Health Reform WK-EDGE Despite eligibility for free or reduced-cost healthcare coverage, millions of Americans remain uninsured
Tuesday, April 6, 2021

Despite eligibility for free or reduced-cost healthcare coverage, millions of Americans remain uninsured

By Jeffrey H. Brochin, J.D.

Prior to the COVID-19 pandemic, an estimated 11 million nonelderly Americans were uninsured despite potentially being eligible for free or reduced-cost coverage through the Affordable Care Act and the marketplace.

The Office of Health Policy of the Assistant Secretary for Planning and Evaluation (ASPE), HHS, has published an Issue Brief identifying both geographic and demographic variations regarding uninsured Americans. Although the national uninsured rate has decreased substantially since the implementation of the Affordable Care Act (ACA) (P.L. 111-148), high uninsured rates persist in some states such as Texas and Florida, and Black and Hispanic Americans remain uninsured in percentages above their representation in the overall population (ASPE Report, HP-2021-06, March 23, 2021).

Lack of awareness of eligibility. When signed into law on March 23, 2010, the ACA extended health insurance coverage to millions of Americans through Medicaid and Marketplace coverage. The number of nonelderly (under age 65) uninsured dropped by 20 million between 2010 and 2016, before rising by about 2 million through the first half of 2020. However, to receive financial assistance for health insurance coverage through the ACA Marketplace, people have to sign up, and they are unlikely to sign up if they are not aware of the Marketplace or do not know they are eligible for financial help. Research suggests that many uninsured people are not aware of affordable health insurance coverage options.

An Urban Institute survey in September 2020 found that 46 percent of uninsured adults knew little or nothing about the ACA Marketplace and 65 percent knew little or nothing about Marketplace subsidies. The Commonwealth Fund Biennial Health Insurance Survey in 2018 found that two-thirds of uninsured adults did not try to obtain coverage through the Marketplace and that 7 percent of them—over a million people—said they did not try because they did not know about the Marketplace.

Higher rates among Latino and Black populations. A separate 2017 Commonwealth Fund survey found that lack of awareness of the Marketplace was higher among Latino and Black respondents than among White respondents. Health insurance literacy, or the familiarity with terms such as ‘premiums’ and ‘deductibles’ that can help people make informed choices among their coverage options, was lower among Hispanic and Black populations than among White populations, and lower among Spanish-speaking survey respondents than among English-speaking respondents.

Despite the fact that Hispanic individuals represent 19 percent of the total U.S. population, they account for 29 percent of the uninsured; and although Black individuals comprise approximately 13 percent of the U.S. population, they comprise 16 percent of the uninsured.

Language barrier as a factor. Many uninsured households include adults whose primary language is not English. The authors’ analysis revealed that among the total U.S. uninsured population, approximately 9 percent resided in households whose adults have limited English proficiency. Among those who were uninsured in 2019, 9 percent reported they primarily spoke Spanish in their household. After English and Spanish, Chinese was the next most common language, spoken among 0.4 percent of the uninsured population.

Geographic disparities. Data gleaned from a 2019 ASPE analysis of uninsured Americans disclosed that there is tremendous variation in the uninsured rate across the United States. The average uninsured rate in the South Census region (12.5 percent) was more than double the uninsured rate in the Northeast Census region (5.6 percent). Among the southern states, Texas had a disproportionate share of the uninsured, with a total uninsured population of more than 4.5 million and an uninsured rate of 19 percent. Although Texas accounts for only 9 percent of the total nonelderly U.S. population, it accounted for over 17 percent of the uninsured population. Of the 50 Public Use Microdata Areas (PUMAs) with the highest uninsured rate, 43 were located in Texas. That state also had the widest intrastate variation across PUMAs with a maximum uninsured rate of 40 percent in Hidalgo County (North & West) and a minimum uninsured rate of 3 percent in Austin City (Northwest).

Conclusions. The authors concluded that health insurance coverage provides individuals and families with financial protection and access to health services, and a substantial amount of research literature demonstrates that access to health insurance coverage leads to better health outcomes. The ACA created new opportunities for affordable health insurance coverage in Medicaid and through the Marketplace, and the 2021 American Rescue Plan Act (ARPA) will expand financial assistance further, making millions of additional Americans eligible for Marketplace subsidies for the first time.

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