Wednesday, August 03, 2022

U.S. uninsured rate hits an all-time low; Biden's HHS takes a victory lap; xpostfactoid claims prepostfactoid credit

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Record broken!

Biden's HHS took something of a victory lap yesterday, announcing that the national uninsured rate -- 8.0% for all ages --  was at an all-time low in the first quarter of 2022. Since the fourth quarter of 2020, the uninsured rate has dropped by 2.7 percentage both for ages 18-64 and for children, according to the ASPE* brief.

The brief is based on quarterly updates from the National Health Interview Survey. Those updates are notoriously bouncy, but the change over the time frame selected is clearly statistically significant. 

The brief asserts: "These gains in health insurance coverage are concurrent with [mustn't claim causality, now...] the implementation of the American Rescue Plan’s enhanced Marketplace subsidies, the continuous enrollment provision in Medicaid, several recent state Medicaid expansions, and substantial enrollment outreach by the Biden-Harris Administration in 2021- 2022."

I must note that I've been something of a canary in the coal mine on this front, first speculating that we might be approaching an uninsured low in April 2021; wondering whether the 2021 Special Enrollment Period coupled with the ARPA subsidy boosts might have got us there by late August 2021; and parsing the NHIS quarterly data in light of the 2022 marketplace enrollment surge in January 2022.

Ultimately, I noted in the January post, the enrollment math, if not the survey data, told a fairly simple story:

What about the overall uninsured rate? The pandemic triggered large increases in Medicaid enrollment -- up by 12.9 million from February 2020 to July 2021 -- and in  ACA marketplace enrollment, up by about 3 million since the end of Open Enrollment for 2020. At the same time, losses of employer-sponsored insurance in the pandemic appear to have been relatively modest, estimated at 5.5 million by the Urban Institute in August 2021 and at 2-3 million by the Kaiser Family Foundation in December 2020.  Nonetheless, public and private surveys found no statistically significant change in the uninsured rate through 2020 and into early 2021. I have wondered whether the data will eventually show a drop in the uninsured rate in 2021 (the federal surveys have warned that their results may be affected by reduced response rates during the pandemic). That remains to be seen.

It's seen now!  A few notes:

1. The ASPE brief attributes the drop in uninsured at ages 18-64 in large part to the ACA marketplace surge apparently triggered by the ARPA subsidy boosts (which Democrats are trying to extend for three years in the Inflation Reduction Act negotiated by Manchin and Schumer) -- noting that an increase of roughly 2 million in adult marketplace enrollment accounts for about half of an increase of 4 million in adult insured.

2. ACA marketplace enrollment increases are heavily concentrated in nonexpansion states. From OEP 2020 to OEP 2022, marketplace enrollment increased by 3.1 million. 83% of those gains (2.3 million) were in the twelve states that still have not enacted the ACA Medicaid expansion. About half of enrollees in those states have income under 150% FPL.

3. The brief highlights apparently strong gains for people below age 65 from Q1 2021 to Q1 2022 at incomes below 100% FPL (4.5 percentage points) and at 200-400% FPL (2.0 percentage points) . NHIS survey data shows more modest and equivocal gains at 100-200% FPL (0.6 percentage points). But marketplace enrollment increased by more than a million from 2021-2022 in the 100-200% FPL income range. There is some mismatch between incomes recorded in the NHIS and in marketplace enrollment, both because self-reporting of income is inexact and because households are defined differently in the survey and the marketplace application -- the NHIS defines a household as people living under one roof, whereas the marketplace considers those included on one tax return. Thus marketplace enrollees may show up in the under-100% FPL category in the NHIS.  Also, some Medicaid enrollees may be reported as having 'private coverage' in the NHIS, as managed Medicaid plans adopt insurers' brand names. I've been told that this is a longstanding issue in survey data.

