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The Uninsured: Who are They?

The number of uninsured Americans younger than 65 years was estimated to be 46 million in 2008 and rose as a result of the economic downturn and the growing cost of health plan BOX 3-12 GENOMICS Genetics and Pharmacogenetics Source Woo, T., & Robinson, M. (2016). Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.). Philadelphia: F.A. Davis. premiums (KFF, 2012). The 2010 ACA is expected to reduce the number of uninsured significantly with the expansion of Medicaid, subsidies to pay premiums in health insurance exchanges, a federal mandate requiring most legal citizens to enroll in an insurance plan or face tax penalties for noncompliance, and a provision allowing children to remain on their parents’ employer family insurance until the age of 26 years (Figure 3-15). Previously, when children reached the age of 19 years and were not full-time college students, they were deleted from employer family insurance plans. Even with all the new options afforded by the ACA, a number of individuals will remain uninsured. Undocumented immigrants (those who are noncitizens and are living in the United States illegally) do not qualify for Medicaid or any other public insurance plan and are also exempt from paying the federal tax penalty. This population is extremely vulnerable because of language and cultural barriers and fear of being discovered as an illegal immigrant; therefore they typically do not seek health care. Provisions in current law require emergency care to be provided as well as care to be provided to pregnant women, regardless of alien status (KFF, 2010a). Another group of individu- als are those who choose not to enroll in a qualified insurance plan and instead elect to pay the annual federal tax penalty. The ACA includes a federal tax penalty for individuals who do not obtain coverage beginning in 2014. The penalty increased every year for the next 3 years for any individual not exempted from the requirement who does not have coverage. For example, the per-adult penalty in 2014 was $95, rose to $325 in 2015, and rose to $695 in 2016. Exemptions from the federal penalty include undocumented immigrants, those whose incomes are below the minimum amount required to file federal income tax returns, those with incomes below 138% of the poverty level in states that have not expanded eligibility for Medicaid, and those who would have to pay more than 8.13% of household income for insurance. In 2016 the tax penalty was calculated to be the greater of the following two amounts: a flat dollar amount of $695 per adult and $347.50 per child, up to a maximum of $2085 for the family, or 2.5% of family income in excess of the 2015 income tax filing thresholds ($10,300 for a single person and $26,600 for a family). It is estimated that 7 million uninsured people are eligible for marketplace premium subsidies to assist with the cost of premiums. For about half who qualify, the cost of the lowest plan (a bronze plan) would have a zero premium cost. For others (an additional 3.5 million people) the cost of a bronze plan using their premium subsidy would be less than the penalty. However, although the cost of the premium for a bronze plan may be zero or reduced, which fulfills the ACA mandate, bronze plans typically have a higher copayment when used. The next level of insurance premiums, called silver premiums, may have a higher premium cost but significantly less copayment cost at the time of use. Health care providers and nurses need to stay abreast of all of these changes to help individuals and families navigate the complexities of the financial aspects of insurance. Once this portion of the law is fully enacted, it is expected that many more Americans will choose to obtain coverage as it will be less costly than paying the penalty. For some, the reality of the ACA insurance mandate will not be realized until federal tax returns are filed for 2016, in the early part of 2017 (KFF, 2016). Nurses and health care providers can assist individuals and families in both gaining coverage and selecting a plan that best suites their needs. Another group of individuals who may not have coverage are noncitizens who are legally traveling within the United States (business, education, tourism) unless they have purchased secondary travel insurance before entering the United States.

Unauthorized Immigrants

The Pew Research Center (Gonzalez-Barrera & Krogstad, 2015) and the US Department of Homeland Security (2014) estimated the number of illegal aliens in 2014 in the United States was 11.3 million, or 3.5% of the nation’s population. Almost 50% of unauthorized immigrants are from Mexico. Although it is difficult to determine exact numbers, in 2012, 8.1 million unauthorized immigrants were estimated to be working or looking for work. Some unauthorized immigrants entered the United States without valid documentation, whereas others arrived with valid visas but stayed past the visa expiration date. About 60% of unauthorized immigrants are located in six states: California, Texas, Florida, New York, Illinois, and New Jersey. Immigration reform remains a contested project with concern about both entry into the country and how to deal with unauthorized immigrants who are already living in the United States. In 2013, 662,483 individuals were apprehended: 438,421 individuals were removed and 178,371 individuals were returned. This is the lowest number of returned or removed individuals since 1972 (Gonzalez- Barrera & Krogstad, 2015). According to federal law, anyone entering an emergency department must be treated regardless of the ability to pay or immigration status. However, those individuals who are in the United States illegally may be reluctant to seek health care for fear of legal action, being removed, or being returned. This vulnerable population is not eligible to enroll in Medicare or Medicaid programs and have various unmet health care