The Lingering Gap: 10 Reasons 30 Million Remain Uninsured

Millions of previously uninsured people have gained access to health care insurance thanks to the Affordable Care Act (ACA). While the second enrollment period for insurance markets is winding down, there are still plenty of Americans who do not have health insurance. More than 30 million non-elderly adults are without healthcare coverage.

But who are the still-uninsured, and why do they not have coverage under the ACA? The Kaiser Family Foundation did a survey of the non-elderly population that is uninsured at the end of 2014 to discover the barriers to access. More than 10,500 people were surveyed, and the results indicated several key areas where state and federal workers can improve their outreach to the uninsured.

The survey also debunked several myths widely held about the ACA and its implementation. While the bumps involved with Healthcare.Gov’s launch last year were well reported, gathering proper documents and finding where to get coverage were much greater obstacles in application. Also, the so called “young invincibles” were less likely to be uninsured than their older, less-healthy counterparts. With younger adults getting insured more readily, concerns about a large pool of newly insured persons that have expensive health concerns is a non-issue.

With the 2015 enrollment period coming to an end, here's a look a look at some of the foundation’s research. Here are 10 facts from KFF about the uninsured population discovered through their survey.

1. One-fifth of the remaining uninsured population is young adults.

By fall of 2014, of the remaining uninsured adults, 22% were between the ages of 19 and 25. KFF attributes this to the lack of jobs with employer-sponsored insurance available to recently-graduated entrants to the job marketplace.

Critics worried that young people would not sign up for healthcare coverage, therefore leaving a more expensive pool of insured people. Among the uninsured, roughly half are under the age of 35. But among people who gained coverage in 2014, since the enactment of the major ACA provisions, nearly half are under 35 as well.

2. More than half of the uninsured population would qualify for Medicaid in states that expanded their coverage.

More than 15 million people who did not gain insurance coverage in 2014 have a family income of 138% of poverty or lower, which would qualify them for Medicaid coverage under the ACA expansion guidelines. The poverty level in 2014 for a family of four is an income of $32,913 or less.

Fifteen states have outright declined to expand Medicaid coverage up to 138% of the poverty level, and 7 states are still in discussions about expansion as of January 2015.

3. Seventy-seven percent of the remaining uninsured do not have access to employer-based coverage.

The majority of those without access to employer-based coverage are self-employed or unemployed, while 27% are employed at a business that does not offer health insurance benefits. About 17% of the uninsured declined their employer-based insurance, either because of unaffordable premiums or other reasons.

4. The uninsured are more likely to be in poor health but not to have a diagnosed condition.

Continually insured people rate themselves in poor-to-fair health about 18% of the time, and newly insured people self-report in this category at a rate of about 27%. But 36% of the uninsured say their health is poor-to-fair. They are also more likely than any other group to report poor-to-fair mental health.

On the other hand, the uninsured are less likely than their insured counterparts to self-report having an ongoing condition or taking a prescription. According to KFF, “these patterns may reflect the fact that uninsured individuals are more likely than insured to have undiagnosed illnesses, and people with insurance coverage are more likely to receive regular and specialty care.”

5. The majority of uninsured people are minorities.

Thirty percent of the remaining uninsured population is Hispanic, 15% is African American, and 9% identifies as another ethnicity/race. In contrast, 34% of adults who are continuously insured are minorities. A report by the Pew Research Center shows that Hispanic immigrants are more likely than US-born Hispanics to be uninsured.

6. Half of the remaining uninsured are eligible for financial assistance under the ACA.

“Based on family income, state of residence, citizenship status, parent status, and access to employer coverage, analysis indicates that 48% of uninsured adults may be eligible for Medicaid coverage or premium tax credits to purchase Marketplace coverage,” according to KFF. Roughly 18% percent of uninsured people are in the “coverage gap,” with incomes too high for Medicaid and too low for financial assistance, 14% are ineligible due to immigration status, and 17% have income too high to qualify for any assistance or access to employer-sponsored insurance.

7. For nearly half of the uninsured, the greatest barrier to coverage is cost.

Despite all of the financial assistance programs available, many Americans still find health insurance to be too expensive. Of the adults surveyed by KFF, 48% responded that cost was the main reason they did not get health insurance in 2014. Other interesting responses included 6% of respondents saying they didn’t need health insurance, and 3% indicating they disagreed with the ACA and preferred to pay the penalty for going without.

8. The majority of the uninsured did not try to get coverage through the ACA in 2014.

Whether through Medicaid, state-run insurance marketplaces, or Healthcare.gov, 63% of people who are uninsured did not try any of these ACA avenues to gain coverage in 2014. This is despite 53% of the people who said insurance was too expensive being eligible for financial assistance through the ACA provisions above. KFF says this indicates that “the availability of financial assistance to offset the cost of coverage is not getting through.”

9. Thirty-seven percent of people who were eligible for financial assistance in 2014 were told they were ineligible while applying for coverage.

Confusion, misinterpretation, and lack of awareness of other opportunities resulted in 37% of uninsured people who were eligible for financial assistance and tried to obtain insurance being told they were not eligible. KFF says some of this discrepancy could be from changing eligibility status from when a person applied to when they were surveyed, but most likely it resulted from being told of ineligibility for one type of assistance while being eligible for another.

10. Two-thirds of adults who unsuccessfully tried to get coverage under the ACA in 2014 reported having difficulty with at least one aspect of applying.

The rollout of Healthcare.gov was disastrous, causing headaches for anyone trying to find coverage at the beginning of the first open enrollment period. But difficulty in applying was not limited to accessing the website. Among the issues cited most often, assembling the required paperwork was difficult for 41% of respondents, while filling in the information requested was an issue for 36%. Other complications included actually submitting the application (36%) and finding out how to apply in the first place (34%). Less than 20% of uninsured adults cited difficulties with the application process as a reason for not having coverage, but “people who had difficulty applying maybe less likely to seek coverage again.”