A new portrait of the uninsured and newly-insured is emerging, with a confluence of factors shaping who is and isn't enrolling in Medicaid or private plans.
The big picture
Through the Affordable Care Act's first open enrollment period, an estimated 8 million previously uninsured Americans gained coverage, either through private subsidized plans or Medicaid -- an enrollment that has brought the nation's rate of uninsured adults to 13.4 percent, the lowest since Gallup-Healthways began tracking the rate in 2008.
But in some fairly large swaths of the country, millions of Americans continue to go uninsured, particularly in the mostly Southern states that are declining to expand Medicaid eligibility. More than 60 percent of the remaining uninsured adults are living in the 25 states not expanding Medicaid eligibility, while about 40 percent live in the states that are, according to new survey data from the Urban Institute.
Why that proportion is so high in Medicaid expansion states isn't entirely clear, although the survey found a small percentage of individuals across the country -- 20 percent -- reporting that they did not want to enroll in insurance or would rather pay the individual mandate fine.
Opting out?
Nationally, adults with low-incomes, at or below 138 percent of the federal poverty level (FPL), comprise 65 percent of the uninsured, with 28 percent earning between 138 and 400 percent FPL and only 6 percent earning above the 400 percent FPL threshold where exchange plan premium subsidies are cut off.
According to the Urban Institute, more than half of the nation's uninsured are actually employed; 22 percent are unemployed and about 25 percent are among the long-term unemployed and not counted in the labor force. Those employed but uninsured were supposed to be able to gain access to at least Medicaid, and they could be eligible for exchange plans.
But perhaps the most head-scratching finding is that more than 16 percent of all the uninsured nationwide actually have access to employer-sponsored insurance through their own job or a family member. Why go uninsured when offered a health plan at work?
According to the Urban Institute's surveys, 60 percent of the uninsured say they remain so because they believe they cannot afford it. Among the other reasons, 20 percent said they do not want health insurance or would rather pay a fine, 14 percent said they were still considering their options, 13 percent said they were in transition and 9 percent said they encountered time or information gaps.
Still, that 16 percent of the uninsured have access to but don't take advantage of employer-based insurance is perplexing. Unless the coverage does not meet minimum affordability standards, these workers are obligated to enroll in the group plans or otherwise pay the individual mandate penalty under the ACA.
A group migration?
Whatever the reasons for so many to remain uninsured, data from the Urban Institute and others suggest the lower end of the group market is in the midst of a transition to individual policies, along with the lower-income workforce.
Among new Medicaid enrollees, 18 percent were previously covered in employer-sponsored insurance and among new exchange members 21 percent were previously in group plans, according to data from the Commonwealth Fund.
Partly, these trends may be related to an ongoing shift to part-time employment in sectors like retail, and it's also partly a reflection of employers more closely calculating the benefit to them and their employees of traditional group plans. Earlier this year, Target decided to end its health insurance options for part-time employees and instead send them to exchanges with a $500 contribution, following the likes of Home Depot, Walgreens, Trader Joe's and others.
WellPoint is one insurer that's started to see the impact of these trends.
In its second quarter financials, WellPoint disclosed that its small group membership shed 218,000 lives this year, now standing 1.6 million, while individual membership increased 172,000 to more than 2 million.
"One thing to keep in mind with the small group," said WellPoint CFO Wayne DeVeydt during an earnings call, "is we fundamentally believe that over time that that business will migrate either to an exchange-like margin while remaining in small group or migrating to an exchange-like margin because it ultimately migrates to a public exchange."