October 2, 2020 Christopher Holt
Last week we looked at the impact of
the COVID-19 pandemic on insurance coverage in 2020, and while good data are
still hard to come by, we are increasingly getting a clearer picture of the
state of health insurance coverage in 2019. As many progressives
continue to clamor for expanded federal health programs ranging from expansions
of the Affordable Care Act (ACA) all the way to single-payer “Medicare for
All,” it’s important to have a firm grasp of the actual experience of the
uninsured to know how to target programs effectively.
Recently the Census Bureau released its annual
Health Insurance Coverage in the United States report for
2019, detailing the results of the Current Population Survey Annual Social and
Economic Supplement (CPS ASEC) and the American Community Survey (ACS).
Then, this week, the Congressional Budget Office (CBO) issued a report providing
a close examination of who went without insurance in 2019. Together these
reports provide helpful insights into who is actually uninsured and why.
According to the CPS ASEC survey, in 2019, 26.1
million people residing in the United States were uninsured for the entire
year. The ACS survey found similar but slightly higher uninsured numbers with
29.6 million respondents reporting being uninsured at the time they were
interviewed. CBO’s finding was virtually the same as in the ACS, estimating
that 29.8 million Americans, or 12 percent of the under-65 population, were
uninsured in 2019.
According to CBO, of the
29.8 million people who were uninsured in 2019, 20 million (or 67 percent) were
eligible for some type of subsidized coverage of which they did not avail
themselves. Of those, 5.1 million were eligible for Medicaid or CHIP—2.2
million because of the ACA’s Medicaid expansion. Another 5.5 million were
eligible for subsidized coverage through the ACA’s exchanges. Finally, 9.4
million were eligible for employer-sponsored insurance (ESI).
Looking at the 9.8 million
uninsured people who did not have access to subsidized coverage in 2019, they
fall into three buckets: those with incomes too high to qualify for government
assistance (2.6 million), those in non-Medicaid expansion states with income
too low to qualify for ACA subsidies (3.2 million), and those who are not
lawfully present in the United States (4 million). CBO
speculates that the primary reasons people remain uninsured are cost or being
unaware of the options available to them. Regarding cost, CBO found that a
third of those without insurance coverage in 2019 would have had to pay more
than 10 percent of their income to obtain insurance. Of note, this correlates
to the share of the uninsured who did not qualify for subsidized coverage in
2019. CBO also estimates that the number of uninsured will increase by roughly
1 million in 2020, suggesting the COVID-19 pandemic has not been as detrimental
to insurance coverage as had been feared.
As policymakers,
particularly on the left, press for ever more expansive federal health
programs, it’s worth noting that the problem is relatively narrow. Of the
12 percent of U.S. residents that CBO estimates to be uninsured, 67 percent had
subsidized coverage options. Before rolling out new entitlement programs,
policymakers should focus on why those people are forgoing viable coverage
options. The problem of the 4 million uninsured individuals not lawfully
present in the United States is a broader challenge involving immigration
policy, among others, but as federal assistance does not extend to those not
lawfully present, a public option, Medicare Buy-In, or single-payer system
won’t address that population’s needs. Regarding those with incomes too high to
qualify for subsidized coverage, it’s important to note that the ACA’s
supporters capped subsidies at 400 percent of the federal poverty level.
Individuals and families above that level can still procure individual market
coverage, with all the ACA’s protections, if they desire, but they make enough
money that Congress has deemed them capable of paying for it themselves.
The challenge, then, is the
3.2 million people, out of 328.2 million, living in non-expansion states. This
subset is where policymakers should focus, and it should not require a total
remaking of the American health care system to help them.
Read more: https://www.americanactionforum.org/weekly-checkup/scoping-who-needs-help-with-health-insurance-coverage/#ixzz6a4dSPfNp
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