US uninsurance rate falls, but 48.6 million still lack coverage: Affordable Care Act contributes to gains
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* Donya Currie

While a drop in the number and rate of uninsured Americans is heartening news to public health advocates and indicates success from some provisions of the Affordable Care Act, nearly 49 million people still lack health insurance.

The U.S. Census Bureau released data in September that showed 48.6 million Americans did not have health insurance in 2011, a drop of 1.3 million from the previous year. That marked the largest one-year drop in uninsured Americans in the past decade, said Sara Collins, PhD, vice president for affordable health insurance at the Commonwealth Fund.

“It is absolutely good news,” Collins told *The Nation’s Health*. “But I think there’s a lot of improvement yet to be made.”

The census figures show the greatest gains in coverage were among young adults, a move credited to the Affordable Care Act’s provision that adults ages 19–26 can remain on their parents’ health plans.

“A decrease in the number of uninsured Americans is strong evidence that the law is working,” APHA Executive Director Georges Benjamin, MD, FACP, FACEP (E), said. “However, the 48.6 million Americans still without health care coverage highlight the important role that full implementation of the Affordable Care Act will play in improving the health of all Americans.”

Growth among public insurance programs such as Medicaid also fueled the drop in uninsured, said David Johnson, PhD, chief of the Census Bureau’s Social, Economic and Housing Statistics Division. During a news conference announcing the 2011 estimates, Johnson said the number of people covered by public insurance programs has been increasing consistently for the past five years, likely due to more children being covered under the Children’s Health Insurance Program and more baby boomers becoming eligible for Medicare.

“I think we’re not surprised by the increase in public insurance because it’s been continuing to happen,” Johnson said.

That growth, though, points to a need to continue to support safety net programs, advocates say.

“I think, through the recession and even before that as private coverage has declined, Medicaid and the Children’s Health Insurance Program have really acted as a safety net,” said Peter Cunningham, PhD, senior fellow and co-director of quantitative research at the Center for Studying Health System Change. “Had those programs not been there, you would have seen a much bigger increase in the number of uninsured.”

The recession has also had an impact on U.S. poverty rates. The census survey found that about 9.5 million American families were in poverty in 2011, an 11.8 percent rate.

This year’s drop in the number of uninsured, especially among young adults, is a hint at how the health reform law is chipping away at the lack of access to insurance and health care, said Andy Hyman, JD, director of the Robert Wood Johnson Foundation’s coverage team.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/42/9/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/42/9/1.3/F1)

Laura Fritz, shown with daughter Adalade Goudeseune, fills out a form at Jackson Action Center, an assistance center in Lakewood, Colo., in July. A recent census survey found that 9.5 million American families were in poverty in 2011.

Photo by Kristen Wyatt, courtesy AP Images

“It’s a window, a small window, into what we can expect and hope for in the years after the law goes into full effect after January 2014,” Hyman told *The Nation’s Health*. “It is bittersweet because we still do have a really tragic, high rate of uninsurance in the country.”

The national census estimates were based on the Current Population Survey, a sample of about 77,000 households that gives a snapshot of poverty rates, income and insurance source and status. The following week, Census Bureau officials released the 2011 American Community Survey estimates of insurance coverage, which were based on a larger sample size of about 2 million households and gave more of a state and local picture.

The community survey found 20 states had significant drops in uninsurance rates, with the largest declines in Oregon, Rhode Island and Vermont.

As expected, states varied in numbers of uninsured because of a variation in their publicly funded insurance programs and safety nets, which range from small charities funding individual clinics to a robust system including community health clinics and hospitals.

Both census surveys are important in understanding the role of the Affordable Care Act in helping more people become insured, said Lynn Blewett, PhD, founding director of the State Health Access Data Assistance Center at the University of Minnesota.

As the Affordable Care Act is implemented, it will have an impact on who is uninsured and who remains without coverage, Blewett noted.

Disparities persist when it comes to those who lack health insurance, the census estimates showed. In 2011, more than 30 percent of Hispanics were uninsured, compared to 19.5 percent of blacks, about 15 percent of whites and about 17 percent of Asians.

Rates of uninsurance were highest in the South and West, and income was a strong predictor of insurance status. The rate of uninsurance among people with yearly incomes below $25,000 was about 25 percent, or more than three times the about 8 percent rate for those with incomes of $75,000 or more. And 28 percent of adults ages 25–34 lacked health insurance in 2011, the age group with the highest rate of uninsurance now that the Affordable Care Act provision allowing younger adults to stay on their parents’ policies has taken effect.

In the weeks following the release of both census reports, analysts said there was no doubt full implementation of the Affordable Care Act would bring insurance to millions more Americans. But a recent Congressional Budget Office estimate found the range of uninsured still is likely to be 27 million to 29 million in 2014 even after health insurance exchanges are up and running and many states expand their Medicaid programs to cover more low-income individuals and families.

But the future is hard to predict, Cunningham said.

“I think there’s also a lot of controversy over what is the ACA is going to do to employer-sponsored coverage,” he said during a mid-September webinar on the census statistics sponsored by the Alliance for Health Reform. “Some would argue it does give employers incentive to drop coverage because it’s going to be cheaper for them to pay the penalties rather than to continue to offer coverage. No one really knows what is going to happen.”

Yet the consequences of lacking health insurance provide a stark reminder for continued advocacy, according to a 2009 study in APHA’s *American Journal of Public Health*. That study found for every 1 million people without health insurance, there were 1,000 related, preventable deaths. That means last year 48,000 people died needlessly because they could not access timely and appropriate care, said Steffie Woolhandler, MD, MPH, a study co-author and professor of public health at the City University of New York and visiting professor of medicine at Harvard Medical School.

“I think we public health professionals need to be advocating for real universal health care,” Woolhandler told *The Nation’s Health*.

Many studies have shown lack of insurance results in poorer health outcomes as well as financial burdens for individuals and families. A 2008 Medicaid expansion in Oregon underscored the demand. The state held a lottery, and about 90,000 low-income adults applied for 10,000 Medicaid slots.

Researchers studying the Oregon expansion found Medicaid coverage raised the likelihood of having a regular office visit or clinic for primary care by 70 percent and decreased by 40 percent the likelihood of having to borrow money or skip paying other bills to pay for health care. Having coverage increased the likelihood of people reporting they were in good to excellent health by 25 percent.

Tracking who and how many people have health insurance will continue to be important as federal health reform moves forward and as health care costs continue to affect insurance rates, said Rachel Garfield, PhD, senior researcher and associate director at the Kaiser Commission on Medicaid and the Uninsured.

“It’s always important to keep in mind that for each number there’s a person behind that,” Garfield said. “Not having health insurance really makes a difference.”

“Income, Poverty and Health Insurance Coverage in the United States: 2011” is available online at [www.census.gov](http://www.census.gov).

*   Copyright The Nation’s Health, American Public Health Association