Austin recently talked about how universal coverage, although a stated goal of many health care systems, is rarely fully achieved. This coincided nicely with recent news that the ACA has significantly reduced the number of uninsured in the United States.

However, many people still do remain uninsured. Who are they? The Urban Institute Health Policy Center has a new report which can help us answer that question:

As of March 2015, 1 in 10 nonelderly adults remained uninsured. As the adults most inclined to obtain health insurance coverage have likely already enrolled, there is concern that the remaining uninsured may be harder to reach and require more assistance or other targeted strategies to encourage enrollment. However, private resources and federal grants supporting outreach efforts are waning, which makes it important to understand the characteristics of the remaining uninsured and the barriers that may be keeping them from enrolling. This brief describes adults who remain uninsured in March 2015 and focuses on their potential eligibility for financial assistance for coverage under the ACA, the reasons they give for not being insured, and potential barriers to and opportunities for expanding coverage to these adults.

They used the ongoing Health Reform Monitoring Survey to gather data in March of this year. The biggest news is that more than 70% of uninsured adults are potentially eligible for financial assistance in gaining coverage under the ACA. More than 27% of uninsured adults earned less than 138% of the federal poverty line, meaning that they would be eligible for Medicaid under the expansion. Another 40% of uninsured adults earn between 138% and 400% of the poverty line, meaning that they are eligible for subsidies in the insurance exchanges.

If they're eligible, why don't they have insurance? Some can't get insurance, even if they're poor enough, because of immigration status. Almost 26% of uninsured adults who might qualify for assistance can't get it because they are noncitizens. Others might qualify for exchange subsidies in the exchanges based on income but can't get them because of the family glitch, where an offering of individual insurance by an employer to an employee makes other family members ineligible for subsidies.

But one of the biggest reasons many remain uninsured is that the Medicaid expansion did not occur in their state. Almost 23% of the uninsured have incomes at or below the federal poverty line, but no expanded Medicaid program to cover them.

Less than 7% of the uninsured have an income at or above 400% of the poverty line, meaning that they would receive no financial assistance in purchasing insurance. This is important because many argue that not purchasing health insurance is a "choice". But very few of the uninsured earn 400% of the poverty line or more. This would suggest that when people earn enough to be able to afford health insurance, most choose to purchase it.

In fact, more than 60% of people who are uninsured said that affordability issues were the reason they didn't have insurance. This was true even among 60% of those who were potentially eligible for financial assistance. Less than 17% of the uninsured said that they "didn't want" insurance.

Depressingly (for those of us who write and talk about this for a living), more than half of those who are potentially eligible for financial assistance don't know about it. While I know that many of them would still be frustrated by a lack of Medicaid expansion in their state, or still unaffordable premiums even with assistance, it's just frustrating that so many still do not know about the basic benefits of the ACA.

While true universal coverage may be unattainable, there are still too many people in the United States who say they want coverage and don't have it. Some of them still find the financial barriers to be too high, whether it be because their state has refused the Medicaid expansion or because subsidies are still not enough to offset the high cost of health insurance. But others still remain unaware that the ACA might have brought insurance into their grasp if they just knew about it. That's simply tragic.


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