The number of Americans who had no health insurance last year was at one of the lowest levels ever recorded, according to an authoritative government survey released Monday.
About 36 million people, or 11.5% of the entire population, were uninsured in 2014. That's down from 16% in 2010, when President Barack Obama's Affordable Care Act was signed into law. More than 170 million people had private health plans. However, the progress of expanding coverage remains unstable as the U.S. Supreme Court prepares to hand down a ruling in King v. Burwell, which will decide the fate of subsidized health insurance for 6.4 million people.
The latest figures come from the Centers for Disease Control and Prevention's National Health Interview Survey (PDF), one of the most comprehensive analyses of health coverage in the U.S. The CDC interviewed almost 112,000 people for the report.
The rates of the uninsured dropped for every age bracket studied. The most pronounced decline was for people ages 19 to 25. Their uninsured rate in 2010 was 33.9% and fell to 20% last year. The ACA allowed children and young adults to stay on their parents' health plans until they are 26.
Poorer citizens and minorities also gained health insurance more than others. The uninsured rate for people who earned between 100% and 200% of the federal poverty level was 12.6% in 2010 and 8.6% in 2014. The ACA expanded Medicaid to low-income Americans up to 138% of poverty. Uninsured levels fell the most for black and Hispanic residents.
But the survey showed wide disparities in health coverage by state. Ten states—Alaska, Arizona, Florida, Georgia, Mississippi, Nevada, North Carolina, Oklahoma, South Carolina and Texas—have uninsured rates of 14% or higher for all ages. Alaska and Texas tied for the highest rate at 19.4%. When only accounting for the non-Medicare, under-65 crowd, 21.5% of people in Oklahoma and Texas had no insurance, the highest in the country.
Republican governors currently lead those 10 states. Many GOP leaders have been hostile to the ACA, particularly when it comes to expanding Medicaid.
Health insurance coverage remains almost universal in Hawaii and Massachusetts. Their uninsured rates for all age groups were 2% and 2.6%, respectively. Hawaii has an employer mandate, and Massachusetts implemented a predecessor of the ACA when former Republican presidential candidate Mitt Romney was governor.
Beyond the state-by-state variation, the CDC's survey also shows potential holes in the health reform law. Millions of people still have no health insurance and won't in the near future.
Undocumented immigrants represent about 30% of the projected uninsured because they simply aren't eligible for coverage under the ACA, according to the Congressional Budget Office.
Many low-income residents would also qualify for expanded Medicaid coverage, but they live in states that decided not to implement that provision. Other poor, uninsured adults in those states that didn't expand Medicaid fall within the “coverage gap,” where their income is above Medicaid requirements but below the minimum to receive premium subsides on the exchanges.
Premium subsidies are at the heart of the debate in King v. Burwell. If the Supreme Court rules in favor of the plaintiffs, subsidies in states that rely on the federal government to run their insurance exchanges would be nixed. Coverage would become unaffordable for many, and the decision would all but eliminate the ACA's employer and individual mandates. Premiums and the uninsured rate would likely rise.
The CDC's survey also reaffirmed that most health plans are moving toward higher deductibles. Almost 37% of people younger than 65 with private health insurance were enrolled in a high-deductible health plan last year, compared with 25.3% in 2010. Those plans had a deductible of at least $1,250 for single coverage and $2,500 for families.
Health insurers have been pushing more employers and individuals toward high-deductible plans to keep premiums down. But many experts have said high deductibles in their current form are blunt instruments that leave people with prohibitively high out-of-pocket costs.