#35677 - 1PG WITHIN 5HRS

Key Facts about the Uninsured Population

The Affordable Care Act (ACA) led to historic gains in health insurance coverage by extending Medicaid

coverage to many low-income individuals and providing Marketplace subsidies for individuals below 400% of

poverty. Under the law, the number of uninsured nonelderly Americans decreased from 44 million in 2013 (the

year before the major coverage provisions went into effect) to less than 28 million as of the end of 2016. Recent

efforts to alter the ACA or fundamentally change the structure of Medicaid may pose a challenge to further

reducing the number of uninsured and may threaten coverage gains seen in recent years. This fact sheet

describes how coverage has changed under the ACA, examines the characteristics of the uninsured population,

and summarizes the access and financial implications of not having coverage.

How has the number of uninsured changed under the ACA?

In the past, gaps in the public insurance system and lack of access to affordable private coverage left millions without health

insurance. Beginning in 2014, the ACA expanded coverage to millions of previously uninsured people through the expansion of

Medicaid and the establishment of Health Insurance Marketplaces. Data show substantial gains in public and private

insurance coverage and historic decreases in uninsured rates under the ACA. Coverage gains were particularly large among

low-income people living in states that expanded Medicaid. Still, millions of people—27.6 million in 2016— remain uninsured.

Why do people remain uninsured?

Even under the ACA, many uninsured people cite the high cost of insurance as the main reason they lack coverage. In 2016,

45% of uninsured adults said that they remained uninsured because the cost of coverage was too high. Many people do not

have access to coverage through a job, and some people, particularly poor adults in states that did not expand Medicaid,

remain ineligible for financial assistance for coverage. Some people who are eligible for financial assistance under the ACA

may not know they can get help, and undocumented immigrants are ineligible for Medicaid or Marketplace coverage.

Who remains uninsured?

Most uninsured people are in low-income families and have at least one worker in the family. Reflecting the more limited

availability of public coverage in some states, adults are more likely to be uninsured than children. People of color are at higher

risk of being uninsured than non-Hispanic Whites.

How does the lack of insurance affect access to health care?

People without insurance coverage have worse access to care than people who are insured. One in five uninsured adults in

2016 went without needed medical care due to cost. Studies repeatedly demonstrate that the uninsured are less likely than

those with insurance to receive preventive care and services for major health conditions and chronic diseases.

What are the financial implications of lacking coverage?

The uninsured often face unaffordable medical bills when they do seek care. In 2016, uninsured nonelderly adults were over

twice as likely than their insured counterparts to have had problems paying medical bills in the past 12 months. These bills can

quickly translate into medical debt since most of the uninsured have low or moderate incomes and have little, if any, savings.

Key Facts about the Uninsured Population 2

In the past, gaps in the public insurance system and lack of access to affordable private coverage left millions

without health insurance, and the number of uninsured Americans grew over time, particularly during periods

of economic downturns. By 2013, more than 44 million people lacked coverage. Under the ACA, as of 2014,

Medicaid coverage has been expanded to nearly all adults with incomes at or below 138% of poverty in states

that have expanded their programs, and tax credits are available for people who purchase coverage through a

health insurance marketplace. Millions of people have enrolled in these new coverage options, and the

uninsured rate has dropped to a historic low. Coverage gains were particularly large among low-income adults

living in states that expanded Medicaid. Still, millions of people—27.6 million nonelderly individuals in 2016—

remain without coverage.1

Key Details:

 The share of the nonelderly population that

was uninsured hovered around 16% between

1998 and 2007, then peaked during the

ensuing economic recession (Figure 1). As

early provisions of the ACA went into effect in

2010, and as the economy improved, the

uninsured rate began to drop. When the major

ACA coverage provisions went into effect in

2014, the uninsured rate dropped dramatically

and continued to fall in subsequent years. In

2016, the nonelderly uninsured rate was

10.3%, the lowest in decades.

