Uncovering Who's Not Covered After the ACA's Second Open Enrollment Period

May 5, 2015

Topics: Health Care Reform, Uninsured

By Rachel Schulze, Staff Writer

From September 2013 to March 2015, the percentage of nonelderly U.S. adults without health insurance dropped from 17.6% to 10.1%, according to Urban Institute Health Reform Monitoring Survey data. In that time, some of the Affordable Care Act's major efforts to expand coverage access -- insurance exchanges, subsidies to offset coverage costs and broadened Medicaid eligibility -- have taken effect. Those efforts have brought about "broad gains" in rising rates of people who are insured "across ... different demographic, economic and social groups," according to Urban Institute researcher Sharon Long.

And yet millions still remain uninsured, according to HHS data. Who are those millions? And what do we know about why they are still uninsured? American Health Line looked at the data and spoke with experts to find out.

Ed. Note: This feature is being released in conjunction with a new analysis of data from the Urban Institute's Health Reform Monitoring Survey, which provides a detailed look at the current uninsurance picture.

Who Is Still Uninsured Under the ACA?

Despite those gains, the age, racial/ethnic and income groups that had the lowest rate of being insured in September 2013 were the same in March 2015. 


Age-wise, young adults continue to have highest rate of uninsurance. Currently, 13.5% of young adults are uninsured, compared with 11.1% of adults ages 31 to 49 and 6.2% of adults ages 50 to 64, according to the Urban Institute data.  

"I don't know that there's a surprise, but given the emphasis on trying to get young adults coverage ... they still have a fairly high uninsurance rate," Long said, noting that young adults tend to be healthier and have incomes lower than the general population's. She added, "But they are a tough group to reach."

Sara Collins, vice president of health care coverage and access at the Commonwealth Fund, said that while young adults have higher uninsured rates than older age groups, they have seen a substantial drop in their rate of uninsurance. According to the Urban Institute data, nearly one-quarter of young adults were uninsured as of September 2013.

HHS data show a decline in uninsured young adults that began in 2010, when an ACA provision took effect that allows dependents to stay on their parents' plans until age 26.


Nearly one-quarter -- 22.7% -- of non-elderly adults with family incomes at or below 138% of the federal poverty level are still uninsured, according to the Urban Institute data. By contrast, 8.6% of those with incomes between 139% and 400% of poverty level are uninsured, and the rate drops to 1.9% among those with incomes above 400%.

Long noted that many of the uninsured with incomes under 138% of poverty level are in states that have not expanded Medicaid.  Meanwhile, such individuals "do tend to have lower educational attainments, less attachment to the workforce, and so are less likely to be exposed to some of the information around the ACA," diminishing the chances they will obtain coverage even in states that have expanded Medicaid, according to Long.

Urban Institute data show the percentage of low-income adults without insurance is nearly twice as high in states that have not expanded in Medicaid compared with states that have. According to the data, 31% of low-income adults in non-expansion states do not have insurance, compared with 16.7% in expansion states.

Overall, the rate of uninsurance is 7.5% in expansion states, versus 14.4% in non-expansion states, according to Urban Institute.

Race & Ethnicity

Looking at different racial and ethnic groups, the uninsurance rate among Hispanics -- which Urban Institute puts at 20.7% -- is nearly twice the rate among blacks, which is 10.4%, and nearly triple the rate among whites, 7.2%.

"Part of that is driven by the fact that people who are undocumented are not eligible for either Medicaid or marketplace coverage," Long said, adding, "It also reflects differences in state approaches to expanded Medicaid programs. And, likely, some language and awareness barriers."

She noted that while Hispanics have a higher rate than whites and blacks, the rate among Hispanics is down by about 40%, from 35.5% in Urban Institute's September 2013 estimate. 

Regarding differences among states, Commonwealth Fund researchers in a recent analysis pointed out a discrepancy in Latino uninsured rates between states that have expanded Medicaid under the ACA (26%) and states that have not (46%).

The researchers wrote that California, with 14 million Latino residents, "provides a road map of what states can do to improve insurance coverage among Latinos," noting a Kaiser Family Foundation survey that found about half of Latinos who previously were uninsured gained coverage over the first open enrollment period. The Commonwealth researchers explained that California:

  • Does not impose a five-year waiting period on coverage eligibility for documented immigrants;
  • "Historically has had generous eligibility levels for Medicaid coverage" and expanded the program under the ACA; and
  • Is investing in outreach to Spanish-speaking residents.

Jennifer Sullivan, director of Enroll America's Best Practices Institute, noted the role that in-person assistance can play in enrollment efforts. She said, "Overall, we know that people who get in-person help are far more likely to successfully complete the enrollment process," adding, "But this is particularly true among certain communities, certain populations, particularly the Latino population that has definitely expressed an interest in seeking out in-person help at a higher rate."

What We Know -- And What We Don't

Looking at subgroups that continue to have the highest rate of uninsurance, Long noted that there are "common characteristics across those that are uninsured." She said, "What we know with the uninsured now, as well as the uninsured before the ACA started and the last open enrollment period is the most common factor, the reason reported for being uninsured, is cost," adding, "What we don't know is whether they actually know what it would cost … or whether it's just an expectation that they can't afford it."

Along those lines, Sullivan said, "What we find is that people tend to believe that coverage is not affordable, despite the fact that there's financial help available; they often don't know or they haven't ever gotten a personalized estimate of exactly what that might mean for them, how much coverage would actually cost them, given their income, given where they live."

According to Long, many who remain uninsured appear to qualify for either Medicaid or a subsidy to purchase coverage through the exchanges.

A Kaiser Family Foundation report from the end of 2014 found that 48% of respondents said cost was the main reason they remained uninsured, making it the most commonly cited factor. The same report found that 53% of those citing cost as the main reason for being uninsured appeared to be eligible for some kind of ACA assistance.

"I think that's the next piece: understanding when people talk about cost, how aware are they of what the actual cost would be," Long said.

Meanwhile, Sullivan said awareness "not surprisingly" is a "key driver" of whether people get covered. "The uninsured by and large when we survey them, we find that they understand the value of health insurance." She added, "They want to have it for themselves, but they think it's unaffordable in most cases."

Sullivan pointed out that those who are uninsured might be interested in learning more about coverage options after facing the penalty for not having coverage for the first time this tax filing season.

Factors in Flux

Meanwhile, the dynamics of who is uninsured could change in the coming months.

Namely, the coming Supreme Court ruling in King v. Burwell, in which the court will decide whether millions of federal exchange customers can continue receiving subsidies, could lead the number of uninsured to increase by 8.2 million, according to an Urban Institute estimate.

In addition, while the federal exchange's second open enrollment period has ended, the number of uninsured residents is still in flux, as some as some federal -- and state exchange -- customers have been able to enroll through special enrollment periods.

Wrapping Up

Millions of U.S. residents still do not have coverage, eliciting broad questions about affordability and awareness remain. Further, in looking at who is still uninsured, researchers face specific questions about those residents' health care needs, primary language and specific location within states, according to Long. Regardless, while questions remain about who is uninsured and why, one factor seems settled: "We don't see very many people saying they don't want health insurance," Long concluded.