The marked gains in health insurance coverage made since the passage of the Affordable Care Act (ACA) in 2010 are beginning to reverse, according to new findings from the latest Commonwealth Fund ACA Tracking Survey. The coverage declines are likely the result of two major factors: 1) lack of federal legislative actions to improve specific weaknesses in the ACA and 2) actions by the current administration that have exacerbated those weaknesses. These include the administration’s deep cuts in advertising and outreach during the marketplace open-enrollment periods, a shorter open enrollment period, and other actions that collectively may have left people with a general sense of confusion about the status of the law. Signs point to further erosion of insurance coverage in 2019: the repeal of the individual mandate penalty included in the 2017 tax law, recent actions to increase the availability of insurance policies that don’t comply with ACA minimum benefit standards, and support for Medicaid work requirements.
In this post, and another soon to follow, we will look at people’s recent experiences with their insurance coverage and the affordability of their health insurance and health care.1 The ACA Tracking Survey is a nationally representative telephone survey conducted by SSRS that tracks coverage rates among 19-to-64-year-olds and has focused in particular on the experiences of adults who have gained coverage through the marketplaces and Medicaid. The latest wave of the survey was conducted between February and March 2018. Forthcoming results from large federal surveys like the National Health Interview Survey will shed more light on the trends our survey has identified.2
Findings
Uninsured Rate Among Working-Age Adults Is Up Significantly Since 2016
The uninsured rate among working-age people — that is, those who are between 19 and 64 — is at 15.5 percent, up from 12.7 percent in 2016, meaning an estimated 4 million people lost coverage (Tables 1 and 2). Rates were up significantly compared with 2016 among adults with lower incomes — those living in households earning less than 250 percent of poverty (about $30,000 for an individual and $61,000 for a family of four).
Uninsured rates were also up significantly among adults living in the 19 states that have not yet expanded their Medicaid programs.
. . . and among adults ages 35–49 and 50–64.
The uninsured rate among adults who identify as Republicans was also up significantly, rising from 7.9 percent in 2016 to 13.9 percent in the current survey period. The uninsured rate among those who identify as Democrats stood at 9.1 percent, statistically unchanged from 2016.
One of five adults living in the South were uninsured, up significantly from 16 percent in 2016. Adults were uninsured at a higher rate in southern states than they were in the Northeast, Midwest, and West.
Five Percent of Insured Adults Plan to Drop Insurance Because of the Individual Mandate Repeal
Congressional Republicans’ 2017 tax bill repealed the penalty people currently owe on their income taxes if they do not have health insurance, effective in 2019. About 60 percent of all adults were aware that the tax bill had included a repeal of the penalty (data not shown). Among adults with insurance coverage, 9 percent of those who got their insurance through the individual market, 5 percent of those with employer coverage, and 5 percent of those with Medicaid said they intended to drop insurance because of the change (Table 3).
Policy Implications
If bipartisan agreement regarding the ACA were possible in Congress, there are several policy options available that have the potential to increase health insurance coverage. These include:
- providing financial support for advertising to improve awareness of coverage options in all states,
- improving health plan affordability in the individual market, and
- ensuring each market has a participating insurer.
Senators Susan Collins (R-Maine) and Bill Nelson’s (D-Fla.) bill to provide reinsurance for the marketplaces is one such example. Senator Elizabeth Warren (D-Mass.) recently introduced a bill that would enhance marketplace premium and cost-sharing subsidies, and require private insurers that participate in Medicare and Medicaid to offer plans in the marketplace. Christine Eibner and Jodi Liu of RAND modeled six incremental options to reduce individual market premiums and increase coverage, including extending premium tax credits to those above the income eligibility threshold and creating a federal reinsurance program. Each policy the researchers modeled increased coverage and affordability with either a minor cost to the deficit or, in the case of reinsurance, significant deficit savings.
Other policymakers have introduced legislation that would cover more people through Medicare. Senators Michael Bennett (D-Col.) and Tim Kaine (D-Va.) are proposing that a Medicare plan open to people under age 65 be offered through the marketplaces. Senators Jeff Merkley (D-Ore.) and Chris Murphy (D-Conn.) go further by also allowing fully insured employers to offer a Medicare plan to their employees, enhancing marketplace subsidies, and lowering out-of-pocket costs for current Medicare beneficiaries. Senator Brian Schatz (D-Hawaii) introduced legislation last year that would establish a state public plan option through the Medicaid program.
In the absence of bipartisan support for federal action, legislative activity has shifted to the states. Eight states have received, or are currently applying for, for federal approval to establish reinsurance programs in their states. Hawaii, New Jersey, Vermont, and the District of Columbia may ultimately join Massachusetts in establishing a state individual mandate. Massachusetts and Vermont are providing additional subsidies for people in marketplace plans. At least one state, New Mexico, is exploring options to allow residents to buy into Medicaid. Of the 19 states without Medicaid expansions, some, like Virginia, appear poised to expand this year; expansion may be on the ballot in as many as four states this fall.
The shift to states carries risks, as well as potential benefits, for consumers. Both Idaho and Iowa are pursuing changes in their individual markets that might make insurance cheaper for some people, but leave them exposed to potentially high out-of-pocket costs if they become seriously ill or injured. These changes also will increase premiums for those who buy comprehensive plans. Similarly, experiments with Medicaid work requirements in at least 12 states are expected to depress enrollment. More broadly, leaving policy innovation to states will ultimately lead to a patchwork quilt of coverage and access to health care across the country, a dynamic that will fuel inequity in overall health, productivity, and well-being. At some point, Congress will likely face pressure to step in to level the playing field.
How We Conducted This Survey
The Commonwealth Fund Affordable Care Act Tracking Survey, February–March 2018, was conducted by SSRS from February 6 to March 30, 2018. The survey consisted of telephone interviews in English or Spanish and was conducted among a random, nationally representative sample of 2,403 adults, ages 19 to 64, living in the United States. Overall, 131 interviews were conducted on landline telephones and 2,272 interviews on cellular phones.
This survey is the seventh in a series of Commonwealth Fund surveys to track the implementation and impact of the Affordable Care Act. To see how the survey was conducted in prior waves, see here.
As in all waves of the survey, the February–March 2018 sample was designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. Interviews in Wave 7 were obtained through two sources: 1) stratified RDD sample, using the same methodology as in Waves 1–6; and 2) households reached through the SSRS Omnibus where interviews were previously completed with respondents ages 19 to 64 who were uninsured, had individual coverage, had a marketplace plan, or had public insurance. SSRS oversampled adults with incomes under 250 percent of the federal poverty level to further increase the likelihood of surveying respondents eligible for the coverage options as well as allow separate analyses of responses of low-income households.
The data are weighted to correct for oversampling uninsured and direct-purchase respondents, the stratified sample design, the overlapping landline and cellular phone sample frames, and disproportionate nonresponse that might bias results. Similar to wave 6’s sample design, the weights also corrected for oversampling respondents with a pre-paid cell phone. The data are weighted to the U.S. 19-to-64 adult population by age by state, gender by state, race/ethnicity by state, education by state, household size, geographic division, and population density using the U.S. Census Bureau’s 2016 American Community Survey. Data are weighted to household telephone use parameters using the CDC’s 2016 National Health Interview Survey (NHIS).
The resulting weighted sample is representative of the approximately 190 million U.S. adults ages 19 to 64. Data for income, and subsequently for federal poverty level, were imputed for cases with missing data, utilizing a standard general linear model procedure. The survey has an overall margin of sampling error of +/– 2.8 percentage points at the 95 percent confidence level. The overall response rate, including the prescreened sample, was 7.5 percent.