 Coverage gains from 2013 to 2016 were

particularly large among groups targeted by

the ACA, including adults and poor and low-

income individuals. The uninsured rate among

nonelderly adults, who are more likely than

children to be uninsured, dropped from 20.5%

in 2013 to 12.2% in 2016, a 40% decline. In

addition, between 2013 and 2016, the

uninsured rate declined substantially for poor

and near-poor nonelderly individuals (Figure

2). People of color, who had higher uninsured

rates than non-Hispanic Whites prior to 2014,

had larger coverage gains than non-Hispanic Whites. Though uninsured rates dropped across all states, they

dropped more in states that chose to expand Medicaid, decreasing by 7.1 percentage points compared to 3.7

points in non-expansion states.2 (See Appendix A for state-by-state data on changes in the uninsured rate).

 Coverage gains were seen in new ACA coverage options. As of February 2017, over 10 million people were

enrolled in state or federal Marketplace plans,3 and as of June 2017, Medicaid enrollment had grown by over

17 million (29%) since the period before open enrollment (which started in October 2013).4

Figure 1

16.6 16.1 16.4

16.6

18.2

16.7

10.3

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

NOTES: Includes nonelderly individuals ages 0-64. SOURCE: Kaiser Family Foundation analysis of the 2016 National Health Interview Survey.

Uninsured Rate Among the Nonelderly Population, 1998-2016

Figure 2

-9.5%

-11.3%

-3.6%

-4.8%

-7.4%

-11.1%

-7.3%

-1.4%

-8.2%

NOTES: Includes nonelderly individuals ages 0-64. SOURCE: Kaiser Family Foundation analysis of the 2013 and 2016 National Health Interview Survey.

Percentage Point Change in Uninsured Rate among the Nonelderly Population by Selected Characteristics, 2013-2016

Poverty Level Race/Ethnicity

<100% FPL

100 to 199% FPL

>200% FPL White Black Hispanic Asian

Age Group

Children 0-17

Nonelderly Adults 18-64

Key Facts about the Uninsured Population 3

Most of the nonelderly in the United States obtain health insurance through an employer, but not all workers

are offered employer-sponsored coverage or, if offered, can afford their share of the premiums. Medicaid

covers many low-income individuals, and financial assistance for Marketplace coverage is available for many

moderate-income people. However, Medicaid eligibility for adults remains limited in some states, and few

people can afford to purchase coverage without financial assistance. Some people who are eligible for coverage

under the ACA may not know they can get help, and others may still find the cost of coverage prohibitive.

Key Details:

 Cost still poses a major barrier to coverage for

the uninsured. In 2016, 45% of uninsured

nonelderly adults said they were uninsured

because the cost is too high, making it the

most common reason cited for being

uninsured (Figure 3). Though financial

assistance is available to many of the

remaining uninsured under the ACA,5 not

everyone who is uninsured is eligible for free

or subsidized coverage. In addition, some

uninsured who are eligible for help may not

be aware of coverage options or may face

barriers to enrollment.6 Outreach and enrollment assistance was key to facilitating both initial and ongoing

enrollment in ACA coverage, but these programs face challenges due to funding cuts and high demand.7

 Access to health coverage changes as a person’s situation changes. In 2016, 23% of uninsured nonelderly

adults said they were uninsured because the person who carried the health coverage in their family lost

their job or changed employers (Figure 3). Nearly one in ten was uninsured because of a marital status

change, the death of a spouse or parent, or loss of eligibility due to age or leaving school (9%), and some

lost Medicaid because of a new job/increase in income or the plan stopping after pregnancy (12%).

 As indicated above, not all workers have access to coverage through their job. In 2016, 74% of nonelderly

uninsured workers worked for an employer that did not offer health benefits to the worker.8 Moreover, nine

out of ten uninsured workers who do not take up an offer of employer-sponsored coverage report cost as

the main reason for declining (90%).9 From 2006 to 2016, total premiums for family coverage increased by

58%, and the worker’s share increased by 78%, outpacing wage growth.10

 Medicaid and CHIP are available for low-income children, but eligibility for adults is more limited. As of

January 2017, 31 states plus DC had expanded Medicaid eligibility for adults under the ACA.11 However, in

states that have not expanded Medicaid, eligibility for adults remains limited, with median eligibility level

for parents at just 44% of poverty and adults without dependent children ineligible in most cases.12 Millions

of poor uninsured adults fall in a “coverage gap” because they earn too much to qualify for Medicaid but not

enough to qualify for Marketplace premium tax credits.13

 Undocumented immigrants are ineligible for Medicaid or Marketplace coverage.14 While lawfully-present

immigrants under 400% of poverty are eligible for Marketplace tax credits, only those who have passed a

five-year waiting period after receiving qualified immigration status can qualify for Medicaid.

