By Jeffrey H. Brochin, J.D.
Two-thirds of America’s under-65 uninsured actually had access to health insurance, yet did not obtain it for a variety of reasons including cost of premiums, lack of awareness of eligibility, complexities of applying, and other reasons.
The Congressional Budget Office (CBO) has issued a report to Congress describing the under-65 population that went without health insurance coverage in 2019, and analyzing the groups that were not covered by comprehensive health insurance even during the strong economy and historically low unemployment that preceded the 2020 coronavirus pandemic. The report broke down the uninsured by percentages related to causes (CBO Report, September 30, 2020).
A heterogeneous population. The uninsured population in 2019 included a wide variety of people, but some demographic groups were more likely than others to be uninsured. The CBO estimates that people in low-income households were more likely to be uninsured than those with higher incomes, and nonelderly adults were much more likely to be uninsured than children. Noncitizens who were not lawfully present in the country were particularly likely to be uninsured, although that group comprised just 16 percent of the uninsured population. By contrast, even though most nonelderly people with health insurance were covered through an employer, people in families in which no one worked were not markedly more likely to be uninsured than people in families with a full-time worker. The vast majority of uninsured people had at least one full-time worker in the family in 2019.
Groupings based on options for coverage. The CBO classified uninsured people into mutually exclusive groups on the basis of their options for subsidized coverage, or, the reasons they lacked those options. In the CBO’s assessment, about two-thirds (67 percent) of uninsured people had access to at least one type of fully or partially subsidized coverage. To categorize those people into groups, the CBO started with those for whom the federal subsidy would cover the greatest share of the cost, on average:
- Seven percent of nonelderly people without health insurance were adults who were eligible for Medicaid because they lived in a state that had expanded the program under the terms of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).
- Ten percent were adults and children who were otherwise eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
- Nineteen percent were eligible for subsidized coverage through the health insurance marketplaces established under the ACA.
- Thirty-one percent had access to subsidized coverage through employment.
Uninsured who did not have access to subsidized coverage. The CBO estimates that about one-third of the under-65 uninsured population generally did not have access to subsidized coverage. The CBO categorized them into mutually exclusive groups on the basis of the primary reason they were not eligible for subsidies:
- Thirteen percent were noncitizens who were not lawfully present in the country and did not have access to coverage through an employer. They were generally eligible for public coverage only for emergency care; otherwise, their options for coverage were limited to private insurance plans purchased outside of the marketplaces at full cost.
- Eleven percent had income below the poverty level but were ineligible for Medicaid because they lived in a state that did not expand the program under the terms of the ACA.
- And perhaps most interestingly, nine percent had income too high to qualify for marketplace subsidies and did not have access to subsidized coverage through an employer; generally, their only option was to buy coverage directly from insurers at full cost.
Awareness and complexity hindrances. Uninsured people who were eligible for Medicaid or CHIP could generally enroll without paying a premium and would have very low-cost sharing in those programs. However, unawareness of their eligibility or the complexity of the enrollment process may have prevented them from applying or may have made it difficult for them to renew their coverage. In addition, some recent immigrants were discouraged from applying for Medicaid coverage for their citizen children because they feared it could prevent them from becoming permanent legal residents.
The most common reason for not obtaining health insurance coverage was the cost of health insurance premiums--the CBO estimates that roughly one-third of uninsured single adults would have to pay more than 10 percent of their income for health insurance—and, uninsured people might not consider insurance to be worth the cost if it required high deductibles, copayments, or other forms of cost sharing. Alternatively, they might be deterred by the complexity of enrolling in coverage, or they might not be aware that subsidized coverage was even available.
Majority could have enrolled for less than 10 percent of income. The CBO estimates that 64 percent of single adults who were uninsured in 2019 could have obtained coverage for 10 percent or less of their income, and 49 percent could have obtained coverage for 5 percent or less of their income. Of the people eligible for some form of subsidized coverage, the vast majority could have enrolled at a cost of 10 percent or less of their income, and a large share could have enrolled for 5 percent or less of their income. By contrast, people ineligible for subsidized coverage were far less likely to have affordable options, including those with an income below the poverty line in states that had not expanded Medicaid.
ReportsLetters: CBOReports AccessNews AgencyNews MedicaidNews NewsFeed
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