Sara R. Collins

How Many Are Underinsured? Trends Among U.S. Adults, 2003 And 2007

With health insurance moving toward greater patient cost sharing, this study finds a sharp increase in the number of underinsured people. Based on indicators of cost exposure relative to income, as of 2007 an estimated twenty-five million insured people ages 19-64 were underinsured-a 60 percent increase since 2003. The rate of increase was steepest among those with incomes above 200 percent of poverty, where underinsurance rates nearly tripled. In total, 42 percent of U.S. adults were underinsured or uninsured. The underinsured report high levels of access problems and financial stress. The findings underscore the need for policy attention to benefit design, to assure care and affordability.

Health Care Coverage under the Affordable Care Act — A Progress Report

The Affordable Care Act encourages health insurance coverage through federal and state exchanges, Medicaid expansion, and other regulations that expand coverage. The authors estimate that so far 20 million Americans have gained coverage through one of these mechanisms.

Affordable Care Act Reforms Could Reduce The Number Of Underinsured US Adults By 70 Percent

To provide a baseline and assess the potential of changes brought about under the Affordable Care Act, this study estimates the number of US adults who were underinsured or uninsured in 2010. Using indicators of medical cost exposure relative to income, we find that 44 percent (81 million) of adults ages 19-64 were either uninsured or underinsured in 2010-up from 75 million in 2007 and 61 million in 2003. Adults with incomes below 250 percent of the federal poverty level account for sizable majorities of those at risk of becoming uninsured or underinsured. If reforms succeed in increasing the affordability of care for people in this income range, we could expect a 70 percent drop in the number of underinsured people and a steep drop in the number of uninsured people.

A shared responsibility: U.S. employers and the provision of health insurance to employees

Employer-based health insurance is the backbone of the U.S. system of health insurance coverage. Yet it has been slowly eroding, and if these trends continue greater numbers of Americans are likely to be uninsured or without affordable coverage. Employer coverage has marked advantages, including benefits to employers and a natural risk pool that offers better benefits at lower cost than individual coverage, and is highly valued by employees. The shift of health care costs from employers who do not cover their workers to other parts of the economy is substantial. Very little attention has been given to policies that might strengthen and expand employer coverage. It will be important to shore up employer coverage both to curb its recent erosion and to build toward a more comprehensive system of health insurance.

The Affordable Care Act and Health Insurance for Latinos

Individuals of Hispanic American or Latino origin are among many millions of Americans at high risk of lacking health insurance who are making considerable gains under the Affordable Care Act (ACA). Historically, Hispanic Americans/Latinos have been more likely to lack health insurance than any other ethnic or racial group. The full implementation of the ACA, however, could substantially reduce this disparity and has the potential to be one of the most important developments affecting Latino health care. Recent survey results from The Commonwealth Fund show that, at the end of the first open-enrollment period of the ACA, the uninsured rate for working-age Latinos decreased from 36% to 23% (Figure).1 Much of this decline has been concentrated among the young and the poor—groups with historically the highest rates of uninsurance. In comparison, the uninsured rate for nonHispanic white adults decreased from 16% to 12%. Recent federal surveys have also found declines in uninsured rates among Latinos early in 2014.2 The potential benefits for these newly insured persons are well established. Past insurance expansions have been associated with reduced mortality, improved mental health, and fewer episodes of bankruptcy.3,4 However, significant barriers complicate continued expansion of health insurance for Latinos under the ACA. First, language continues to pose a considerable obstacle. At the end of open enrollment, 30% of Latinos who primarily speak Spanish remained uninsured, compared with 19% of English-dominant Latinos.1 Second, comparatively few Latinos know about their new coverage options. By the end of the first enrollment period, only 50% of potentially eligible Latinos were aware of the insurance marketplaces compared with 74% of non-Hispanic whites, and only 29% of potentially eligible Latinos had visited a marketplace. Rates were even lower among Spanish speakers. Even though Latinos were less likely to visit the insurance marketplace than non-Hispanic whites, they were more likely to enroll in a health plan when they did.1 Third, state decisions not to expand eligibility for Medicaid under the law have had significant consequences for Latinos with the lowest incomes. In states that expanded Medicaid, the uninsured rate for Latinos decreased from 35% to 17%; in the 25 states without Medicaid expansion as of April 2014,5 the uninsured rate remained statistically unchanged (Figure).1 Twenty million Latinos live in these states that have not expanded Medicaid, including 14 million in Texas and Florida alone. As the second enrollment period of the ACA approaches, there are important lessons from the first enrollment period. Foremost is the need to dedicate sufficient resources to ensure that enough bilingual enrollment counselors are available for Latinos seeking information or wishing to enroll, including, although not limited to, the Spanish-language website for the federal marketplace.6 In addition, trusted organizations, such as churches and community groups, will be key venues for reaching Latinos potentially eligible for the law’s coverage options.7 Despite these remaining challenges, millions of Latinos are gaining new health insurance coverage and with it the financial ability to access health care when they need it. The increased access to affordable quality care will hopefully serve to improve the health and quality of life for millions of Hispanic Americans/Latinos in the United States. Michelle M. Doty, PhD, MPH The Commonwealth Fund, Survey Research and Evaluation, New York, New York.

State Health Insurance Exchanges: Progress and Challenges

By 2014, each of the fifty states and the District of Columbia will have a new health insurance exchange, or marketplace, established under the Patient Protection and Affordable Care Act. These exchanges are the centerpiece of the reform law: they will be the main portals where people who do not have health insurance coverage through their jobs and small businesses will go, either in person or online, to find a health plan and to learn about and apply for federal subsidies. The most immediate challenge facing all fifty-one exchanges is fulfilling their most basic role: ensuring that all who are eligible to enroll in qualified health plans and to receive federal subsidies in fact enroll.