Figure 3

NOTES: Includes nonelderly adults ages 18-64. Respondents can select multiple reasons. Status change includes marital status change, death of spouse or parent, or ineligible due to age or leaving school. SOURCE: Kaiser Family Foundation analysis of the 2016 National Health Interview Survey.

Reasons for Being Uninsured Among Uninsured Nonelderly Adults, 2016 Share who say they are uninsured because:

2%

9%

10%

12%

23%

45%

No need for health coverage

Family status change

Employer does not offer or ineligible for coverage

Lost Medicaid

Lost job or changed employers

Cost is too high

Key Facts about the Uninsured Population 4

Most remaining uninsured people are in working families, are in families with low incomes, and are nonelderly

adults.15 Reflecting income and the availability of public coverage, people who live in the South or West are

more likely to be uninsured. Most who remain uninsured have been without coverage for long periods of time.

Key Details:

 In 2016, three quarters of the uninsured (75%)

had at least one full-time worker in their

family, and an additional 11% had a part-time

worker in their family (Figure 4).

 Individuals below poverty16 are at the highest

risk of being uninsured. In total, eight in ten of

the uninsured were in families with incomes

below 400% of poverty in 2016 (Figure 4).

 While a plurality (44%) of the uninsured are

non-Hispanic Whites, people of color are at

higher risk of being uninsured than Whites.

People of color make up 42% of the nonelderly

U.S. population but account for over half of the

total nonelderly uninsured population (Figure

4). Hispanics and Blacks have significantly

higher uninsured rates (16.9% and 11.7%,

respectively) than Whites (7.6%).17

 Most (85%) of the uninsured are nonelderly

adults. The uninsured rate among children was

just 5% in 2016, less than half the rate among

nonelderly adults (12%),18 largely due to

broader availability of Medicaid/CHIP for

children than for adults.

 Most of the uninsured (78%) are U.S. citizens,

and 22% are non-citizens.19 Uninsured non-

citizens include both lawfully present and undocumented immigrants. Undocumented immigrants are

ineligible for federally funded health coverage, but legal immigrants can qualify for subsidies in the

Marketplaces and those who have been in the country for more than five years are eligible for Medicaid.20

 Uninsured rates vary by state and by region, with individuals living in the South and West the most likely to

be uninsured. The eight out of the twelve states with the highest uninsured rates in 2016 were in the South

(Figure 5 and Appendix A). This variation reflects different economic conditions, state expansion status,

availability of employer-based coverage, and demographics.

 Over two-thirds (67%) of the remaining uninsured in 2016 have been without coverage for more than a

year.21 People who have been without coverage for long periods may be particularly hard to reach in outreach

and enrollment efforts.

Figure 4

24%

25%31%

400%+ FPL 20%

Family Income (%FPL)

<100% FPL

100-199% FPL

200-399% FPL

75%

11% 15%

Family Work Status

NOTES: Includes nonelderly individuals ages 0-64. The U.S. Census Bureau's poverty threshold for a family with two adults and one child was $19,318 in 2016. Data may not total 100% due to rounding. Persons of Hispanic origin may be of any race; all other race/ethnicity groups are non-Hispanic. SOURCE: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

44%

15%

33%

5%

3%

Race

Characteristics of the Nonelderly Uninsured, 2016

Total = 27.5 Million Nonelderly Uninsured

1 or More Full-Time Workers

No Workers

Part-Time Workers Hispanic

White

Other

Asian/Native Hawaiian or

Pacific Islander

Black

Figure 5

DE

WY

WI

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI

PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH

NV NE

MT

MO

MS

MN

MI

MA

MD

ME

LA

KYKS

IA

INIL

ID

HI

GA

FL

DC

CT

CO CA

AR AZ

AK

AL

>12% percent (12 states)

7-12% (28 states) <7% (11 states including DC)

Uninsured Rates Among the Nonelderly by State, 2016

NOTES: Includes nonelderly individuals ages 0-64. SOURCE: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

Key Facts about the Uninsured Population 5

Health insurance makes a difference in whether and when people get necessary medical care, where they get

their care, and ultimately, how healthy they are. Uninsured adults are far more likely than those with insurance

to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable

conditions or chronic diseases go undetected.

