Every Group Saw Drops in the Uninsured Rate Under the ACA, but Poll Finds Few Know It

Data show that the biggest factor affecting distribution of uninsured rates was whether a state expanded Medicaid. Even with that limitation, uninsured rates have reached historic lows. The trouble is, only about one-fourth of Americans know this, and more have moved on to issues that affect them personally, such as the cost of premiums or high deductibles.

New data released today by HHS show the Affordable Care Act (ACA) has brought across-the-board declines in rates of uninsured Americans—the gains that cut across racial, ethnic, geographic, and even income groups.

That would seem to be good news for Democrats heading into the November elections, but there’s one problem: a separate poll finds only about one-fourth of Americans (26%) realize that uninsured rates are at historic lows. At the end of 2015, the insured rate was 9.1%, and it has since fallen to 8.6%.

And, while the poll finds voters are increasingly interested in healthcare issues, they aren’t focused on declining uninsured rates. Instead, because most Americans now have coverage, they are eyeing the things that affect them directly: rising premiums, deductibles, and co-pays for prescription drugs.

Drops in Uninsured Rates Across the Board

Nearly 21 million Americans have gained health coverage since 2010, and uninsured rates have fallen by about 40% across all income groups, according to the HHS analysis, which covered the years 2010 to 2015. That figure includes households with incomes above 400% of the federal poverty level (FPL). Breakouts provided by HHS show that the ACA has had its greatest impact on young adults, who had the highest uninsured rates before the law took effect:

· 18- to 25-year-olds saw a 52% reduction in their uninsured rates, largely through the ACA provision that allows this group to say on their parents’ policies to age 26

· 26- to 34-year-olds saw a 36% reduction

· 35- to 54-year-olds saw a 39% reduction.

Data also show significant reductions across all income groups, with the largest drop coming among households earning between 100% and 138% of the FPL—the target group eligible for Medicaid expansion. The poorest Americans also benefited from expanded Medicaid eligibility and rules, and all groups benefited from rules that barred discrimination based on pre-existing conditions. In some of the poorest states, the ACA raised awareness of Medicaid limits, causing some families to learn they were eligible and simply had never enrolled. Breakouts included:

· Those earning less than 100% of the FPL: 39% reduction

· 100% to 125% of the FPL: 48% reduction

· 125% to 250% of the FPL: 41% reduction

· 250% to 400% of the FPL: 37% reduction

· 400% of the FPL and higher: 42% reduction

Whites have gained coverage at rates on par with African Americans; they have seen a 46% reduction in uninsured rates, while African Americans have seen a 47% reduction. Asians have seen a 59% reduction and Hispanics have seen a 35% reduction.

The single biggest factor in how much a state’s insured rate dropped was whether Medicaid expansion was chosen: in expansion states, rates dropped 50%, in the rest, rates dropped 32%. Rural insured rates dropped slightly less (39% to 42%), which the analysis attributed to the high number of rural states that declined expansion. To date, 31 states have expanded Medicaid; most of the holdout states are in the deep South.

Poll Finds Americans Look at Out-of-Pocket Costs

The Kaiser Health Tracking Poll, taken at intervals since 2010, has found views of the ACA evenly split along partisan lines with remarkable consistency since it passed; however, there is an exception: the public soured on the law during the period after the botched rollout in late 2013. That trend continued during the most recent poll, with 44% viewing the law favorably and 47% unfavorably, even though other polls have found Americans support individual elements of the law.

In the current poll, Americans were divided on whether the insurance exchanges were working, with 48% saying they were working “very well” or “somewhat well” in their state, and 49% saying they were working “not too well” or “not well at all” in the nation overall. States with their own exchanges viewed them more favorably, but these states are more Democratic.

Of note, 36% of Americans were aware of the news that Aetna had withdrawn from most states on the exchanges—more than were aware of the historically low rates of uninsured. The Kaiser poll found Americans were less likely to be following stories about the rate of uninsured Americans than stories about EpiPen prices, the Zika virus, or the campaigns of the presidential candidates. A few more Americans (25% vs 21%) thought stories about the opioid crisis were “very important” compared with stories about the uninsured. The plight of the uninsured matters to 57% of Hillary Clinton supporters compared with 28% of Donald Trump supporters.

What healthcare issues matter most? Supporters for both candidates give high ratings to “the future of the healthcare law” (Clinton supporters, 71%; Trump supporters, 64%). The cost of deductibles is "very important" to 59% of Clinton supporters and 52% of Trump supporters; while the cost of premiums is important to 62% of Clinton supporters and 57% of Trump supporters. Prescription drug costs matter to 58% of Clinton supporters and 42% of Trump supporters.