Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.
It's worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that:
Data collected from the 2015 Current Population Survey— Annual Social and Economic Supplement (CPS-ASEC) provides information on those with and without insurance coverage from a large, federal, nationally representative survey (most of the data are collected in March, although there are some interviews in February and April;3 hereafter we refer to the data as having been collected in March 2015). Although the CPS-ASEC questionnaire changed in significant ways in 2014 such that it should not be used to compare 2015 coverage to 2013, the data allow analysts to assess the characteristics of those remaining uninsured following the first year of implementation of the ACA’s main coverage provisions and after two marketplace open enrollment periods
According to their most recent surveys, about 12.2% of the non-elderly, non-military, non-institutionalized population remains uninsured. This is just under 33 million people. About half of those people live in states that have refused the Medicaid expansion. This has certainly made a difference. The rate of uninsurance in states with the Medicaid expansion is 10.1%, compared to 15.4% in states which have refused it. It's clear, therefore, that one way to reduce the numbers of uninsured at this point would increase the numbers of states participating in the program.
More than a quarter of the uninsured are eligible for Medicaid of CHIP. About two-thirds of uninsured children fall into this category. These are all people who could have insurance if they could overcome the barriers and hurdles necessary to sign up for coverage. It's also possible this could be an information gap. Many of them may not know they are eligible, and may not have tried to obtain Medicaid or CHIP for themselves, or their children.
An additional 21% of the uninsured qualify for subsidies on the exchanges, but have not obtained plans. This, too, could be an information issue, where people do not know they are eligible for tax credits. It could be that they feel that, even with the tax credits, they still cannot afford coverage. It could also be that they simply do not want insurance, and would rather pay the penalty of the individual mandate.
Clearly, however, there is much to be gained from outreach. Efforts to increase enrollment in both Medicaid and CHIP, as well as through the exchanges, could significantly increase the number of people who are already eligible for coverage, but have not yet obtained it. More than 80% of the uninsured eligible for Medicaid or CHIP live in metropolitan areas. More than two-thirds of them live in families in which at least one family member is already receiving the earned income tax credit and some other public benefit. Nearly half have at least one school-aged child in their family. It's possible to locate many of these people, and help them sign up for coverage.
In addition, furthering the Medicaid expansion is a straightforward way to decrease uninsurance. That will require more political efforts, and a different skill set.
Regardless, increasing the number of Americans who have health insurance is only one goal of improved access. Making sure that care is still affordable, and that underinsurance doesn't become a bigger issue, is a whole different ball game.