Federal data shows that the uninsured rate has been rising since 2016 and rose again in 2019. New analyses of the uninsured population in 2019 show that consumers were struggling with coverage affordability even before the COVID-19 pandemic. And recent surveys and mediareports suggest a deepening affordability crisis in 2020 as millions have been laid off from work or lost income. Enrollment in Medicaid and the Children’s Health Insurance Program is rising, and some state-based marketplaces have reported much higher enrollment throughout 2020. In the meantime, the federal government still has not authorized a broad special enrollment period through HealthCare.gov where anyone who is uninsured could enroll in marketplace coverage.
This post highlights some of the latest data on the uninsured rate in 2019 and 2020.
Who Was Uninsured In 2019?
The uninsured rate continued to rise in 2019. Two new analyses—one from the Centers for Disease Control and Prevention (CDC) and the other from the Congressional Budget Office (CBO)—discuss who was uninsured in 2019 and why. Consistent with a prior CDC analysis, an estimated 14.5 percent of non-elderly adults were uninsured in 2019. Men, young adults, Hispanic adults, and those in fair or poor health were more likely to be uninsured (compared to women, older adults, white adults, and those in better health, respectively).
CDC Analysis Delves Into Reasons For Uninsurance
But the latest CDC analysis went further to assess why adults were uninsured in 2019. The most common reason? Coverage was not affordable. Affordability was cited by an overwhelming 73.7 percent of respondents as their reason for being uninsured. Affordability challenges increased with age: 80.9 percent of those aged 50 to 64 cited affordability challenges, compared to 66.8 percent of those aged 18 to 29. Even so, young adults were more likely to be uninsured than older adults.
Beyond affordability, about one-quarter of respondents were uninsured because they were ineligible for coverage; this rate was higher among Hispanic adults relative to non-Hispanic white adults and higher among women relative to men. About one-fifth of uninsured adults reported not needing or wanting coverage: this rate was far higher for men and those in better health than for women and those in fair or poor health. Other reasons for being uninsured were that enrolling in coverage was too difficult or confusing, the individual could not find a plan that met their needs, or the individual applied for coverage but it had not yet gone into effect.
CBO Report Finds Many Uninsured Adults Eligible For, But Not Enrolled In, Job-Based Coverage
The CBO released a similar analysis on who went without health insurance and why. Low-income people were more likely than others to be uninsured in 2019, and employment status was not strongly linked to coverage in 2019. In fact, the vast majority of uninsured people had at least one full-time worker in their family in 2019. Of the estimated 29.8 million uninsured people in 2019, 67 percent (20 million) were eligible for subsidized coverage whether through Medicaid, the marketplace, or job-based coverage. Most of these individuals—31 percent (9.4 million people)—were eligible for but not enrolled in job-based coverage. Of the remaining 33 percent (9.8 million) who were not eligible for subsidized coverage, 13 percent were not lawfully present in the United States and thus ineligible, 11 percent were in the Medicaid coverage gap, and 9 percent had incomes too high to qualify for marketplace subsidies.
Consistent with the CDC analysis, the CBO found that many uninsured people do not enroll in coverage because of cost. About one-third of uninsured single adults would have to contribute more than 10 percent of their income towards health insurance. Others do not realize they qualify for subsidies or are deterred by the complexity of the enrollment process. Still others qualified for marketplace subsidies but could not afford to enroll in coverage; this was especially true for those whose income is over 250 percent of the federal poverty level. The public charge rule may also have discouraged recent immigrants from enrolling eligible children in Medicaid coverage because of the perceived impact on their ability to become a permanent legal resident.
The CBO also looked at the length of time that individuals remain uninsured. The vast majority of the uninsured—80 percent—went without coverage for one year or more, 11 percent were uninsured for 1 to 5 months, and another 9 percent were uninsured for 6 to 11 months. This suggests that many uninsured people are chronically uninsured for long stretches of time.
Significant Coverage Losses Ahead?
Although definitive data will not be available until 2021, numerous studies have estimated the effect of the 2020 recession on job-based coverage and the uninsured rate. Analyses have been conducted by Avalere Health, the Commonwealth Fund, the Economic Policy Institute, Families USA, the Kaiser Family Foundation, and the Urban Institute, among others. The Urban Institute even conducted a separate analysis of some of these studies to compare their assumptions and estimates.
Most of these studies suggest significant coverage losses already, as economic upheaval from the pandemic has led consumers to lose their job-based coverage or a family member’s job-based coverage. Covered California, for instance, reports record-high numbers of covered members and enrolled nearly 290,000 Californians since late March 2020.
Others, such as a Commonwealth Fund survey through early June 2020, did not show significant coverage changes relative to prior years (although it did show persistent affordability challenges). The CBO expects the number of uninsured people to increase to only about 31 million in 2020, with coverage losses mitigated by a range of factors, including the fact that the Affordable Care Act has enabled many would-be uninsured people to obtain Medicaid or marketplace coverage. And while nationwide enrollment through Medicaid and CHIP has grown by nearly 4 million people since March, observers believe that this growth is driven not by the newly uninsured but by a requirement that states freeze disenrollment during the public health crisis under the Families First Coronavirus Response Act.
Coverage losses may have been blunted so far for several reasons. Some employers, for instance, continue to provide coverage to laid-off and furloughed employees, but this trend may not last for long as the pandemic and recession continue. Media reports warn of looming cutoffs, especially as employers grapple with end-of-year coverage renewal deadlines. And many consumers who find their way to the individual market, including those eligible for premium tax credits, may not be able to afford even subsidized coverage. Some state-based marketplaces that allowed broad enrollment during COVID-19 found that consumers who selected a plan were unable to pay their first month’s premium, and Covered California reportsaffordability challenges (including for consumers who receive subsidies) even though the state offers supplemental subsidies for low- and middle-income consumers.
These challenges—for employers and individuals—are among the reasons why stakeholdershave urged Congress to further enhance federal funding for Medicaid programs, provide COBRA subsidies for employees, and require a broad special enrollment period through HealthCare.gov. Some of these priorities were in the revised Heroes Act passed by the U.S. House of Representatives in early October.