some states. In addition, renewal and other policies that make it harder for people to keep Medicaid likely contributed to the decline in Medicaid enrollment. While financial assistance for Marketplace coverage is available to many people of moderate income, few people can afford to purchase private coverage without financial assistance. Some people who are eligible for coverage under ACA may not know they can get help, and others may still find the cost of coverage prohibitive.

key details:

• Cost still represents a significant barrier to coverage for the uninsured. in 2019, 73.7% of uninsured older adults said they were uninsured because coverage is not affordable, making it the most common reason cited for being uninsured (Figure 7).
• Access to health coverage changes as a person’s situation changes. in 2019, a quarter of uninsured older adults said they were uninsured because they weren’t eligible for coverage, while 21.3% of uninsured older adults said they were uninsured because they didn’t need or didn’t they wanted coverage (figure 7). nearly one in five were uninsured because they found signing up too difficult or confusing or because they couldn’t find a plan to meet their needs (18.4% and 18.0%, respectively).3 to lose their job in 2019, The number of people losing their jobs and job-based coverage is likely to have increased in 2020 due to the coronavirus pandemic.
• As stated above, not all workers have access to coverage through their job. in 2019, 72.5% of uninsured older workers worked for an employer that did not offer health benefits.4 Among uninsured workers who are offered coverage by their employers, cost is often a barrier to accepting coverage. offer. from 2010 to 2020, total premiums for family coverage increased 55% and worker participation increased 40%, outpacing wage growth.5 Low-income families with employer-sponsored coverage spend a significantly higher proportion of your income in premiums and out-of-pocket medical expenses compared to those with incomes greater than 200% fpl.6
• Eligibility for adult Medicaid varies by state and is sometimes limited. As of October 2020, 39 states, including DC, have adopted expanded Medicaid for adults under the ACA, although 34 states had implemented the expansion by 2019. In states that have not expanded Medicaid, eligibility for adults remains limited, with a median level of parental eligibility at just 41% of poverty and adults without dependent children ineligible in most cases. In addition, state renewal policies and periodic data matches can make it difficult for people to maintain Medicaid coverage. Millions of poor, uninsured adults fall into a “coverage gap” because they earn too much to qualify for Medicaid but not enough to qualify for marketplace premium tax credits.
• While lawfully present immigrants below 400% of the poverty level are eligible for Marketplace tax credits, only those who have served a five-year waiting period after receiving qualified immigration status can qualify for Medicaid. . Public charge policy changes that allow federal officials to consider the use of Medicaid for non-pregnant adults when determining whether to grant certain people a green card are likely to contribute to the decline in coverage among lawfully present immigrants. undocumented immigrants are not eligible for Medicaid or Marketplace coverage.7
• Although financial assistance is available to many who become uninsured under CA, not everyone who is uninsured is eligible for free or subsidized coverage. Nearly six in ten of the uninsured before the pandemic were eligible for financial assistance through Medicaid or through Marketplace coverage. However, more than four in ten uninsured people were out of reach under the ACA because their state did not expand Medicaid, their income was too high to qualify for Marketplace subsidies, or their immigration status made them ineligible. Some uninsured people who are eligible for help may be unaware of coverage options or may face barriers to enrolling, and even with subsidies, Marketplace coverage may be unaffordable for some uninsured. While outreach and enrollment assistance helps facilitate initial and ongoing enrollment in ACA coverage, these efforts face ongoing challenges due to funding cuts and high demand.

How does not having coverage affect access to health care?

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Health insurance makes a difference in whether and when people get needed medical care, where they get it, and ultimately how healthy they are. uninsured adults are much more likely than those with insurance to postpone medical care or forego care altogether. The consequences can be serious, especially when preventable conditions or chronic diseases go undetected.

key details:

