The ACA as a Survivor

Number of uninsured dwindles as ACA takes hold


Robert Calandra

Government and other surveys are showing that the number of Americans without health insurance is dwindling, with credit going to the expansion of Medicaid and the ACA insurance exchanges.

Nothing is free in this world, however. After a lull, related in part to the 2008 recession, health care spending is picking up again partly because the ACA has successfully expanded insurance coverage. In July, CMS actuaries projected that health care spending will increase, on average, by 5.8% over the next decade.

Data collected in the CDC’s National Health Interview Survey show that the percentage of adult Americans, ages 18 to 64, without insurance decreased from 22.3% in 2010 to 13% during the first three months of this year.

Percentage of adults aged 18–64 who were uninsured at the time of interview, by age group: United States, 2010–March 2015

The CDC data show a shift toward public insurance, which includes Medicaid, Medicare, the CHIP program, and military plans. Of those with insurance this year, 18.1% had public insurance compared with 15.9% in 2010.

Percentage of adults aged 18–64 who were uninsured at the time of interview, by poverty status: United States, 2010–March 2015

*Income below the federal poverty level (FPL)

**Income between 100% and 200% of FPL (inclusive of 100% of FPL)

Sources: CDC, “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2015,” Aug. 15, 2015; Gallup-Healthways Well-Being Index, Aug. 10, 2015

This survey data also shows that young adults are twice as likely to be without insurance as middle-aged adults (18.3% vs. 9%). That tilt is not surprising but is a problem for insurance markets because young people are less expensive to insure and their participation can help keep premium costs down.

A survey done for the Gallup-Healthways Well-Being Index paints a picture similar to that of the CDC. The survey shows that the percentage of Americans without health insurance fell from 17.3% in 2013 to 11.7% in the first half of this year. Randomly selected adults were asked: “Do you have health insurance coverage?” Sample sizes ranged from 232 in Hawaii to 8,600 in California.

States that went all-in and expanded Medicaid as well as set up an exchange by Dec. 31, 2014, saw the greatest decrease in the uninsured rate: 7.1 percentage points collectively. For the 28 states that implemented only one or neither of these options, the uninsured rate dropped 5.3 percentage points collectively.

Medicaid expansion plus an exchange decreases uninsured rates the most

PP = percentage points

The effectiveness of expanding Medicaid and participating in an exchange becomes even more noticeable when Gallup-Healthways looked at the 10 states with the largest reductions in the percentage of uninsured. Seven of those did both. (Arkansas installed a private option program that uses federal Medicaid funds to purchase private insurance for low-income residents.)

States with largest reductions in uninsured
State % uninsured, 2013 % uninsured first half of 2015 Change in uninsured (percentage points)
Arkansas 22.5 9.1 –13.4
Kentucky 20.4 9.0 –11.4
Oregon 19.4 8.8 –10.6
Rhode Island 13.3 2.7 –10.6
Washington 16.8 6.4 –10.4
California 21.6 11.8 –9.8
West Virginia 17.6 8.3 –9.3
Alaska 18.9 10.3 –8.6
Mississippi 22.4 14.2 –8.2
North Dakota 15.0 6.9 –8.1
Results based on telephone interviews conducted on Jan. 2 to Dec. 30, 2013 (random sampling of 178,072 adults) and Jan. 2 to June 30, 2015 (88,667).

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