We provide an overview of the characteristics of those who have gained insurance coverage due to the ACA as well as the characteristics of the remaining uninsured. We also describe the implications for the broader sharing of health care risks required under the law, and how they vary by individuals' health status. Finally, we assess the implications of state decisions to expand or not expand Medicaid eligibility under the law, how those decisions affect state finances, health care providers, residents, and how the effects may vary for those states using waivers to expand eligibility using strategies designed to be more broadly politically acceptable.
The 18 million estimate reflects the effect as of March 2015 (Blumberg, Garrett, Holahan 2016 Inquiry); the 20 million estimate reflects the effect as of March 2016, estimated using different methods by M. Buettgens, L.J. Blumberg, J. Holahan, and S. Ndwandwe, The Cost of ACA Repeal, The Urban Institute, June 2016, available at <http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000806-The-Cost-ofthe-ACA-Repeal.pdf> (last visited October 11, 2016) and by N. Uberoi, K Finelgold, and E. Gee, Health Insurance Coverage and the Affordable Care Act, 2010-2016, Washington: US Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, available at <https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-2010-2016> (last visited October 11, 2016).
Findings on the characteristics of the remaining uninsured here differ somewhat from those in our other recent work due to differences in data (Current Population Survey versus American Community Survey); differences in year of analysis (2015 versus 20106); the fact that the current work benchmarks to administrative data on enrollment in marketplaces and Medicaid, thereby adjusting for underreporting of public insurance, whereas the prior research did not; and the use of a simulation model in the current work rather than relying strictly on self-reported data. L. J. Blumberg, M. Karpman, M. Buettgens, and P. Solleveld, Who Are the Remaining Uninsured, and What Do Their Characteristics Tell Us About How to Reach Them? Robert Wood Johnson Foundation, March 2016, available at <http://www.rwjf.org/en/library/research/2016/03/who-arethe-remaining-uninsured--and-what-do-their-characteristi.html> (last visited September 28, 2016).
8.
Worker take-up of employer-sponsored insurance increased due to the ACA's individual mandate to obtain insurance coverage or pay a fine.
This last group includes those caught in the so-called “family glitch.” The ACA has been interpreted through regulation as prohibiting all family members from qualifying for marketplace premium tax credits if at least one member has an employer based insurance offer for single coverage with a direct worker contribution of less than 9.66 percent of income, regardless of the direct cost of family coverage.
11.
See Blumberget al., supra note 7.
12.
These include: prohibitions on lifetime and annual benefit limits, prohibitions on rescissions, first dollar coverage of in-network preventive care, utilization of uniform explanation of coverage documents and standardized definitions, requirements for appeals processes for claims denials, and extension of dependent coverage to adults under age 26.
13.
See Blumberget al., supra note 4.
14.
Many of these examples will apply to enrollees in the fully insured small group insurance market as well; however, extensions of ACA non-compliant plans through 2017 suggest that many of these individuals are still not enrolled in ACA compliant coverage.
Calculations based on The Cost of Not Expanding Medicaid using data for the following states that have yet to decide to expand Medicaid eligibility: Alabama, Florida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming. See J. Holahan, M. Buettgens, and S. Dorn, The Cost of Not Expanding Medicaid, The Henry J. Kaiser Family Foundation, July 17, 2013, available at <http://kff.org/medicaid/report/the-cost-ofnot-expanding-medicaid/> (last visited September 28, 2016).
According to a 2015 state survey conducted by the Kaiser Family Foundation, California, Colorado, Kentucky and Nevada reported they plan to increase provider taxes in order to fund some of the state share of expansion costs when the federal matching rate declines to 95% in 2017.
23.
See Holahanet al., supra note 18; Dorn et al., supra note 21.
