Medicaid and the health insurance exchanges spurred much of the decline. More than 6.7 million people gained Medicaid coverage last year, a direct result of the ACA's expansion of Medicaid eligibility to people who make up to 138% of the federal poverty level. Thirty-one states and the District of Columbia have expanded Medicaid. Republicans control the governor's seat or statehouse in the states that have yet to expand Medicaid, which was made optional under a 2012 Supreme Court ruling.
Approximately 10 million Americans have purchased coverage through the state and federal exchanges created by the ACA, most of whom receive premium tax credits or cost-sharing subsidies to help pay down their insurance costs. Several million more directly purchase healthcare policies from insurers, often called off-exchange plans.
“There is a healthy increase in the nongroup market and in Medicaid, and this is consistent with what other federal surveys have seen,” said Katherine Hempstead, the director of health insurance research at the Robert Wood Johnson Foundation. “It's indisputable that there's been a statistically significant decline in the uninsured.”
Most people still get their health insurance through their jobs, the Census data confirmed. More than 55% of Americans had employer-based coverage. Government-based plans, mostly Medicare and Medicaid, accounted for 36.5% of health insurance.
Medicaid expansion and the exchanges also fueled the drop in the uninsured rate among low-income earners and minorities. The number of uninsured people who made between $25,000 and $49,999 per year fell by 5 percentage points from 2013 to 2014. The uninsured rate among blacks, Hispanics and Asians all declined by more than 4 percentage points in the same period.
However, 1 in 5 Hispanics, or 11 million people, still lacked health insurance last year, the most of any race or ethnicity studied by the Census Bureau. The uninsured rates for blacks, Asians and non-Hispanic whites in 2014 were 11.8%, 10.1% and 7.6%, respectively.
But as many health insurance experts have pointed out, higher rates of health insurance don't equate to comprehensive coverage. For instance, a recent report from the Commonwealth Fund report showed 14 million adults were “underinsured,” meaning their deductibles and out-of-pocket medical expenses absorbed a sizable portion of their household income. That includes people with employer-based health insurance.
The Census data shows that medical expenses are a major factor for those living in poverty. “We're witnessing a dramatic acceleration of the trend of shifting more and more medical costs onto the shoulders of patients and their families,” Dr. Robert Zarr, president of Physicians for a National Health Program, a left-leaning group that supports a single-payer insurance system, said in a statement. “Such financial barriers are untenable, economically and morally,” he added.
However, the ACA caps how much people have to pay out of their own pockets. The maximum amount any person has to pay for in-network care next year is $6,850 for individuals and $13,700 for families.
“The main advantage of health insurance is protecting against catastrophic expenses,” Hempstead said. While many low-income earners still may struggle with the health law's out-of-pocket limits, “it's nothing like the kind of exposure they used to have,” she said.
The Census Bureau changed its health insurance survey methodology last year to get a more accurate read of who has coverage. Conservatives have criticized the switch. Ed Haislmaier, a senior fellow at the right-leaning Heritage Foundation, said in a statement there are discrepancies between the CMS and Census Bureau data and that there was “little net growth in the number of people with private health insurance coverage.”