Even After Obamacare, Some Americans Are Uninsured. Who Are They?


While the uninsured rate has significantly fallen in the two years after the rollout of Obamacare’s major coverage provisions, a small portion of the American population remains without health care for reasons that not even the advent of targeted outreach strategies has been able to solve, a new study has found.

The study, conducted by the Robert Johnson Wood Foundation and the Urban Institute, shows that as of March, more than half of uninsured Americans currently live in states that haven’t expanded Medicaid under the Affordable Care Act (ACA). Residents of the non-expansion states who fall in the coverage gap — with incomes that are too high the Medicaid eligibility mark but too low to qualify for subsidies — account for nearly 23 percent of Americans without coverage.

More than two-thirds of Americans without coverage do qualify for Medicaid or subsidies to help them purchase plans through insurance marketplaces. Even so, more than 60 percent of the uninsured designated affordability as their primary reason for not obtaining coverage, a data point that the Urban Institute’s Adele Shartzer describes as indicative of financial hardships burdening people across the country.

“For some patients, many of whom have less than $100 in savings, health care isn’t a priority,” Shartzer, co-author of the paper, told ThinkProgress. In the research document, titled the Health Reform Monitoring Survey, Shartzer and her colleagues note that improvements to in-person assistance of technology could help uninsured adults find affordable options and better navigate the enrollment process.


“Many people might not know about subsidies available to them so information is a solution,” Shartzer, research associate at the Urban Institute, added. “The health care law was meant to facilitate appropriate use of health care services and direct people to lower cost care that provides some financial security. A catastrophic health event can wreck your finances.”

This report comes amid renewed discussion about Obamacare among lawmakers, particularly the more than dozen GOP presidential candidates, most of whom say they’ll do away with the health care law altogether if they get elected. This week, Wisconsin Gov. Scott Walker and Florida Sen. Marco Rubio released details about how they plan to repeal and replace Obamacare if they win. Plans included the establishment of insurance across state lines, extension of tax credits to Americans of various income levels, and expanding Health Savings Accounts — ideas that analysts say wouldn’t meaningfully help the poor.

Instead, a better solution to provide covering for the remaining 10 percent of Americans could be accepting Obamacare’s optional Medicaid expansion, which has been implemented unevenly across the country.

However, there has been great resistance among governors in the 21 non-expansion states, partially out of a concern that they would shoulder the cost of expansion, even with the Obama administration’s assurances that their expenditures would be reimbursed through 2020. That decision has affected nearly 4 million people — many of whom hail from African American and Latino communities in the South and fall within the coverage gap.

To address this dilemma, some GOP lawmakers have developed substitutes for Medicaid expansion, using waivers through the Centers for Medicare and Medicaid Services. Arkansas, Indiana, and Iowa implemented an expansion alternative by using federal dollars to purchase private insurance for the uninsured, a move that critics say will place state legislatures in financial states since they have to reauthorize financing annually. These ongoing discussions follow decisions by lawmakers’ decisions to expand Medicaid in Alaska and Montana earlier this year, perhaps signs that other changes may happen in other states.


“Non-expansion states have been vocal about their opposition to the Affordable Care Act but situations change and states are incredibly diverse,” Shartzer said. “Lawmakers are finding other ways they can expand coverage. It’s certainly better to have expanded through an alternative mechanism than do nothing.”

But the even with insurance coverage, health issues persist for Americans struggling to make ends meet.

Single people with incomes more than triple the federal poverty level — between $30,000 and $40,000 annually — receive relatively small tax credits. People with higher incomes get nothing. Additionally, high deductible plans — a coverage option in which health care costs shift to emergencies and large-scale procedures — can place a stranglehold on individuals and families without much discretionary income. Ron Pollack, executive director of nonprofit Families USA, told the Huffington Post that those high costs often discourage people from getting insurance.

For first-time insurance holders, navigating the health care system can also be a frustrating experience. An analysis conducted by researchers at D.C.-based advocacy organization Alliance for a Just Society found that people of color contend with a dearth of primary care providers, a lack of internet access, and general confusion about health plans. Additionally, disparities exists between community health clinics in low-income neighborhoods and more affluent areas. Gary Delgado, principal investigator in the study, previously told ThinkProgress that a significant number of people in that population don’t have a “medical home” so it’s likely that they will use the emergency room instead of seeking preventative services.

Another hurdle is the high cost of treatment for chronic illnesses, which has sparked criticism of pharmaceutical drug companies. While the ACA forbids insurance companies from refusing coverage to those with preexisting conditions, providers have placed these “special medications” in a different category so patients shoulder up to 50 percent of the costs, much more than the individual and family caps on out-of-pocket payments. In recent months, attention has shifted to Hepatitis C medication, now on the market for up to $90,000. Medicare outlays for the payment of that treatment have surpassed $4.5 billion, more than 15 times the amount officials doled out on older version.

Shartzer said that that addressing these cost-related issues would make navigating the health care system a more enjoyable experience for Americans, as envisioned by the architects of the ACA.


“Access to care has been improving, but health care has been lagging behind other industries in making tools available to consumers,” she said. “There are clear gaps in health insurance care and literacy. We have to acquaint people with health care vocabulary because that can be intimidating.”

Even with these issues, a significant number of Americans do favor the ACA. More than 7 out of 10 Americans who bought new health insurance policies through exchanges last year rated their coverage as “good” or “excellent” in a Gallup poll. Amid their calls to “repeal and replace,” even Obamacare’s most ardent opponents favor many specific policies included in the legislation — including providing subsidies on a sliding scale to aid people who can’t afford insurance and forbidding the cancellation of policies when a person becomes ill.