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:

Fewer Americans qualify for ACA marketplace subsidies

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Regardless of whether ACA marketplace enrollment for 2020 is lagging 2019 totals, one persistent marketplace headwind that should get more attention is the long economic recovery. In an article by Bloomberg's Sara Hansard, Andrew Strohman of the American Action Forum puts one finger to this wind:

Unemployment is now about 3.6%, compared with 4% in January. “You could see some more people taking up employer-sponsored insurance rather than enrolling in the individual market,” Strohman said.

Regardless of whether more people are in jobs that offer affordable insurance, the population with incomes in ACA subsidy range (100-400% of the Federal Poverty Level in states that have refused the Medicaid expansion, 138-400% FPL in states that have implemented it) has shrunk since the ACA marketplace launched in 2014. At the same time, the population with incomes above 400% FPL (and so ineligible for ACA subsidies) has swelled.

Drop in low income uninsured is partly due to drop in low income population

In 2015, I noted that Democrats had paid in political blood for devising a health reform scheme that primarily benefited people in the lower third of the national income distribution  (those with incomes below 200% of the Federal Poverty level), where more than half of the country's uninsured were concentrated pre-ACA.

Chance led me this morning to take a bird's eye view of how the income distribution of the uninsured changed from 2013 (pre-ACA) to 2017. This snapshot is based on the Census Bureau's annual September report, Health Insurance Coverage in the United States, for 2014 and 2017.

The percentage of the uninsured in the lowest income brackets has shrunk considerably. But that's in part because the percentage of the total population in those brackets has also shrunk.  In 2013, 39% of the population and 59% of the nation's uninsured were in households with incomes below $50k. In 2017, 49% of the uninsured and 34% of the total population were in households with incomes below that threshold.

Here is the breakout by income group.