Why 27 Million Are Still Uninsured Under Obamacare

By Jeremy Scott DiamondJeremy Scott Diamond, Zachary Tracer,Zachary Tracer, and Chloe WhiteakerChloe Whiteaker
October 19, 2016

When the Affordable Care Act was signed into law in 2010, it promised to extend health insurance to tens of millions of people. And although the law has helped push the U.S. uninsured rate down to a record low, the ACA’s new insurance markets are proving to be volatile, with insurers recording big losses and pulling out. Meanwhile, there are still millions of people without health insurance.

One key to stabilizing the law is drawing in more of those who are uninsured, particularly the younger, healthier ones. In fact, young people are the most likely to go uninsured, according to a detailed analysis by the Kaiser Family Foundation. The analysis shows that those who lack insurance cut across age and income and vary from state to state. Taking a look at who these people are can give clues to how the health law is falling short, and what can be done to fix it.

That’s not to say that the law hasn’t achieved a primary goal: reducing the number of people without health insurance. When President Barack Obama signed the ACA in 2010, about 47 million Americans under the age of 65 lacked health insurance.

Since then, people with low incomes became eligible for Medicaid in states that expanded the program, adults younger than 26 rejoined their parents’ plan, and customers bought insurance on the law’s new markets—usually with subsidies. In all, the government estimates that about 20 million people have gained coverage.

But there are still those 27 million uninsured. And there are a variety of reasons they’re being left behind by the law’s gains, according to the Kaiser analysis.

Kaiser surveyed the uninsured in late 2015 in a separate study, to get a better idea of who still lacks coverage and why. Nearly half the people who didn’t buy coverage thought it was too expensive.

Of the uninsured, the largest group is between 26 and 34 years old—which makes sense when you consider that they’re just moving off their parents’ plans and may not have a good job that provides them with insurance, or that pays them enough to be able to buy it on their own.

The uninsured tend to have relatively low incomes. About 7 million of them make less than the poverty level—approximately $24,000 for a family of four—while about the same number of uninsured people make between one and two times the poverty line.

Yet, altogether, less than half of them are eligible for financial assistance.

In many states, more than half of the uninsured are ineligible for help

Source: Kaiser Family Foundation analysis based on 2016 Medicaid eligibility levels and 2016 Current Population Survey

Of those, 2.6 million fall into the coverage gap.

Those are people who make less than the federal poverty line but live in one of the 19 states such as Texas and Florida that decided not to expand Medicaid after a 2012 Supreme Court ruling made that part of the law optional for states. Because the ACA assumed those people would be covered under Medicaid, the law doesn’t give them subsidies either.

The poorest slip through the cracks in states that didn't expand Medicaid

Note: Wisconsin offers Medicaid to adults up to 100% of the federal poverty line under a waiver but did not adopt the ACA expansion; Maine isn’t included because it did not have sufficient data
Source: Kaiser Family Foundation

An additional 3 million of the uninsured don’t qualify for subsidies because they make too much money—about $96,000 for a family of four. And 4.5 million aren’t eligible because they’re offered insurance through work. It’s possible they can’t afford that insurance, but there’s no way to tell from the data.

Under federal law, undocumented immigrants aren’t eligible for ACA plans. Kaiser estimates that they account for 20 percent of the uninsured, or about 5.4 million people. A big chunk of them are in states like California, Florida, and New Jersey.

All told, that’s more than 15 million people who aren’t eligible for financial assistance to help them get insurance, for one reason or another…

…leaving 11.7 million who are eligible for government help.

Of those, 6.4 million can sign up for Medicaid, children’s programs, or some state-funded programs for immigrants. The remaining 5.3 million could get tax subsidies to help lower the cost of insurance.

Those are the people the federal government is working to draw in when sign-ups start on Nov. 1. The Centers for Medicare and Medicaid Services recently unveiled its outreach strategy, relying on direct contact with people—the government plans to send 10 million pieces of mail—as well as advertising on TV, radio, and platforms like Instagram and Facebook. The government has said its outreach will emphasize the affordability of health plans, as well as the climbing penalties that individuals could face for not signing up.

Because people tend to move in and out of different kinds of health coverage over time—perhaps they get married or lose a job, for instance—the outreach has to be constant.

“It’s not just a one-time media blitz or a one-time outreach at health fairs,” says Rachel Garfield, a senior researcher at Kaiser. “There’s a lot of room for ongoing education and outreach to let people know about the affordable coverage options.”

Options are decreasing ahead of open enrollment

Note: Data is preliminary for some states and couldn’t be confirmed for Texas and Wisconsin
Source: Bloomberg reporting

The stakes are high. Premiums are climbing by an average of about 25 percent next year, and the exits of big insurers like UnitedHealth Group Inc. and Aetna Inc. from many of the law's markets are limiting options in big parts of the country. While a new president and Congress could make big changes to shore up the law or dismantle it after the November election, this sign-up season is clearly key to the law's fate.