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Adults who Remained Uninsured at the End of 2014

In January 2014, the major coverage provisions of the Affordable Care Act (ACA)—including the expansion of Medicaid eligibility and the availability of subsidized coverage through Health Insurance Marketplaces— went into effect. As the first year of new coverage under the ACA comes to a close and the end of the second open enrollment period nears, there is great interest in understanding why some people continue to lack coverage and in reaching out to the eligible uninsured. This report, based on the 2014 Kaiser Survey of Low-Income Americans and the ACA, profiles the nonelderly adult population that remained uninsured as of Fall 2014. The survey of 10,502 non-elderly adults was fielded between September 2 and December 15, 2014, with the majority of interviews (70%) conducted prior to November 15, 2014 (the start of open enrollment for 2015 Marketplace coverage; Medicaid enrollment is open throughout the year). Additional detail on the survey methods is available in the methods appendix available on line.

While millions have enrolled in coverage under the ACA, many remain uninsured. Though much attention was paid to difficulties with the application and enrollment process during the 2014 open enrollment period, logistical issues in applying for coverage do not appear to be a leading reason why people went without insurance in 2014. Rather, lack of awareness of new coverage options and financial assistance appear to be a major barrier. When asked in their own words, uninsured adults were most likely to name cost as the main reason they don’t have coverage, and this pattern held even among those who appear to be currently eligible for low-cost or free coverage under the ACA. In addition, most uninsured adults (63%) say that they did not try to get health insurance from either their state Marketplace, healthcare.gov, or their state Medicaid agency in 2014. Some who did not seek coverage were ineligible for assistance, but the pattern of the majority not seeking coverage holds even among those who are now likely eligible for help. Thus, despite the availability of subsidies for Marketplace coverage and comprehensive Medicaid coverage, misperceptions about cost or lack of awareness are barriers to reaching some eligible uninsured.

Further, gaps in eligibility or confusion about eligibility are evident among uninsured adults. Among those who did try to get ACA coverage, the most common reason people gave for not obtaining that coverage was that they were told they were ineligible (41%). Notably, many people who appear to be eligible for some type of assistance say someone told them they were ineligible. While it is possible that they were ineligible at the time they applied, it is likely that these people received incorrect information or misinterpreted information they were given. For people who may be eligible but were told they were not, more accurate or easily understood information about the availability of coverage is particularly important. In addition, some who were told they were ineligible encountered difficulty with the application process or paperwork.

Lastly, costs—or perceptions of costs— continue to pose a barrier to coverage according to the survey. Nearly three in ten (29%) uninsured adults who applied for ACA coverage said they did not obtain that coverage because they believed it was too expensive. Many who cited cost barriers were ineligible for financial assistance under the ACA and would have faced the full cost of Marketplace coverage. However, more than four in ten who cited cost as a reason for not enrolling in coverage were eligible for financial assistance. Many appear to be eligible for tax subsidies, but they may have still found Marketplace coverage to be unaffordable even with subsidies.

Those who remained uninsured in Fall 2014 still have substantial health needs, as they were more likely than those who took up coverage to rate their health as fair or poor but less likely to have a diagnosed condition or take a prescription on a regular basis. Still, few uninsured indicated plans to seek ACA coverage in 2015. Even among those likely eligible, only about half of uninsured adults indicate that they plan to get health insurance from any source in 2015, and few who do plan to get coverage identified Medicaid or Marketplace coverage as their goal.

The survey results underscore the importance of reaching the eligible uninsured with information about their eligibility for coverage and the availability of  affordable coverage, both comprehensive Medicaid coverage and subsidized marketplace coverage.  While Marketplace enrollment closes on February 15, 2015 for most people, Medicaid coverage is available throughout the year. Thus, ongoing efforts to let the eligible uninsured know about the availability of Medicaid coverage will remain important.

Issue Brief

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.