Census Figures Show U.S. Health Insurance Coverage Declined for the First Time in a Decade

2018 sees the uninsured rate jump, leaving an additional 1.9 million people without coverage

The U.S. Census Bureau released its health insurance coverage estimates for 2018. September’s figures show a 0.5 percentage point jump in the uninsured between 2017 and 2018 — that’s approximately 1.9 million more people without coverage. The new statistics reveal 27.5 million people in total had no health insurance in 2018 — which is approximately 8.5 percent of the U.S. population. The report represents the first government-based evidence indicating an increase in the uninsured rate in a decade.

Medicaid by Far the Biggest Loser

The decline in people covered by any health insurance in 2018 appears to be driven by a 0.4 percentage-point decrease in public health insurance. Medicaid coverage was by far the biggest loser, experiencing the sharpest drop of 0.7 percentage points overall. In contrast, the rate of Medicare coverage shifted in the opposite direction, increasing by 0.4 percentage points

The four states witnessing the most significant rise in their uninsured population — Alabama, Idaho, Tennessee, and Texas, have not fully expanded Medicaid under the ACA. According to the figures, Texas continued to lead the pack with the highest uninsured rate of 17.7 percent. Conversely, the three states experiencing the biggest decline in people without health insurance coverage were Wyoming (1.8 percentage points), South Carolina (0.5 percentage points), and New York (0.3 percentage points). In general, the uninsured rate in states that expanded Medicaid eligibility prior to January 1, 2018, was lower than the states that did not expand eligibility. 

Significant Coverage Losses for Children and Young Adults

Another worrying statistic from the report reveals the number of children covered by Medicaid and the Children’s Health Insurance Program fell by more than 0.6 percentage points in 2018. According to administrative data, 5.5 percent of children under the age of 19 lacked any health insurance. Driven by a dip in public coverage, the figure represents an estimated increase of 425,000 children over the previous year. In total, 4.3 million children had no health insurance coverage in 2018. Coverage losses were also evident across different age groups. Overall, there were more uninsured adults aged 35-64.

Young adults remained the least likely to be insured in 2018 — those aged 19 to 25 had the highest uninsured rate (14.3 percent) of any age group.

Racial and Age Disparities Persist

The report also highlights the emergence of racial disparities in the level of insurance coverage. Under the ACA, people of color have seen big gains in coverage, narrowing long-standing disparities between white non-Hispanic, Hispanic and black people. However, between 2016 and 2017, those coverage gains began to stall. By 2018, those gains were reversed for several groups, including small but significant uninsured rate increases for whites, blacks, and Hispanics. The 2018 census numbers showed 5.4 percent of white non-Hispanic people were uninsured, while 9.7 percent of blacks and 17.8 percent of Hispanics lacked coverage. 

Economy Doing Well but Had Little Impact 

A booming economy and creation of more jobs haven’t helped increase the rate of coverage either. Although health coverage typically increases when the economy grows, in 2018 that didn’t happen. Even though the number of Americans living in poverty hit the lowest level since 2001, and despite household incomes reaching their highest level on record, the number of people with health insurance coverage plunged between 2017 and 2018. This growth in the uninsured population is a surprising trend given the economy was doing so well. 

Overall, health insurance coverage rates for workers and nonworkers decreased by 0.8 percentage points and 0.7 percentage points, respectively. Coverage rates also declined 0.9 percentage points for people who work full-time, year-round and for people who work less than full-time, year-round. What this means is even when employers provide insurance policies to employees and their families, the appeal of these policies sours due to hefty premiums and high deductibles. As a result, consumers are experiencing little respite from the mounting costs of medical care. 

VisitPay: Your Revenue Cycle’s Best Defense

For rural and urban health systems battling to reduce costs and find better ways to provide sustainable healthcare, it’s an uphill struggle to keep the revenue cycle management books healthy. With noticeable declines in insurance coverage and the continued rise in restrictive premiums and deductibles, healthcare executives are exploring how to improve revenue cycle performance while providing patients with alternative ways to manage their healthcare obligations. With so many insured patients presenting at the time of registration or service with unknown deductibles and co-insurance, patient-pay is the rule rather than the exception. Having the ability to offer patients a different path — one where they are able to propose what they feel they can pay, based on a combination of discussion and analytics, is a more effective strategy for collections and charity write-offs. 

To understand what patient payment means for your health system, explore the myth-busting post entitled, Charity Care and Traditional Collections Strategies Are Fit for Purpose for Consumer Payments.

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