Key Details:

 Studies repeatedly demonstrate that the

uninsured are less likely than those with

insurance to receive preventive care and

services for major health conditions and

chronic diseases.22, 23 One in five (20%)

nonelderly adults without coverage say that

they went without care in the past year

because of cost compared to 3% of adults with

private coverage and 8% of adults with public

coverage. Part of the reason for poor access

among the uninsured is that many (49%) do

not have a regular place to go when they are

sick or need medical advice (Figure 6).

 Because of the cost of care, many uninsured people do not obtain the treatments their health care providers

recommend for them. In 2016, uninsured nonelderly adults were three times as likely as adults with private

coverage to say that they postponed or did not get a needed prescription drug due to cost (18% vs. 6%).24

And while insured and uninsured people who are injured or newly diagnosed with a chronic condition

receive similar plans for follow-up care, people without health coverage are less likely than those with

coverage to obtain all the recommended services.25

 Because people without health coverage are less likely than those with insurance to have regular outpatient

care, they are more likely to be hospitalized for avoidable health problems and to experience declines in their

overall health. When they are hospitalized, uninsured people receive fewer diagnostic and therapeutic

services and also have higher mortality rates than those with insurance.26,27,28,29

 Research demonstrates that gaining health insurance improves access to health care considerably and

diminishes the adverse effects of having been uninsured. A seminal study of a Medicaid expansion in Oregon

found that uninsured adults who gained Medicaid coverage were more likely to receive care than their

counterparts who did not gain coverage.30 A comprehensive review of research on the effects of the ACA

Medicaid expansion finds that expansion led to positive effects on access to care, utilization of services, the

affordability of care, and financial security among the low-income population.31

 Public hospitals, community clinics and health centers, and local providers that serve disadvantaged

communities provide a crucial health care safety net for uninsured people. However, safety net providers

have limited resources and service capacity, and not all uninsured people have geographic access to a safety

net provider.32,33

Figure 6

Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2016

6%

3%

6%

12%

14%

8%

9%

12%

18%

20%

23%

49%

Postponed or did not get needed prescription drug due

to cost

Went Without Needed Care Due to Cost

Postponed Seeking Care Due to Cost

No Usual Source of Care

Uninsured

Medicaid /Other Public

Employer/Other Private

NOTE: Includes nonelderly adults ages 18-64. Includes barriers experienced in past 12 months. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. All differences between uninsured and insurance groups are statistically significant (p < 0.05). SOURCE: Kaiser Family Foundation analysis of the 2016 National Health Interview Survey.

Key Facts about the Uninsured Population 6

The uninsured often face unaffordable medical bills when they do seek care. These bills can quickly translate

into medical debt since most of the uninsured have low or moderate incomes and have little, if any, savings.34

Key Details:

 Those without insurance for an entire year

pay for one-fifth of their care out-of-pocket.35

In addition, hospitals frequently charge

uninsured patients much higher rates than

those paid by private health insurers and

public programs.36,37

 Medical bills can put great strain on the

uninsured and threaten their financial well-

being. In 2016, nonelderly uninsured adults

were over twice as likely as those with

insurance to have problems paying medical

bills (29% vs. 14%; Figure 7) with two thirds

of uninsured who had medical bill problems unable to pay their medical bills at all (67%).38 Uninsured

adults are also more likely to face negative consequences due to medical bills, such as using up savings,

having difficulty paying for necessities, borrowing money, or having medical bills sent to collection.39

 Uninsured nonelderly adults are also much more likely than their insured counterparts to lack confidence

in their ability to afford usual medical costs and major medical expenses or emergencies. Uninsured

nonelderly adults are over twice as likely as insured adults to worry about being able to pay costs for normal

health care (63% vs. 26%; Figure 7). Furthermore, over three quarters of uninsured nonelderly adults (76%)

say they are very or somewhat worried about paying medical bills if they get sick or have an accident,

compared to 44% of insured adults.

