Why Do People Remain Uninsured Post-ACA?

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A student-led study shows why patients remain uninsured despite the passage of the Affordable Care Act.

Many people remain without health insurance despite the enactment of the Affordable Care Act (ACA). To get a better idea of why this is the case, medical students and a professor at the University of Michigan Medical School student-run free clinic did in-depth interviews with 80 patients in the rural town of Pinckney to better understand why they lack health insurance.

Publishing their findings in the Journal of Community Health, the students found that the main barriers to coverage were perceived cost and a knowledge gap about who is eligible for low-cost plans or programs to help pay for coverage.

“Almost everyone we see in our clinic should have an option for low- or reduced-cost insurance under the ACA,” said second-year medical student Brian S. Desmond, first author of the paper. However, only 35% of those eligible had actively applied in the last 6 months.


Most of those who had not applied said they thought they weren’t eligible, or that it would cost too much. Though the Healthy Michigan Plan does include modest cost-sharing for participants above the poverty level, the program is free for most residents, including those who previously did not qualify for Medicaid.

The study found that of the patients whose incomes were too high for Medicaid or the Healthy Michigan Plan (above 138% of the poverty level), most said that the cost of private insurance was what kept them from getting insured. Many reported having shopped for coverage on the healthcare marketplace but said they had not bought it because of premium or deductible costs.

However, when the medical students examined the patients’ situations, they found that all but 1 person would have qualified for tax credits to help cut the monthly premium costs. Fifty-seven percent qualified for Medicaid by self-reported income.

Most of the patients studied were in their 40s and 50s and 80% had jobs. Only 18% had had health insurance within the past 2 years; 40% had been uninsured for more than 10 years. Twenty-five percent reported not seeing a doctor for more than a year before coming to the clinic and 8% hadn’t seen a doctor in more than 5 years.

Most of the patients surveyed who said they were not actively seeking health insurance were qualified for the Healthy Michigan Plan, which suggests that the patients assumed no program was open to them. It is possible some of these patients were undocumented immigrants who aren’t eligible for ACA plans, but the students did not ask about immigration status.

The study’s results demonstrate the root causes of uninsurance under the ACA and what can be done to change the situation, as well as the challenges of getting patients good information and addressing the complexities of eligibility, tax credits, and affordability.