4. Current enrollment gains are precarious. The pandemic Public Health Emergency has to end some time, and when it does, 15 million people or more may lose Medicaid coverage, as a moratorium on Medicaid redeterminations and disenrollments (effected by the Families First Act in March 2020) will also end.  CMS has asked states to act with all due deliberation when the time comes to work through a backlog of redeterminations, allowing up to 14 months to complete the process. Some states will act swiftly, some slowly. Some will make a good faith effort to find those who don’t respond to a first notice – e.g., because they have moved – and some will eagerly disenroll all they can. As for the marketplace gains, extension of the ARPA subsidy boosts that drove a 21% enrollment increase this year is going down to the wire and almost certainly depends on passage of the Inflation Reduction Act, which requires unanimous Democratic support in the Senate. That extension in the current bill text is only for three years, its long-term future highly uncertain. Finally, the unemployment rate won't stay below 4% forever.

Still, the fact remains that the ACA, bolstered by pandemic relief legislation, saved the nation from a massive spike in the uninsured population during the pandemic and laid groundwork to get the country closer to universal coverage.  


* The brief was produced by the office of the HHS Assistant Secretary for Planning and Evaluation (ASPE). 

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Photo by Mick Haupt


  1. Something here in the labelling of that stat "national uninsured rate -- 8.0%" enrages me, actually.

    The label is fraudulent. It has to do with my favorite odious ACA aspect, the Medicaid estate recovery in about 20 states of ACA expanded Medicaid and other non-long-term care Medicaids for people 55+, and in particular in the case when the recovery is, as it can be, of all medical that were paid by the Medicaid.

    People subject to that estate recovery do not have insurance on any sense of the term. When you have insurance, they don't come after estate when you die for the medical bills that were paid out. That's not what insurance means. (Just like the car insurance, home insurance, etc. -- the same meaning -- they can't call it insurance if the money insurance pays has to be paid back at death.)

    A fine example of how this affects the true numbers is my own Massachusetts, which does do an estate recovery.

    The so-called "great health insurance paradise of Massachusetts" claims from a 2021 survey a 2.4% uninsured rate against at that time 9.2% nationally. (,the%20national%20rate%20of%209.2%25.)

    But, about 20% of the people in Massachusetts are "insured" in their stats with a Medicaid including ACA expanded Medicaid. About 20% of those, that is 4% of the people in MA, are 55 or older, and therefore have an estate-recoverable Medicaid.
    as their "insurance". (Further, I was told at a point that the state pays Medicaid bills directly, despite having administrative companies processing the bills -- this is the configuration where all medical bills paid out are estate recovered.)

    Thus, the true Massachusetts insured rate is about 6.4%, not 2.4%.

    With about 20 states estate recovering non-long-term-care Medicaids, and especially with some of those recovering all medical expenses paid out and others also not telling people what they will recover, that 8% Federal number is a bit low. Maybe the true number is 9% or 10% uninsured.

    (I used to work professionally as a statistician. An honest one, and never participated in any false labelling, and this one here is a whopper by the government. E.g. if you look at the definition of Health Insurance Coverage here for the Census, here on p.25, all Medicaid is included.)

    (Andrew, who wrote the blog post, is well aware of the issue, and has in fact publicized the problem with the ACA status and wants it fixed. For example, The blatantly false labelling is by the U.S. government, and by state governments, not Andrew. Andrew has, however, inadvertantly passed along the lie.)

    P.S. Massachusetts note: there is a bill in, actually, that would stop the estate recovery on non-long-term care in Massachusetts, Senate S.749 ( )and the same bill in the House. )

    Amazingly, the bill, and the estate recovery on non-long-term-care Medicaids and some Obamacare issue just a few days ago, with an NPR story from Boston's WBUR. . The mentioned bill is S.749, however, the 2-year session of the legislature just ended 7/31 with the bill apparently NOT making it. .

    Incidentally, the story (the audio version that was broadcast, anyway, happens to precisely mention that the estate-recovered Medicaid is a LOAN, not insurance.

  2. Part 2 (comment-length limit was exceeded):

    (For people coming here first finding out about the estate recovery on much what the government is falsely labelling "insurance", on reference is the Wikipedia article on Medicaid estate recovery, or its backup,, in case it changes.

    As Andrew knows, I wrote most of that article myself in 2019, after being shocked to find out about the recovery in about 20 states on what Obamacare is supposed to keep us from having to worry about -- non-long-term-care medical expenses.)