 Lacking insurance coverage puts people at risk of medical debt. In 2016, three in ten (30%) of uninsured

nonelderly adults said they were paying off least one medical bill over time (Figure 7). Medical debts

contribute to over half (52%) of debt collections actions that appear on consumer credit reports in the

United States40 and contribute to almost half of all bankruptcies in the United States.41 Uninsured people

are more at risk of falling into medical bankruptcy than people with insurance.42

 Though the uninsured are typically billed for medical services they use, when they cannot pay these bills,

the costs may become bad debt or uncompensated care for providers. State, federal, and private funds

defray some but not all of these costs. With the expansion of coverage under the ACA, providers are seeing

reductions in uncompensated care costs, particularly in states that expanded Medicaid.43

 Research suggests that gaining health coverage improves the affordability of care and financial security

among the low-income population. Multiple studies of the ACA have found larger declines in trouble paying

medical bills in expansion states relative to non-expansion states. A separate study found that, among those

residing in areas with high shares of low-income, uninsured individuals, Medicaid expansion significantly

reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies.44

Figure 7

29%

63%

76%

30%

14%

26%

44%

24%

Problems paying or unable to pay medical

bills

Worried about being able to pay costs for normal

care

Worried about paying medical bills if get sick

Medical bills being paid off over time

Uninsured Insured

NOTE: Includes nonelderly adults ages 18-64. All differences between uninsured and insured groups are statistically significant (p < 0.05). SOURCE: Kaiser Family Foundation analysis of the 2016 National Health Interview Survey.

Problems Paying Medical Bills by Insurance Status, 2016

Key Facts about the Uninsured Population 7

Millions of people have gained coverage under the ACA provisions that went into effect in 2014, and current

debate over rolling back ACA coverage threaten these gains in coverage and make it difficult to reach the 27.6

million who remain without coverage. Proposed policies to change the structure of the Medicaid program or

cut back subsidies for Marketplace coverage may lead to even more uninsured individuals. On the other hand,

if additional states opt to expand Medicaid as allowed under the ACA, there may be additional coverage gains

as low-income individuals gain access to affordable coverage. Going without coverage can have serious health

consequences for the uninsured because they receive less preventive care, and delayed care often results in

serious illness or other health problems. Being uninsured also can have serious financial consequences. The

outcome of current debate over health coverage policy in the United States has substantial implications for

people’s coverage, access, and overall health and well-being.

Key Facts about the Uninsured Population 8

Expansion States 13.6% 8.1% -5.5% -9,110,784 Alaska 15.8% 15.2% -0.5% -4,605 Arizona 21.2% 14.0% -7.1% -383,719 Arkansas 17.8% 9.1% -8.7% -206,013 California 16.4% 8.7% -7.6% -2,526,529 Colorado 13.8% 10.8% -3.1% -139,372 Connecticut 11.8% 7.2% -4.6% -145,215 Delaware 8.3% 10.6% 2.3% 20,756 District of Columbia 8.9% 5.9% -2.9% -15,885 Hawaii 5.7% 6.3% 0.6% 7,414 Illinois 11.9% 8.6% -3.3% -403,107 Indiana 14.6% 7.6% -7.0% -382,508 Iowa 9.5% 6.2% -3.3% -87,375 Kentucky 16.3% 7.2% -9.1% -351,749 Louisiana 16.4% 12.1% -4.3% -158,238 Maryland 13.3% 7.2% -6.0% -309,202 Massachusetts 3.6% 6.4% 2.7% 161,492 Michigan 12.1% 7.4% -4.8% -412,911 Minnesota 7.9% 6.9% -1.0% -52,380 Montana 19.0% 8.5% -10.4% -85,493 Nevada 22.0% 10.2% -11.8% -270,526 New Hampshire 13.2% 7.6% -5.6% -65,367 New Jersey 13.4% 9.0% -4.4% -339,457 New Mexico 19.5% 13.0% -6.5% -112,780 New York 11.1% 6.6% -4.5% -775,319 North Dakota 12.1% 8.9% -3.2% -19,617 Ohio 13.9% 6.5% -7.4% -708,788 Oregon 14.2% 6.2% -8.0% -257,142 Pennsylvania 11.6% 5.7% -5.9% -647,343 Rhode Island 10.7% 5.8% -5.0% -43,871 Vermont 9.1% 6.5% -2.6% -13,549 Washington 13.4% 8.1% -5.4% -299,746 West Virginia 14.2% 8.8% -5.4% -82,642 Non-Expansion States 18.1% 13.3% -4.8% -4,575,853 Alabama 17.8% 10.1% -7.7% -305,483 Florida 22.0% 14.6% -7.5% -1,128,462 Georgia 18.5% 13.7% -4.7% -334,624 Idaho 16.8% 10.2% -6.6% -87,058 Kansas 11.5% 9.8% -1.7% -41,999 Maine 11.3% 8.7% -2.6% -30,792 Mississippi 16.4% 13.9% -2.6% -63,174 Missouri 13.1% 9.8% -3.2% -168,358 Nebraska 10.6% 8.2% -2.4% -38,713 North Carolina 17.3% 12.4% -5.0% -377,650 Oklahoma 18.1% 12.4% -5.7% -163,857 South Carolina 18.9% 10.8% -8.1% -297,343 South Dakota 11.6% 9.4% -2.2% -15,268 Tennessee 15.2% 13.2% -2.0% -90,107 Texas 22.8% 17.1% -5.7% -1,191,130 Utah 13.7% 13.5% -0.2% 16,342 Virginia 13.1% 11.5% -1.7% -125,841 Wisconsin 10.4% 8.3% -2.2% -98,298 Wyoming 17.5% 11.2% -6.3% -34,040 SOURCE: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

