Can we celebrate the decline in the numbers of uninsured?

In U.S., Uninsured Rates Continue to Drop in Most States

By Dan Witters
Gallup, August 10, 2015

The marketplace exchanges opened on Oct. 1, 2013, with new insurance plans purchased during the last quarter of that year typically starting on Jan. 1, 2014. Medicaid expansion among initially participating states also began with the onset of 2014. As such, 2013 serves as a benchmark year for uninsured rates as they existed prior to the enactment of the two major mechanisms of the healthcare law.

Nationwide, the uninsured rate fell from 17.3% in full-year 2013 to 11.7% in the first half of 2015.

Collectively, the uninsured rate in states that have chosen to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace has declined significantly more since 2013 than the rate in states that did not take these steps. The uninsured rate declined 7.1 points in the 22 states that implemented both of these measures by Dec. 31, 2014, compared with a 5.3-point drop across the 28 states that had implemented only one or neither of these actions.

Although the 22 states that implemented both mechanisms before Jan. 1, 2015, had a lower uninsured rate to begin with, the 7.1-point drop is larger than what is reported among the other 28 states, and represents a 44% decline since 2013 in the uninsured rate among adults residing there. The 5.3-point drop in the 28 states that have implemented one or neither of the mechanisms represents a 28% decline in uninsured rates. Still, the difference in the rate of decline in uninsured rates between the two groups of states has now leveled off, and is unchanged relative to the same 1.8-point gap in the rate of decline measured in midyear 2014.



By Don McCanne, MD

Although supporters of the Affordable Care Act (ACA) celebrate the reductions in the numbers of uninsured into the second year of plan enrollment, those of us who believe that everyone should be covered certainly do not have cause to celebrate.

Nationally, the rate of uninsured fell from 17.3% before ACA expansions were implemented to 11.7% after the second annual enrollment period. That is a decline in the uninsured of only 32%. Two-thirds of the numbers previously uninsured still remain uninsured.

Even in those states that cooperated with ACA by both expanding Medicaid and by establishing exchanges themselves or partnering with the federal government to establish exchanges still saw reductions in the uninsured of only 44% - less than half (a decline from 16.0% to 8.9%). Thus even the optimal results are disappointing. States that failed to cooperate saw even less of a decline in the uninsured - 28% (from 18.7% to 13.4%).

With two seasons of ACA implementation, the low fruit has been picked. With increasing penalties for remaining uninsured, a few more enrollees should trickle into the exchanges. Also some states missing in action will likely reluctantly expand their Medicaid programs. But even with optimistic estimates of the increases in participation, it is quite clear that far too many will remain uninsured.

The defect is in the design of the Affordable Care Act - an administratively complex, fragmented system that could never result in truly universal coverage, not to mention all of the inequities that it perpetuates. In contrast, a single payer system automatically enrolls everyone, while reducing inequities. That’s the design that we need.