Saturday, December 14, 2019

Uninsurance goes (slightly) upscale, Kaiser edition

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In September, the annual Census Bureau update on health insurance coverage in the U.S. reported a 0.5% rise  in the uninsured population in 2018 -- an increase of 1.9 million uninsured. I noted at the time:
Affluent uninsured population spikes. Notwithstanding a drop of 2 million  (0.7%) in Medicaid enrollment, the sharpest increases in the uninsured were at high incomes. At 300-399% FPL, the insured rate dropped a full percentage point, from 92.9% to 91.9%, and at over 400% FPL, the rate dropped 0.8%, from 97.3% to 96.6%. Together, these two income groups account for 55% of the population. Particularly striking, the number of uninsured at incomes over 300% FPL increased 23.8% (from 6.631 million in 2017 to 8.215 million in 2018).  The spike in uninsured children at high income levels seems congruent with this drop.

These losses were concentrated in private insurance, down 1.3% percentage points at both income levels. The private insurance losses stem in part from the individual market, where unsubsidized enrollment dropped by 1.8 million in 2018, according to the Kaiser Family Foundation's estimate.  That drop is part of a longer term free-fall, from 9.1 million unsubsidized in the individual market in in the first quarter of  2016  to 4.7 million in Q1 2019, according to Kaiser.
Yesterday, the Kaiser Family Foundation released an updated analysis of the uninsured population. Kaiser finds a smaller increase in the uninsured in 2018 than did the Census, 500,000.  In contrast to the Census, Kaiser finds equal increases in the uninsured at 100-199% of the Federal Poverty Level and at over 200% FPL, with a statistically insignificant decrease at incomes below 100% FPL.  Regarding the increase at not-poor incomes, a couple of points from the analysis stand out:

1. People "earning out" of Medicaid. Kaiser reports: "More than one in ten were uninsured because they lost Medicaid due to a new job/increase in income or the plan stopping after pregnancy (13%)."  As I noted recently, the national population with income below 100% FPL shrank by 1.4 million from 2017-2018, according to the Census.*  From 2014-2018, the under-100% FPL population shrank 18.4%, from 46,657 to 38,056.

2. Employer-sponsored insurance grows more unaffordable. Kaiser (endnotes omitted, but check out 13-15 here):
Among uninsured workers who were offered coverage by their employer, but did not take up the offer, nine out of ten reported cost as the main reason for declining in 2017 (90%). From 2009 to 2019, total premiums for family coverage increased by 54%, and the worker’s share increased by 71%, outpacing wage growth. Low-income families with employer-based coverage spend a significantly higher share of their income toward premiums and out-of-pocket medical expenses compared to those with income above 200% FPL (per this Kaiser report).
3. Mystery stat: Kaiser pegs the uninsured population that earns too much to qualify for subsidies at just 2.4 million. Yet as noted above, Kaiser has also charted a drop of about 4.5 million (nearly 50%)  in unsubsidized ACA-compliant individual market enrollment since 2016, and a drop of 1.8 million in 2018 alone. I would think that's a factor in any uptick in higher income uninsured.

As the Kaiser report notes, the uninsured population remains concentrated at lower income levels.  But that eternal reality has moderated somewhat in recent years as income shifts upward and more states adopt the ACA Medicaid expansion.

*As for the post-pregnancy loss, that should be addressed by legislation -- mothers should be covered for a year postpartum, rather than the 1-2 months allowed in many states. In expansion states, hospitals serving a large Medicaid population should try to hammer home to pregnant patients that they should apply for coverage through the marketplace when their pregnancy Medicaid runs out.

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