Key Facts about the Uninsured Population 9

Total Nonelderly 271.1 100.0% 27.5 100.0% 10.1% Age

Children - Total 78.2 28.8% 4.2 15.3% 5.4% Nonelderly Adults - Total 192.9 71.2% 23.3 84.7% 12.1%

Adults 19 - 25 29.8 11.0% 3.9 14.2% 13.1% Adults 26 - 34 39.7 14.7% 6.2 22.7% 15.7% Adults 35 - 44 40.0 14.8% 5.3 19.1% 13.1% Adults 45 - 54 42.0 15.5% 4.3 15.8% 10.3% Adults 55 - 64 41.3 15.2% 3.5 12.8% 8.5%

Annual Family Income

<$20,000 35.9 13.3% 6.7 24.3% 18.6%

$20,000 - <$40,000 43.1 15.9% 6.8 24.9% 15.9% $40,000 + 192.1 70.8% 13.9 50.8% 7.3%

Family Poverty Level

<100% 36.5 13.5% 6.5 23.6% 17.7%

100% - <200% 44.2 16.3% 6.8 24.7% 15.3% 200% - <400% 78.8 29.1% 8.6 31.4% 10.9%

400%+ 111.6 41.2% 5.6 20.4% 5.0% Household Type

Single Adults Living Alone 45.0 16.6% 6.7 24.5% 15.0% Single Adults Living Together 35.7 13.2% 4.9 17.7% 13.6%

Married Adults 37.1 13.7% 3.2 11.5% 8.5%

1 Parent with Children 23.4 8.6% 2.2 8.1% 9.5% 2 Parents with Children 83.4 30.7% 5.5 19.9% 6.6%

Multigenerational 14.2 5.2% 1.6 5.9% 11.4% Other with Children 32.3 11.9% 3.4 12.4% 10.5%

Family Work Status

2+ Full-time 93.4 34.4% 6.8 24.8% 7.3%

1 Full-time 131.1 48.4% 13.7 49.9% 10.4% Only Part-time 19.4 7.2% 2.9 10.7% 15.1%

Non-Workers 27.2 10.0% 4.0 14.6% 14.7% Race/Ethnicity

White 157.5 58.1% 12.0 43.9% 7.6% Black 34.9 12.9% 4.1 14.9% 11.7%

Hispanic 53.6 19.8% 9.1 33.0% 16.9% Asian/N. Hawaiian and Pacific Islander 17.1 6.3% 1.4 5.2% 8.3%

American Indian/Alaska Native 2.1 0.8% 0.4 1.5% 18.9% Two or More Races 5.8 2.1% 0.4 1.6% 7.4%

Citizenship U.S. Citizen - Native 233.7 86.2% 19.8 72.3% 8.5%

U.S. Citizen - Naturalized 15.7 5.8% 1.6 6.0% 10.4% Non-U.S. Citizen, Resident for <5 Years 5.9 2.2% 1.4 5.0% 23.2% Non-U.S. Citizen, Resident for 5+ Years 15.8 5.8% 4.6 16.7% 29.0% Health Status

