Health Law's Big Tent Still Leaves Some People Out

Dec 4, 2014
Originally published on December 4, 2014 5:57 am

A Shots post earlier this week by NPR's John Ydstie detailed the "family glitch" in the Affordable Care Act. That's where people who can't afford their insurance at work aren't eligible for help in the new insurance exchanges. Many of these Americans, most of whom make middling incomes, will remain uninsured.

That story got us wondering: Who else is getting left out by health law? And who is getting coverage?

Official government statistics won't be out until next year, but several other surveys, including one out just this week from the Urban Institute, all agree that between September 2013 and September 2014, the percentage of adults who are uninsured dropped by about by about a third. That translates into about 10 million more people getting health insurance during the year.

That number is considerably larger than the just under 7 million or so people reported to have bought coverage at a health exchange. The difference arises because some customers buying from an exchange were people who previously bought their own insurance. They weren't uninsured, but their plans might have been newly canceled, or they shopped in the exchanges to get a subsidy. There were also several million who got coverage through the Medicaid program in states that opted to expand it. And some people picked up job-based coverage as the economy continued to improve.

A series of surveys looking at who got coverage found that the biggest gains have come among groups that had the lowest rates of insurance. These groups include young adults, who are just starting out in the job market, people of color, people in states that expanded their Medicaid programs, people with lower incomes, and people in rural areas.

Another interesting trend is that the uninsured rate fell more for women than for men. That's a little unexpected because the Medicaid expansion allows low-income men who aren't parents to qualify for the first time. Women who are pregnant or mothers of young children have long been eligible, so there was a bigger pool of uninsured men who could gain coverage.

Who does this leave out?

Several diverse groups. The biggest is probably undocumented immigrants. They are not eligible, by law, to purchase coverage in the health exchanges and, in most cases, they're not eligible for Medicaid. It's also worth mentioning that President Obama's executive order from last month didn't make any new immigrants eligible for health benefits under the Affordable Care Act.

The next big group is adults with low incomes who aren't disabled and aren't parents and who live in the 23 states that haven't expanded the Medicaid program. The law was written to extend Medicaid to all low-income people, so you're not eligible to buy coverage on the exchanges if your income is under the federal poverty line, which is about $11,700 for an individual this year.

In 2012 the Supreme Court ruled that the Medicaid expansion was optional; a little under half the states have opted to decline the federal government's offer to pay nearly all the cost of that expansion. Those states — including Texas, Florida, and Georgia — have, all told, several million residents in the Medicaid gap.

Then there are the people who fall into the so-called family glitch. They can theoretically afford their own, individual coverage, but find that insuring the rest of the family is too expensive. Yet, because of the way the law is written, those family members aren't eligible for subsidies in the exchanges.

And, finally, there are people who don't want coverage (and particularly don't want to be required by the government to buy it), and other people who still don't know that if they don't get health insurance one way or another, they may have to pay a fine next year.

In fact, many of those who remain uncovered won't have to pay any fines. There are lots of exceptions to the rules for who will have to pay tax penalties for not having coverage. People who are undocumented are exempt, as are people who don't earn enough to have to file federal income taxes. Also you're exempt if the least expensive insurance would cost more than 8 percent of your income. And there are other case-by-case exemptions for people who can claim financial hardships.

The bottom line is this: Framers of the health law never expected it to cover everyone. Instead, their aim continues to be to get the insured rate up to around 90 percent.

This story is part of an NPR partnership with Kaiser Health News.

Copyright 2019 Kaiser Health News. To see more, visit Kaiser Health News.


We are also, this morning, following up on a story about Obamacare. We heard this week on the program about people who are stuck. They make too much money to qualify for insurance subsidies but not enough to buy insurance for their families. Suzanne Shugart's (ph) husband can afford insurance for himself through his job but...

SUZANNE SHUGART: If you were to increase it to a family plan, which would include me, it goes up to about $380 a month, which is nearly our mortgage payment.

INSKEEP: More than they can afford. So let's run some numbers. Obamacare was supposed to address a problem - tens of millions of people with no health insurance. And let's ask how it's doing with the Julie Rovner now at Kaiser Health News. Hi, Julie.


INSKEEP: So how many more people are covered in America since the start of this year when the law took full effect?

ROVNER: Well, it seems to be about 10 million or so adults - nonelderly adults. We don't know all the specific numbers, but generally there have been a lot of surveys over the course of the year, and they all seem to pretty much agree on that number, and also that that's about 5 percentage points lower in the percentage of the population that doesn't have insurance.

INSKEEP: OK. Ten million more people have insurance than had it at the beginning of the year. Generally speaking, who are they?

ROVNER: Well, they're people who went to the health exchanges and bought insurance who didn't have coverage before.

INSKEEP: Oh, those websites we've heard so much about, sure.

ROVNER: That's right. They're people who got expanded Medicaid. Medicaid's been expanded in a little more than half the states. And there are people who just got jobs with health insurance. Remember the economy is getting better so some of those people actually may have bought insurance on the exchange and left the exchange because they got a job and health insurance.

INSKEEP: Oh, now that's really interesting. So you're saying that there're 10 million more people with health insurance this year, but that's not just about Obamacare. Part of it is the improving economy?

ROVNER: Indeed. We don't know exactly what - how the numbers relate to each other, but yes.

INSKEEP: So 10 million extra nonelderly adults are insured along with a - some number of children. It's not clear exactly how many. But, Julie Rovner, we used to hear about more than 40 million people in this country who are uninsured. There must be tens of millions of people who are still not insured.

ROVNER: Well, there are several sort of discrete groups of people who still lack insurance. And remember this is a work in progress. But some of those groups will probably continue to lack insurance. The biggest one are people - are undocumented immigrants. They are not eligible to purchase insurance in the exchanges with or without a subsidy. And for the most part, they're also not eligible for Medicaid.

INSKEEP: Undocumented immigrants. Who else?

ROVNER: Well, the next big group are adults with low incomes who are in the states that did not expand Medicaid. So almost half the states that didn't expand Medicaid to what they call able-bodied adults, adults with disabilities, do get Medicaid.

INSKEEP: Are there other big groups who are not insured here?

ROVNER: Yeah, as we heard earlier this week, there's people in what's called this family glitch where the individual who has the job can afford his or her insurance, but if you add the cost of family coverage to that, it becomes unaffordable. But because the individual has an offer of coverage from the employer, the family is not eligible for subsidies on the exchange, and so therefore, insurance is too expensive on the job, too expensive in the exchanges. And those people can't afford insurance.

INSKEEP: So will all of these people - and it may be tens of millions of people uninsured at this point - will all of them be subject to fines under Obamacare?

ROVNER: Actually, most of them won't. There are a lot of exceptions to the rules for who's going to have to pay those tax penalties for not having insurance. People who are undocumented are exempt, also are people who don't earn enough money to have to file federal taxes. You're also exempt if the least expensive insurance would cost more than 8 percent of your income, and there other case-by-case exemptions for people who can claim financial hardships.

INSKEEP: OK, so what does it say about Obamacare that 10 million adults and some number of children are insured additional people here, but tens of millions still are not?

ROVNER: Well, a couple of things. First of all, this was just the first year - was expected always to take four, five years for it to fully cover the people that it was expected to, but this law was never expected to cover everyone. I think it was anticipated that when everything is fully implemented, about 90 percent of the population would have health insurance. But there was always going to be some number of people who weren't.

INSKEEP: Julie, thanks very much.

ROVNER: Thank you.

INSKEEP: That's Julie Rovner of Kaiser Health News. Transcript provided by NPR, Copyright NPR.