The Uninsured: A Primer - Key Facts about Health Insurance and the Uninsured in the Wake of National Health Reform
In the past, gaps in the public insurance system and lack of access to affordable private coverage left millions without health insurance, and the number of uninsured Americans grew over time, particularly during economic downturns. By 2013, the year before the major coverage provisions of the Affordable Care Act (ACA) went into effect, more than 43 million people lacked coverage.1 Poor and low-income adults were particularly likely to lack coverage, and the main reason that most people said they lacked coverage was inability to afford the cost.2
Under the ACA, as of 2014, Medicaid coverage has been expanded to nearly all adults with incomes at or below 138% of poverty in states that have adopted the expansion, and tax credits are available for people with incomes up to 400% of poverty who purchase coverage through a health insurance marketplace. Millions of people have enrolled in these new coverage options, and the uninsured rate has dropped to a historic low. Coverage gains were particularly large among low-income people living in states that expanded Medicaid.
Still, millions of people—28 million nonelderly people as of the end of 2015— remain without coverage.3 Groups with historically high uninsured rates continue to be at highest risk of being uninsured, including low-income individuals, adults, and people of color. Cost continues to pose a major barrier to coverage with nearly half (46%) of the uninsured in 2015 saying that the main reason they lacked coverage was because it was too expensive.4
Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured people are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected. While the safety net of public hospitals, community clinics and health centers, and local providers provide a crucial health care safety net for uninsured people, it does not close the access gap for the uninsured.
For many uninsured people, the costs of health insurance and medical care are weighed against equally essential needs, like housing, food, and transportation to work, and many uninsured adults report difficulty paying basic monthly expenses such as rent, food, and utilities.5 When uninsured people use health care, they may be charged for the full cost of that care (versus insurers, who negotiate discounts) and often face difficulty paying medical bills and potential medical debt. Providers absorb some of the cost of care for the uninsured, and while uncompensated care funds cover some of those costs, these funds do not fully offset the cost of care for the uninsured.
Even with the ACA, the nation’s system of health insurance continues to have many gaps that currently leave millions of people without coverage. Over half (57%) of the remaining uninsured are outside the reach of the ACA either because their state did not expand Medicaid, they are subject to immigrant eligibility restrictions, or their income makes them ineligible for financial assistance. The remainder are eligible for assistance under the law but may still struggle with affordability and knowledge of options and require targeted outreach to help them gain coverage. For both eligible and ineligible remaining uninsured people, health care needs persist regardless of insurance status, underscoring the importance of safety net providers and community health clinics to serve this population.6Introduction