Number of uninsured rising thanks to inaction under ACA

The number of individuals lacking health care coverage has risen, due in large part to the federal government’s action and inaction regarding the Patient Protection and Affordable Care Act (ACA), according to a recent report from the Commonwealth Fund. The tracking survey finds that the recent decline in coverage is due in large part to Congress’s failure to address specific weaknesses in the ACA, the repeal of the individual mandate in the 2017 tax law, and actions by the Trump Administration to limit advertising and outreach for the ACA. The report notes that several states have begun acting to fill the gap and that several bills have been introduced in Congress to address flaws in the ACA.


Since the passage of the ACA in 2010, the Commonwealth Fund has conducted tracking surveys analyzing coverage rates among 19 to 64 year-olds, with a particular emphasis on adults who obtained coverage through the ACA marketplaces and expansion. The current survey was conducted between February and March 2018.

Rising number of uninsured.

The survey found that the number of working adults lacking coverage has risen sharply since 2016. The uninsured rate for that population has risen from 12.7 percent in 2016 to 15.5 percent, an increase of approximately 4 million. The rise was especially steep for adults with lower incomes, i.e. individuals living in households earning less than 250 percent of poverty (about $30,000 for an individual and $61,000 for a family of four.) One in five adults living in the South, for example, now lack coverage, a steep increase from the 16 percent seen in 2016. The uninsured rate has also risen sharply in the 19 states that have yet to expand their Medicaid programs.

This uninsured rate is expected to rise, as five percent of individuals with employer coverage and five percent of individuals covered through Medicaid stated that they planned to drop insurance coverage following the 2017 repeal of the individual mandate.

Legislative responses.

The report found that Congress could take concrete action to reverse the trend. Congress could increase the ACA’s advertising budget to better ensure that individuals are aware of coverage options. Congress could also act to improve the affordability of health plans in the individual market and to ensure that each market has one participating insurer. Senators Susan Collins (R-Maine) and Bill Nelson’s (D-Fla) sponsored legislation to offer reinsurance for the marketplaces and Senator Elizabeth Warren (D-Mass) sponsored legislation that would improve marketplace premium and cost-sharing subsidies and require private insurers participating in Medicare and Medicaid to offer plans in the marketplace. In addition, Senators Michael Bennet (D-Colo) and Tim Kaine (D-Va) sponsored legislation that would offer Medicare plans open to individuals under 65 through the marketplaces. Senators Jeff Merkley (D-Ore) and Chris Murphy’s (D-Conn) bill would allow fully insured employers to offer Medicare plans to their employees and would increase marketplace subsidies. Senator Brian Schatz (D-Hawaii) sponsored a bill that would create state public plan options through Medicaid. None of these bills are expected to receive a vote in the Republican-controlled Senate.

The report states that in light of congressional inaction, states have taken steps to increase coverage. Eight states have either received, or have applied for, federal approval to establish reinsurance programs in their states. Additionally, Hawaii, New Jersey, Vermont, and the District of Columbia have contemplated adding a state individual mandate. Massachusetts and Vermont currently offer additional subsidies for individuals in marketplace plans. Some of the 19 states that did not expand Medicaid, including Virginia, may expand coverage, with expansion being on as many as four state ballots in the 2018 election cycle.

The report notes that the state-by-state approach poses risks to consumers. It found that proposed changes in the Idaho and Iowa individual markets, even while making insurance cheaper for some, could expose these individuals to high out-of-pocket costs in case of serious illness or injury. These changes also will increase premiums for those who buy comprehensive plans. The report also found that the 12 states that are experimenting with Medicaid work requirements are expected to see a decrease in enrollment and coverage.

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