Excellent/Very Good 186.8 68.9% 16.9 61.5% 9.0% Good 61.9 22.8% 8.0 29.0% 12.9%

Fair/Poor 22.4 8.3% 2.6 9.5% 11.7% NOTES: Includes nonelderly individuals ages 0-64. The U.S. Census Bureau’s poverty threshold for a family with two adults and one child

was $19,318 in 2016. Parent includes any person with a dependent child. Multigenerational/other families with children include families

with at least three generations in a household, plus families in which adults are caring for children other than their own. Part-time

workers were defined as working <35 hours per week. Respondents who identify as mixed race who do not also identify as Hispanic fall

into the “Two or More Races” category. All individuals who identify as Hispanic ethnicity fall into the Hispanic category regardless of race.

SOURCE: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

Key Facts about the Uninsured Population 10

1

Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

2

Robin A. Cohen, Michael E. Martinez, and Emily P. Zammitti, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January – March 2017 (Hyattsville, MD: National Center for Health Statistics, August 2017), https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201708.pdf

3

State Health Facts. “Total Marketplace Enrollment and Financial Assistance, February 2017.” Kaiser Family Foundation, 2017, http://kff.org/health-reform/state-indicator/total-marketplace-enrollment-and-financial-assistance/

4

State Health Facts. “Total Monthly Medicaid and CHIP Enrollment.” Kaiser Family Foundation, June 2017, http://kff.org/health- reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/.

5

Rachel Garfield, Anthony Damico, Cynthia Cox, Gary Claxton, and Larry Levitt, New Estimates of Eligibility for ACA Coverage among the Uninsured (Washington, DC: Kaiser Family Foundation, Jan 2016), http://kff.org/health-reform/issue-brief/new- estimates-of-eligibility-for-aca-coverage-among-the-uninsured/

6

Bianca DiJulio, Jamie Firth, and Mollyann Brodi, Kaiser Health Tracking Poll: December 2015, (Washington, D.C.: Kaiser Family Foundation, Dec 2015), http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-december-2015/

7

Karen Pollitz, Jennifer Tolbert, and Ashley Semanskee. 2016 Survey of Health Insurance Marketplace Assister Programs and Brokers (Washington, DC: Kaiser Family Foundation, June 2016), http://www.kff.org/health-reform/report/2016-survey-of-health- insurance-marketplace-assister-programs-and-brokers/

8

Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

9

Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

10

Kaiser Family Foundation. 2016 Employer Health Benefits Survey (Washington, DC: Kaiser Family Foundation, September 2016), http://kff.org/report-section/ehbs-2016-summary-of-findings/

11

State Health Facts. “Status of State Action on the Medicaid Expansion Decision.” Kaiser Family Foundation, 2017, http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

12

Tricia Brooks, Karina Wagnerman, Samantha Artiga, Elizabeth Cornachione, and Petry Ubri, Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2017: Findings from a 50-State Survey (Washington, DC: Kaiser Family Foundation, January 2017), http://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost- sharing-policies-as-of-january-2017-findings-from-a-50-state-survey/

13

Rachel Garfield and Anthony Damico, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update (Washington, DC: Kaiser Family Foundation, January 2016), http://kff.org/health-reform/issue-brief/the-coverage-gap- uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/

14

Samantha Artiga and Anthony Damico, Health Coverage and Care for Immigrants (Washington, DC: Kaiser Family Foundation, July 2017), http://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/ 15

Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

16

$19,318 for a family of three in 2016

17

Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

18

Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

19

Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement

20

Samantha Artiga and Anthony Damico, Health Coverage and Care for Immigrants (Washington, DC: Kaiser Family Foundation, July 2017), http://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/

21

Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

22

Jack Hadley, “Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition.” JAMA 297, no. 10 (March 2007):1073-84.

23

Stacey McMorrow, Genevieve M. Kenney, and Dana Goin,“Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act,” American Journal of Public Health 104, no. 12 (Dec 2014): 2392-9.

24

Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

25

Jack Hadley, “Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition,” JAMA 297, no. 10 (March 2007): 1073-84.

