While the rate of increase in enrollment has slowed, it is too early to determine whether Marketplace enrollment has leveled off.
What’s the Issue?
The uninsurance rate for nonelderly adults increased in the decade before the passage of the Affordable Care Act (ACA), driven by declining rates of employer-based coverage, especially during the recession at the end of the decade. The ACA was intended to decrease the percentage of the population without health insurance and to provide “quality, affordable health care for all.” The purpose of this brief is to consider how uninsurance rates are changing under the ACA.
The decline in the uninsurance rate from 2013 to 2014 when most coverage provisions went into effect is one measure of the ACA’s effect on providing “quality, affordable health care for all.” What remains to be seen is whether the uninsurance rate continues to decline in the coming years. Early release of NHIS data is promising. In 2015, 10.5 percent of the nonelderly population was uninsured. Overall, Gallup data indicate that an estimated twenty million adults have gained coverage since 2010, although not all of that decline can be attributed to the ACA and might be a result of the improving economy.
About 12.7 million people were enrolled in a Marketplace plan at the end of the third open enrollment period, up from 11.7 million at the end of the second enrollment period and 8.0 million at the end of the first open enrollment period. However, history has shown that not all people who select plans will pay their premiums to keep them, so the number of enrollees is expected to decrease throughout the year because of attrition. While the rate of increase in enrollment has slowed, it is too early to determine whether Marketplace enrollment has leveled off.
Despite the increased penalty in 2016 for not having insurance, the remaining uninsured people might be hard to enroll. In addition, a significant number of the remaining nonelderly uninsured people (about thirty-three million as of March 2015, according to the CPS) are likely ineligible for either Medicaid or subsidized plans through the Marketplace because they are undocumented immigrants. Recent briefs by the Henry J. Kaiser Family Foundation and Urban Institute estimate that between 15 percent and 16 percent of currently uninsured people are ineligible for coverage because of immigration status. The board of Covered California just proposed allowing undocumented immigrants to purchase unsubsidized health insurance through the California Marketplace, a move that will require state and federal approval before taking effect.
Finally, many of the states with the largest number of uninsured people have publicly expressed no intention at this time to expand Medicaid, leaving many poor adults without access to financial assistance for purchasing coverage. While improved outreach is crucial to reaching uninsured people who are eligible for Medicaid or subsidized Marketplace insurance but have not yet taken up coverage, continued progress in reducing the ranks of the uninsured will also depend on federal and state policy changes that expand the number of people who are eligible for assistance and ensure that assistance is sufficient to make coverage affordable.