• studies repeatedly show that people without insurance are less likely than people with insurance to receive preventive care and services for major health conditions and chronic diseases.8,9,10,11 more than two of in five (41.5%) non-elderly uninsured adults reported not seeing a doctor or health care professional in the past 12 months. three in ten (30.2%) non-older adults without coverage said they did not need care in the past year due to cost compared to 5.3% of adults with private coverage and 9.5% of adults with public coverage. Part of the reason for poor access among the uninsured is that many (40.8%) don’t have a fixed place to go when they’re sick or need medical care (Figure 8).
• More than one in ten (10.2%) uninsured children did not receive needed care due to cost in 2019 compared to less than 1% of privately insured children. furthermore, one in five (20.0%) children without insurance had not seen a doctor in the past year compared to 3.5% of children with public and private coverage (figure 9).
• many people without insurance don’t get the treatments their health care providers recommend because of the cost of care. in 2019, uninsured older adults were more than three times as likely as adults with private coverage to say they delayed filling or didn’t get a prescription drug they needed because of cost (19.8% vs. 6.0% ).12 and while insured and uninsured people injured or newly diagnosed with a chronic condition receive similar plans for follow-up care, people without health coverage are less likely than those with coverage to get all recommended services.13 ,14
• Because people without health coverage are less likely than those with insurance to receive regular outpatient care, they are more likely to be hospitalized for preventable health problems and experience declines in their overall health. when hospitalized, people without insurance receive fewer diagnostic and therapeutic services and also have higher mortality rates than those with insurance.15,16,17,18,19
• Research shows that getting health insurance greatly improves access to health care and decreases the adverse effects of being uninsured. a comprehensive review of research on the effects of aca medicaid expansion finds that the expansion had positive effects on access to care, utilization of services, affordability of care, and financial security among the low-income population . Medicaid expansion is associated with higher rates of early-stage cancer diagnosis, lower rates of cardiovascular mortality, and greater odds of smoking cessation.20,21,22
• Public hospitals, community clinics and health centers, and local providers serving underserved communities provide a critical health care safety net for the uninsured. however, safety net providers have limited resources and service capacity, and not all uninsured people have geographic access to a safety net provider. greatest disadvantage in accessing care.

what are the financial implications of not having insurance?

People without insurance often face unaffordable medical bills when seeking care. these bills can quickly translate into medical debt, since most uninsured people have low or moderate incomes and have little, if any, savings.26,27

key details:

• Those who are uninsured for an entire calendar year pay nearly half of their care out of pocket.28 In addition, hospitals often charge uninsured patients much higher rates than health insurers pay. private health and public programs. 29,30,31
• Uninsured non-elderly adults are much more likely than their insured counterparts to lack confidence in their ability to pay for regular medical costs and for major medical expenses or emergencies. More than three-quarters (75.6%) of uninsured older adults say they are very or somewhat concerned about paying medical bills if they get sick or have an accident, compared to 47.6% of adults with Medicaid/other public insurance and 46.1% of the privately insured. adults (figure 10).
• Medical bills can put a huge strain on the uninsured and threaten their financial well-being. in 2019, uninsured adults who were not elderly were nearly twice as likely as those with private insurance to have trouble paying medical bills (24.1% vs. 11.6%; Figure 10).32 Uninsured are also more likely to face negative consequences due to medical bills, such as depleting savings, having difficulty paying for necessities, borrowing money, or sending medical bills to collection that result in medical debt.33
• Although the uninsured are generally billed for the medical services they use, when they are unable to pay these bills, the costs can turn into bad debt or uncompensated care for providers. state, federal, and private funds bear some but not all of these costs. With the expansion of coverage under ACA, providers are seeing reductions in uncompensated care costs, particularly in states that expanded Medicaid.
• Research suggests that obtaining health coverage improves care affordability and financial security among the low-income population. Multiple studies of the ACA have found greater decreases in problems paying medical bills in expanding states relative to non-expanding states. a separate study found that, among those residing in areas with a high proportion of low-income and uninsured people, the expansion of medicaid significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies.

conclusion

The number of people without health insurance grew for the third year in a row in 2019. Recent increases in the number of uninsured older people occurred amid a growing economy and before the economic turmoil of the coronavirus pandemic that It has led to millions of people losing their jobs. In the wake of these record job losses, many people who have lost income or job-based coverage may qualify for expanded Medicaid and subsidized marketplace coverage under the ACA. In fact, recent data indicates that enrollment in both Medicaid and the Marketplaces has increased since the start of the pandemic. however, the number of people without insurance is expected to rise even more in 2020.

Drops in coverage among Hispanics drove much of the increase in the overall uninsured rate in 2019. Changes in federal public charge policy may be contributing to declines in Medicaid coverage among adults and Hispanic children, leading to a growing number of people without health insurance. coverage. These coverage losses also come as COVID-19 has disproportionately affected communities of color, leading to a higher proportion of cases, deaths, and hospitalizations among people of color. lack of health coverage presents barriers to accessing needed care and can lead to worse health outcomes for people affected by the virus.

While ACA’s coverage options provide an important safety net for people who lose their jobs during the pandemic, a Supreme Court ruling in California vs. texas could have major effects on the entire health care system. If the court invalidates the ACA, the coverage extensions that were essential to the law would be eliminated and would result in millions of people losing health coverage. such a large increase in the number of uninsured would reverse the gains in access, utilization, affordability of care, and treatment disparities achieved since the law was implemented. These coverage losses occurring in the midst of a public health pandemic could further jeopardize the health of people infected with COVID-19 and exacerbate disparities for vulnerable people of color.

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