The Post-Affordable Care Act Uninsured:

How to Cover the Last … Million Uninsured

Elizabeth Wiley, MD, JD, MPH@elizabeth_wiley

2015 Policy Prescriptions Health Policy Symposium

13 June 2015

DISCLOSURE

I serve as an independent contractor developing course content for ELM Exchange.

LEARNING OBJECTIVES

• Identify key characteristics of the uninsured in the U.S.

• Describe strategies and policy approaches to reduce the number of uninsured Americans and/or achieve universal health coverage in the U.S.

HOW MANY AMERICANS ARE CURRENTLY

UNINSURED?

The ACA & the Uninsured

The ACA expanded health coverage by:• Subsidies for purchase of private insurance through

exchanges (up to 400% FPL)• Coverage for young adults on parent/guardian’s

plan• Medicaid expansion (up to 138% FPL)• Employer-sponsored insurance

Image: Kaiser 2015

Post-ACA Uninsured: Trends

The ACA & the Uninsured

So far…• At least 9.5 million previously uninsured Americans

are now covered (Rand, Commonwealth 2014)• At least 3 million young adults (under 26) have

obtained coverage under parent/guardian plan• An estimated 16 million Americans have been

covered as a result of the ACA (HHS 2015)However…the CBO (2012) estimated that the ACA would result in coverage of 30-33 million Americans, leaving only 26-27 million uninsured by 2016…

ACA Coverage: Status of Medicaid Expansion (May 26, 2015)

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT**

MO

MS

MN

MI*MA

MD

ME

LA

KY KS

IA*

IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Adopted (30 States including DC)

Adoption under discussion (3 States)

Not Adopting At This Time (18 States)

Image/Data: Kaiser 2015

What Opting Out of Medicaid Expansion Means…The Coverage Gap

Image: Kaiser 2015

Coverage Gap: Geography

TX26%

FL18%

NC10%

GA8%

Other States Not Moving Forward

39%

South89%

Midwest7% North

east 1%

West4%

Distribution By State: Distribution By Geographic Region:

Data/Image: Kaiser 2015

The Coverage Gap: Race/Ethnicity & Health Status

White43%

Black27%

Hispanic24%

Other5%

Excellent or Very Good47%

Good35%

Fair or

Poor18%

Distribution By Race/Ethnicity:

Distribution By Health Status:

Data/Image: Kaiser 2015

The Coverage Gap: If all states expanded Medicaid….

Total Whites Blacks Hispanics Other All People of Color

41% 41%

57%

34% 37% 41%

10.8 M 2.9 M 18.7 M

SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels, updated to reflect state Medicaid expansion decisions as of March 2015, and 2014 Current Population Survey data.

Share of Uninsured Adults Who Would be Eligible if All States Expanded Medicaid, by Race/Ethnicity:

35.4 M 16.6 M 5.1 M

Beyond The Coverage Gap:The Post-ACA Uninsured• Business owners: 1 in 5 uninsured • Veterans: 1 in 14 uninsured• Undocumented

immigrants: 1 in 7 uninsured• Neonates: 1 in 20 uninsured (at hospital discharge)

Data/Image: Kaiser 2015

Coverage + Access?

The Post-ACA Uninsured: Toward Universal Health Coverage?

• Medicaid expansion • Private insurance exchanges• Employer-sponsored coverage• Medicare expansion• ???

REFERENCES

Caman K & Eibner C. Changes in Health Insurance Enrollment Since 2013. Rand Corporation, 2014. Collins S, Rasmussen P & Doty M. Gaining Ground: Americans’ Health Insurance Coverage and Access to Care After the Affordable Care Act’s First Open Enrollment Period, The Commonwealth Fund, July 2014. Dark C & Eswaran V. Policy Prescriptions STAT*Sheets: Who Are the Uninsured? May 2014. Kaiser Commission on Medicaid and the Uninsured. Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion? June 2015. Majerol M et al. The Uninsured: A Primer – Key Facts About Health Insurance and the Uninsured in America. Kaiser Family Foundation 2015; Jan 13. Nardin R et al. The Uninsured After Implementation of the Affordable Care Act: A Demogrpahic And Geographic Analysis. Health Affairs Blog 2013; June 6. Sommers B et al. Health Reform and Changes in Health Insurance Coverage in 2014. N Engl J Med 2014;371:867-874.