Summary of the National Center for Health Statistics, National Health Insurance Survey on Insurance Coverage (January-March 2016)
This is the most recent federal survey of the nation’s uninsured from the first quarter of 2016. These surveys are compiled and released quarterly and thus catalogue the nation’s remarkable progress in reducing its number of uninsured under the Affordable Care Act (ACA).
The uninsured: progress and remaining challenges
8.6% (27 million) of Americans remain uninsured. Close to 100% of those over 65 are insured, only 1% remain uninsured; this is due to Medicare. 95% of children are now insured due to private and public coverage (Medicaid, CHIP and the ACA), only 5% remain uninsured. 88% of adults (18-64) are now insured by private insurance and Medicaid; 11.9% still remain uninsured.
The percentages of uninsured children have fallen from 13.9% in 1997 to 5% in 2016. The initial decline was the federal CHIP expansion (Healthy Families in California), followed by the ACA’s expansions of Medicaid and subsidized coverage through the Exchanges.
The percentages of uninsured young adults (18-24) fell from 31% in 2010 to 13.7% in 2016. The declines were due to the ACA’s provisions allowing them to remain on their parent’s coverage, the Medicaid expansion for adults, and subsidized coverage through the Exchanges.
Uninsured adults (18-64) fell from 22.3% in 2010 to 11.9% in 2016. The declines were due to the ACA’s provisions barring pre-existing condition exclusions, the Medicaid expansion for adults, and subsidized coverage through the Exchanges. Over time, the adult uninsured rate should approximate the 5% uninsured rate that we have now achieved for the nation’s children.
Measurements of the uninsured
The analysis has three different measurements of uninsured. The first is point in time – i.e. the insured or uninsured status when the survey respondent answered the question. The second is at any point in the past 12 months; this is a larger number encompassing those who are part year insured and part year uninsured. The third is uninsured for the past 12 months or more; these are the long term uninsured, and this is a smaller number than the first two and the issue of greatest concern in that lack of insurance results in lack of access to care and deteriorating health status.
The uninsured rate for adults 18-64 who have been uninsured for 12 months or more (the long term uninsured) has fallen from 16.4% to 7.4%. This is a remarkable achievement, primarily achieved in 27 months from 2014 to 2016.
The point in time uninsured rate fell from 22.3% to 11.9% -- i.e. nearly 50% -- between 2010 and 2016. This is the most common measurement of the nation’s uninsured rate.
The uninsured rate over the course of the year fell from 26.7% to 16.9% between 2010 and 2016. This is the largest number and includes both those uninsured for only a few months (the frictionally uninsured) and those uninsured for the entire year.
Due to the Supreme Court’s decision in NFIB v. Sebelius and Florida v. Sebelius https://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf , states were given a choice to expand their Medicaid programs for uninsured adults to the maximum permitted under the ACA – 138% of the federal poverty level or not to expand. 31 states (most recently including Louisiana) have chosen to expand. 20 states (including Texas and Florida have not yet decided to expand.
In the Medicaid expansion states like California, the uninsured rates fell 50% from 18.4% to 9.2% between the end of 2013 and the first quarter of 2016 (27 months).
In the non-expansion states like Texas and Florida, the uninsured rates fell from 22.7% to 16.7%. In other words the nation’s uninsured rates could be further reduced by the actions of 20 primarily Southern states (mostly with Republican Governors) to adopt the Medicaid expansion. President Obama and Democratic Presidential Candidate Hilary Clinton have proposed three years of 100% federal match as added incentives for these states to act.
Types of Exchanges
Under the ACA, states can choose to operate their own Exchanges like California, have the federal government administer their Exchanges like Texas and Florida, or partner with the federal government in the administration of the Exchanges like Illinois and Michigan.
In the states with state-based Exchanges like California, the uninsured rates fell from 18.7% to 9.1% between the end of 2013 and the first three months of 2016. Almost all of these states also adopted the Medicaid expansion.
In the states with Partnership Exchanges like Michigan and Illinois, the uninsured rates fell from 17.9% to 8.2%. All of these states also adopted the Medicaid expansion.
In the states with federally administered Exchanges like Texas and Florida, the uninsured rates fell from 22% to 14.5%. Over half of these states have so far rejected the Medicaid expansion.
Prior to the ACA, the poor (below 100% of the federal poverty level) and the near poor (100-200% of FPL) had uninsured rates substantially of 42 to 43%. Their uninsured rates in 2016 are less than 25% and could be lower when and if Southern states expand their Medicaid programs. http://www.luciensblog.com/blog/2016/8/9/the-impacts-of-the-medicaid-expansion-arkansas-kentucky-and-texas The non-poor (above 200% of FPL) had much lower uninsured rates of 12.6%, and these were cut in half to 6.5% due to the ACA’s Exchanges and reforms of the individual insurance market.
The uninsured rates vary widely by region. In 2016 they were 4.6% in the Northeast (Massachusetts), 9.4% in the Pacific (California) and 19.3% in the West South Central (Texas) region. The primary differences are the differing state decisions on Medicaid expansion for adults (nearly non-existent in the South) and the high rates of private insurance through employment in the Northeast and Midwest. For California to make further progress in reducing its uninsured, it will need to close the nearly 9% gap in private insurance coverage with the Northeast and the 10% gap with the Midwest.
Republican Presidential candidate Donald Trump proposes repealing the ACA with no plan to replace it. Democratic Presidential candidate Hillary Clinton proposes to increase financial assistance to working families struggling with affordability in the Exchanges, to increase assistance available to those states that have not yet expanded Medicaid, to allow for the public option in the Exchanges and to enhance competition and regulatory pressures to bring down spiraling drug prices – e.g. allow Medicare to negotiate prices and authorize importation of Canadian drugs. http://www.luciensblog.com/blog/2016/7/25/comparison-of-national-health-reform-proposals
Prepared by: Lucien Wulsin
Date: September 8, 2016