26 Fizan Abdullah, et al., “Analysis of 23 Million US Hospitalizations: Uninsured Children Have Higher All-Cause In-Hospital Mortality,” Journal of Public Health 32, no. 2 (June 2010): 236-44.

27

Andrew Wilper, et al., “Health Insurance and Mortality in US Adults,” American Journal of Public Health 99, no. 12 (December 2009): 2289-2295.

28

Wendy Greene, et. al., “Insurance Status is a Potent Predictor of Outcomes in Both Blunt and Penetrating Trauma.” American Journal of Surgery 199, no. 4 (April 2010): 554-7.

29

Sarah Lyon, “The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients,” American Journal of Critical Care Medicine 184, no. 7 (October 2011): 809-15.

30 Amy Finkelstein, et. al, “The Oregon Health Insurance Experiment: Evidence from the First Year” (National Bureau of Economic Research, July 2011), http://www.nber.org/papers/w17190

31

Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Samantha Artiga, The Effects of Medicaid Expansion on the ACA: Findings From a Literature Review (Washington, D.C.: Kaiser Family Foundation, Jun 2016), http://kff.org/medicaid/issue-brief/the-effects- of-medicaid-expansion-under-the-aca-findings-from-a-literature-review/

32

Mark Hall, “Rethinking Safety Net Access for the Uninsured,” New England Journal of Medicine 364 (January 2011):7-9.

33

John Holahan and Brenda Spillman, Health Care Access for Uninsured Adults: A Strong Safety Net is not the Same as Insurance (Washington, DC: The Urban Institute, January 2002), http://www.urban.org/research/publication/health-care-access-uninsured- adults

34

Sherry Glied and Richard Kronick, The Value of Health Insurance: Few of the Uninsured Have Adequate Resources to Pay Potential Hospital Bills (Washington, DC: Office of Assistant Secretary for Planning and Evaluation, HHS, May 2011), http://aspe.hhs.gov/health/reports/2011/ValueofInsurance/rb.pdf

35

The Kaiser Commission on Medicaid and the Uninsured, Uncompensated Care for the Uninsured in 2013: A Detailed Examination, (Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured, May 2014), https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8596-uncompensated-care-for-the-uninsured-in-2013.pdf

36

Glenn Melnick, “Fair Pricing Law Prompts Most California Hospitals to Adopt Policies to Protect Uninsured Patients from High Charges,” Health Affairs 32, no. 6 (Jun 2013); 1101-8.

37

Stacie Dusetzina, Ethan Basch, and Nancy Keating, “For Uninsured Cancer Patients, Outpatient Charges Can Be Costly, Putting Treatments out of Reach,” Health Affairs 34, no. 4 (April 2015): 584-591, http://content.healthaffairs.org/content/34/4/584.abstract

38

Kaiser Family Foundation analysis of the 2016 National Health Interview Survey

39

Liz Hamel, Mira Norton, Karen Pollitz, Larry Levitt, Gary Claxton, and Mollyann Brodie, The Burden of Medical Debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey, (Washington, D.C.: Kaiser Family Foundation, Jan 2016), http://kff.org/health-costs/report/the-burden-of-medical-debt-results-from-the-kaiser-family-foundationnew-york-times-medical- bills-survey/

40

Consumer Financial Protection Bureau, “Consumer Credit Reports: A Study of Medical and Non-Medical Collections.” (Consumer Financial Protection Bureau: December 2014), http://files.consumerfinance.gov/f/201412_cfpb_reports_consumer-credit-medical- and-non-medical-collections.pdf

41

David U. Himmelstein, Deborah Thorne, Elizabeth Warren, Steffie Woolhandler, “Medical Bankruptcy in the United States, 2007: Results of a National Study.” The American Journal of Medicine, 122, no. 8 (2009): 741-6, http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf

42

Ibid.

43

Larisa Antonisse, Rachel Garfield, Robin Rudowitz, and Samantha Artiga, The Effects of Medicaid Expansion on the ACA: Findings From a Literature Review (Washington, D.C.: Kaiser Family Foundation, Jun 2016), http://kff.org/report-section/the-effects-of- medicaid-expansion-under-the-aca-findings-from-a-literature-review-issue-brief/ 44

Ibid.

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