Who’s Still Uninsured? Location Makes A Difference

Adults age 18-64 who are still uninsured months after the end of open enrollment in the Patient Protection and Affordable Care Act’s (ACA) Marketplace are increasingly concentrated in states that opted not to expand Medicaid, according to a new Health Reform Monitoring Survey (HRMS) from the Urban Institute’s Health Policy Center. In September 2013, 49.7 percent of uninsured U.S. adults lived in states that had not expanded Medicaid, and, by June 2014, those same states had 60.6 percent of adults who were still uninsured.

Also, the South was found to have the highest number of uninsured, and the HRMS noted that very few southern states opted for Medicaid expansion. The share of adults remaining uninsured has increased in the South—48.9 percent of the remaining uninsured lived there as of the HRMS June 2014 survey date, up from 41.5 percent in September 2013.

Age has minimal impact. Age ranges for adults who still do not have health insurance were, according to the HRMS, 36.8 percent for ages 18-30, 41.5 percent for ages 31-49, and 21.7 percent for ages 50-64. Aside from state Medicaid expansion status, factors other than age appeared to have a greater impact on health insurance status. For example, the Urban Institute reports that now, the shift toward groups of uninsured seems to be moving modestly toward those with less education, who are unmarried, and for whom English is not a primary language.

The HRMS also reveals that, nationally, adults with incomes at or below 138 percent of the federal poverty level (FPL) make up 65.3 percent of all remaining uninsured adults. Communication with this group of adults may be key to increasing their levels of health coverage, since fewer than two in five of those surveyed reported that they had heard either “a lot,” or “some,” about subsidies for premiums and out-of-pocket costs available through the Marketplace. Only 58.5 percent said they had heard about the Marketplace, and 56.4 percent had heard at least “some” about the individual mandate.

Many (59.5 percent) of the uninsured stated that the reason they still do not have coverage is because they cannot afford it.

Just over 20 percent said they did not want health insurance and preferred to pay the fine. However, the Urban Institute theorizes that knowledge gaps about subsidies might add to a perception that coverage through the Marketplace is too expensive.

Cost is not the only barrier. The HRMS also shows that time, information, and technical reasons are also barriers to coverage that uninsured adults face. The Urban Institute therefore recommends that they could be helped with improved in-person assistance, decision supports, easier-to-use enrollment technology, and faster and more trouble-free application processing. Knowing someone who did not apply because of worries about immigration status also was reported by one in ten respondents. Finally, uninsured adults with family incomes at or below 138 percent of the FPL who live in states that chose not to expand Medicaid will have limited options for coverage, and they are likely to remain uninsured because of cost, the HRMS states.

For more information, visit http://www.urban.org/center/hpc/.

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