Who Will Be Uninsured After Health Insurance Reform?

Abstract

National health reform will expand insurance coverage by about 30 million people, reducing the number of uninsured by more than half. In this report, the authors analyze the likely composition, state by state, of those who will remain uninsured. Of the nonelderly adults uninsured under national health reform, 37% would be eligible for Medicaid but not enrolled and 25% would be undocumented immigrants. Sixteen percent would be exempt from the individual mandate because they had no affordable insurance option. The authors find significant state and regional variation in the characteristics of the uninsured.

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Introduction

The Patient Protection and Affordable Care Act (ACA) will expand insurance coverage by about 30 million people. Although this still falls short of universal coverage, the number of uninsured people will be reduced by more than half. Safety net providers and programs, therefore, will still face the challenge of substantial numbers of uninsured who cannot afford a full range of needed services.

Even more than the number of uninsured, the composition of the uninsured will change substantially under the ACA, and accordingly, their reasons for being uninsured. Beginning in 2014, most Americans will be required to have health insurance coverage meeting certain minimum requirements and will be subject to financial penalties if they do not comply. Exemptions will also be granted if no affordable insurance coverage is available and for a variety of other specialized circumstances, such as people who are Native Americans, prisoners or have religious objections.1 Medicaid eligibility will expand greatly for adults in many states, but little or not at all for children. Due to CHIP, their eligibility levels for public coverage are already much higher than for adults. Undocumented immigrants are not subject to the mandate, nor are they eligible for Medicaid or for any federal subsidies.

This brief analyzes this changing composition, state by state, of those who will remain uninsured. This information can assist states and communities in health policy planning on several fronts, such as planning for expected demand in the new insurance exchanges. Most importantly, knowing how many and what kinds of people will remain uninsured will assist safety net providers, organizations, and support systems to determine ongoing needs for those who cannot afford access and optimal structures for addressing those needs.

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