Despite Strong Economy, Census Report Says Uninsured Rate Rose in 2018

Health insurance gains since the implementation of the Affordable Care Act (ACA) may be starting to erode, according to a report from the US Census Bureau, which revealed that for the first since since the landmark health law was enacted, the amount of Americans with health insurance declined in 2018.

The figures, based on the Current Population Survey and American Community Survey, showed that 8.5% of Americans, or 27.5 million, did not have insurance at any point in 2018, which increased from the 7.9% of Americans, or 25.6 million, who did not have insurance in 2017.

According to the report, the decline in coverage appears to be a result of a 0.4 percentage-point decrease in public health insurance, with Medicaid coverage decreasing by 0.7 percentage points. Medicare coverage increased by 0.4 percentage points, partly due to the growth in the number of people aged 65 years and older.

These findings come as a surprise as the economy is doing particularly well. In 2018, the poverty rate fell for the fourth straight year, dropping from 12.3% in 2017 to a low of 11.8% in 2018. At the same time, for the seventh straight year, the economy added more than 2 million jobs in 2018, explained Robert Greenstein, president of the Center on Budget and Policy Priorities (CBPP), during a press call. The median household income remained essentially unchanged from 2017, increasing 0.9% to $63,179.

“This backsliding almost certainly reflects—at least in part—Trump Administration policies to weaken public health coverage,” said Greenstein, in a statement. “While the uninsured rate remains far below its pre-ACA level, the gains achieved through the ACA will entirely disappear if the Administration ultimately succeeds in its continued efforts to repeal the law through legislation and the courts.”

There were a number of policies from the administration that have contributed to the drop in coverage, said Aviva Aron-Dine, the CBPP's vice president for health policy, during the call. These include:

• The 90% cut in federal outreach and advertising for the ACA marketplace
• Policies that have led immigrants being afraid to enroll in the marketplace and subsidized coverage despite being eligible
• Policies that have weakened Medicaid coverage
• The repeal of the ACA’s individual mandate

Aaron-Dine noted that although the repeal of the individual mandate took effect in 2019, its impact began in 2018.

Aaron-Dine added that with expected coverage losses from the repeal of the individual mandate and other policies from the administration, the uninsured rate will continue to grow. With the fate of the entire ACA in question as it continues to go through litigation, a full repeal of the health law would undoubtedly further jeopardize the gains in coverage offered by the law’s protections for people with pre-existing conditions, Medicaid expansion, and more.

Today’s report from the Census Bureau underscored the importance of Medicaid expansion, in particular, for coverage. States that have expanded Medicaid had nearly half the uninsured rate as states that have not expanded Medicaid (6.6% vs 12.4%). According to Greenstein, if the uninsured rate in non-expansion states fell to the same degree it fallen in expansion states since 2013, 4.7 million fewer Americans would have been uninsured last year.

Other findings of the report include:

• In 2018, 5.5% of children aged under 19 years did not have health insurance, a 0.6 percentage-point increase from 2017
• Between 2017 and 2018, there was a 1.1 percentage-point decrease in coverage for people with a disability
• In 2018, people with lower incomes had coverage rates that were lower than that of people with higher incomes