Who will be Uninsured Following Health Insurance Reform?

The Patient Protection and Affordable Care Act (ACA) will not only greatly reduce the number of uninsured, but also change substantially the composition of the uninsured. This study analyzes this changing composition, state by state.

Design: The Urban Institute's Health Insurance Policy Simulation Model was used to estimate the effects of health reform on the uninsured. The main coverage provisions of the ACA were simulated as if they were fully implemented in 2011 and results compared to the HIPSM baseline results for 2011 without reforms.

Population: Comparisons were made within each state, and nationally, for each of four major categories of the uninsured: Medicaid-eligible, undocumented immigrants, low-income legal residents, and others.

Findings: Due to the expansion of Medicaid eligibility, the segment of the uninsured who are eligible for Medicaid will increase, to almost 40 percent. Due to the individual mandate and subsidies through the new insurance exchanges, legal residents not eligible for Medicaid will drop to about 33 percent of the uninsured. Undocumented immigrants will constitute about 25 percent of the uninsured. The proportion of uninsured people who are substantially above poverty will increase. People below 200 percent of the federal poverty level (FPL) will account for only about 15 percent of uninsured legal residents not eligible for Medicaid. Among nonelderly adults, only about 10 percent of the uninsured will be legal residents not eligible for Medicaid but eligible for an affordability exemption from the individual mandate, if the ACA were in full force in 2011. Almost a quarter of uninsured will not have an affordability exemption. Uninsured adults with an affordability exemption will be older and have lower incomes than those without. The majority will be below 300 percent of poverty.

Conclusions: The number, composition and characteristics of the uninsured will change substantially after 2014, and will vary substantially among states, according to economic and demographic baseline characteristics that will be shown.

Implications: This information can assist states and communities in health policy planning on several fronts, such as planning for expected demand in the new insurance exchanges. Most importantly, knowing how many and what kinds of people will remain uninsured will assist safety net providers, organizations, and support systems to determine ongoing needs for those who cannot afford access and optimal structures for addressing those needs.