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From Health Reform WK-EDGE, April 29, 2019

Almost 30 million people under 65 have no health insurance

By Robert B. Barnett Jr., J.D.

A new Congressional Budget Office Report, which estimates the number of people in the U.S. who have health insurance through various private and public sources, has revealed that an estimated 28.9 people in the U.S. who are under age 65 lack health insurance coverage.

About 28.9 million people in the U.S. under age 65 lacked health insurance in 2018, an increase from the 28.3 million who were uninsured in 2015, according to a new report from the Congressional Budget Office (CBO). The report sought to track the number of individuals who had comprehensive health insurance coverage from any source, including employment-based coverage, individually obtained coverage, Medicaid and CHIP, Medicare (for the disabled who are under 65), and what were characterized as "other coverages" for 2015 through 2018 (CBO Report, April 22, 2019).

Coverage estimates. The number of people covered through their employer in 2018, easily the largest number in the survey, was 159.7 million, an increase from the 157 million who were covered in 2015. The second largest group were those covered by Medicaid and CHIP, with approximately 69.4 million covered by those federal programs, an increase from the 66.9 million who were covered in 2015. The fourth largest group (the uninsured were the third largest group) were those who purchased their insurance individually at 14.7 million, actually a drop from the 17.3 million who had such coverage in 2015. Medicare’s disability program covered another 8.3 million, a decrease from the 8.6 who had coverage in 2013. The final group, those who obtained coverage from other sources, consisted of another 3.8 million people, an increase from the 3.2 million who had such coverage in 2013. The "other" category included the 800,000 people (up from 300,000 in 2013) who obtained their coverage from the Basic Health Program, which was created by the Patient Protection and Affordable Care Act (ACA) to allow states to cover certain individuals with income between 138 percent and 200 percent of the federal poverty guidelines.

Nongroup coverage. Perhaps the most interesting number in the coverage estimates was the decrease in those individuals who obtained coverage for themselves. The report referred to the coverages obtained individually as nongroup coverages. The CBO further broke down nongroup coverages onto those who purchased nongroup coverage through the ACA marketplaces and those who purchased coverage outside the marketplaces. The data showed that the number who purchased through the ACA marketplaces was growing while those who purchased outside the market was shrinking. In 2015, for example, 9.4 million individuals had coverage through the ACA marketplaces, which grew slightly to 9.8 in 2017 (but dropped back slightly to 9.7 in 2018). Those who purchased their coverage individually but not within the ACA marketplaces shrank steadily from 8 million in 2015 to 7.4 million in 2016 to 6 million in 2017 to 4.9 million in 2018. One possible explanation for that trend is the increase in the number of states offering the ACA marketplace option.

Methodology. The CBO took great pains to explain that "private insurance coverage" (i.e., for those who had employer-provided or nongroup coverage) was defined as comprehensive major medical coverage. Thus, only those individuals with comprehensive major medical coverage—further defined as insurance protection against high-cost, low-probability events—were counted in the totals as having insurance coverage. Military personnel, though covered by TRICARE and able to use the VHA, were counted as employer-provided individuals because their employer (the U.S government) provided them with coverage. To reach its estimates, the CBO combined data from household and employer surveys with administrative data about government programs.

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