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Trend Reversal: Uninsured rates tick upwards since passage of the Affordable Care Act
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From the President: Emerging Issues

 Trend Reversal: Uninsured rates tick upwards since passage of the Affordable Care Act

Atyya Chaudhry, M.P.P.
Senior Program Manager, Health Systems Transformation
The Association of Maternal and Child Health Programs

Since the passage of Affordable Care Act (ACA) in 2010, the uninsured rate for adults in the United States had been on a steady decline, until recently.

In September 2019, the U.S. Census Bureau released data of health insurance coverage estimates for 2018. The data revealed that the uninsured rate rose by 0.6 percent in 2018 for adults, meaning that approximately 2 million more people were uninsured in 2018. The data also revealed that young adults have also seen an increase in uninsured rates and continue to have the highest uninsured rate overall.  Alarmingly, the percentage of uninsured children increased by 0.6 percent, confirming earlier warnings from child health coverage experts. Among the increases for children, rates varied by geography and demographics. Those who are Hispanic and/or living in families with incomes at or above 400 percent of the federal poverty level, and children in southern states, were more likely to be uninsured.

Although Census officials do not cite specific causes for the declines in insurance coverage, health insurance experts believe the current Administration's efforts to roll back ACA consumer protections and approve waivers that permit states to test new Medicaid coverage requirements may be causing some of the observed declines. Efforts such as minimum coverage "bare-bones" plans, repeal of the individual mandate, Medicaid work requirements, and reduced enrollment support may influence health coverage rates. For example, in Arkansas, between June 2018 and March 2019, 18,000 people lost Medicaid coverage after a work requirement took effect. Many beneficiaries who lost coverage reported that they did not know about the work requirement or whether it applied to them.

This Administration's recent efforts to uphold a federal "public charge" rule may also account for some of the increase in the national uninsured rate.  Anecdotal evidence shows that some immigrant families are neither enrolling nor renewing Medicaid coverage, in response to concerns that enrollment in public benefit programs could have a negative effect on their prospects for citizenship. This holds true even in mixed status families, in which children are U.S. citizens, but parents/guardians are green card holders or undocumented. State Medicaid regulatory changes, which include adjusting the frequency of income verification from one year to six months, may also be having a negative effect on coverage rates, because parents may be unaware of new requirements.  

The upward tick in the nation's uninsured rate is concerning for programs serving maternal and child health (MCH) populations. However, with the ACA Marketplace open enrollment season approaching, Title V programs have an opportunity to actively promote coverage for children and families. Title V programs should consider:

  • Promoting the ACA open enrollment period on Department of Public Health websites and other social media, for both federal and state-based Marketplaces. Sample messaging can be found at Healthcare.gov and health care consumer organizations such as Get America Covered and Young Invincibles. These sites include templates that can be modified.  
  • Disseminating AMCHP public education resources and sharing them with state and community partners to distribute to their constituencies.  Resources are available on the AMCHP website:

  • Working with others in the state health department to engage grantees and contractors to educate communities about healthcare coverage options, focusing attention on lower-income populations, those at risk of losing coverage, and those who have had historically low coverage rates.

ACA Marketplace open enrollment will run from Friday, November 1 to Sunday, December 15, 2019, for coverage that starts January 1, 2020.