The Washington PostDemocracy Dies in Darkness

The Health 202: The rate of people without health insurance is creeping upward

Placeholder while article actions load

with Paulina Firozi


New Census Bureau data on the number of uninsured Americans is either a testament to the resiliency of the Affordable Care Act or a sign that President Trump's anti-ACA rhetoric and policies are starting to work. 

As our colleague Jeff Stein reported Wednesday, there was a slight uptick in the number of Americans without health insurance in 2017 compared to 2016, even though that number essentially remained statistically flat. Still, the fact that uninsured rate went up at all, by about 400,000 people, marks the first time since the ACA's implementation that the uninsured rate didn't drop. 

Supporters of the ACA worry the news marks the beginning of a trend, especially when some of Trump administration policies intended to circumvent the ACA go into effect next year. 

Ahead of open enrollment last year, the Trump administration dramatically decreased funding for any Obamacare outreach or advertising, limited resources for "navigators" who help people find an insurance plan, and shortened the window for people to sign up for insurance from three months to six weeks in states that use a federally run marketplace. 

"Even with all of that, health coverage stayed steady. But at the same time, we’d like to see further progress in the rate of the uninsured," said Judith Solomon of the Center on Budget and Policy Priorities. 

It's part of a pattern to weaken the 2010 health-care law known as Obamacare. After the GOP Congress failed to repeal and replace the ACA last summer, the Trump administration moved to dilute the law in other ways: including signing off on a plan to eliminate the individual mandate penalty next year; allowing individuals to buy skimpier, short-term health plans without certain coverage requirements under Obamacare; and seeking to allow states to put conditions on Medicaid coverage.

Some of the most prominent health care organizations in the country came together this morning to voice their disapproval of those short-term plans — including the American Cancer Society Cancer Action Network, the American Heart Association, Planned Parenthood Federation of America, the National Women’s Law Center, the , American Academy of Family Physicians, the American Academy of Pediatrics and Families USA. 

“The Administration’s decision to expand short-term health plans will leave cancer patients and survivors with higher premiums and fewer insurance options," said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

The groups' statements, compiled and released by Sen. Tammy Baldwin (D-Wis.), are in support of the senator's effort to have Congress rescind the White House regulation. Nearly every Democratic senator has signed a resolution of disapproval to overturn it.  

The census data reflects trends that started last year, when the administration's policies had yet to be implemented. Fourteen states saw their uninsured populations rise in 2017. The only three states that didn't see a spike in that number were New York, California and Louisiana. The first two aren't surprising given those states' robust efforts to enroll their own residents, while Louisiana expanded Medicaid in June 2016 so its decrease represents those low-income individuals who now have government coverage. 

Medicaid expansion in most of the 33 states and D.C. that have done so under the ACA has predictably decreased the number of people without coverage. The uninsured rate last year in states with an expanded Medicaid program was 6.6 percent compared to 12.2 percent in non-expansion states — a gap that has only continued to grow since 2013. 

To be fair, as Larry Levitt, senior vice president at the Kaiser Family Foundation, pointed out on Twitter: the uninsured rate started leveling off before the Trump administration started its work. But Levitt suggested the uninsured rate may really rise in 2019 when elimination of the individual mandate penalty takes effect. Moreover, states are increasingly taking the White House up on its suggestion to add work requirements to their Medicaid programs — in just the first three months of it being implemented in Arkansas, more than 4,000 people were jettisoned from the rolls for failure to comply. 

Matthew Fiedler, a health-policy expert at the Brookings Institution, agreed with Levitt's assessment, noting that the bulk of the people who were uninsured pre-ACA have already been enrolled  in the program. He contended that if policy had remained static, there would likely have been a modest decline instead of similar increase in the uninsured rate -- though not a dramatic one. The real effects, he said, of the Trump administration's efforts to chip away at the ACA are still to come. 

"I don’t think the right takeaway is that none of the policy changes will have a negative effect. I think they will going forward, we just haven't seen that yet," he said. "I think if your goal is to evaluate the ACA, I think the right takeaway is that there was a lot of progress, but more policy progress to be made."

Of course, Democrats and Republicans have disparate views on how to get there. Democrats are now pushing for a public option or a universal health care system in which the government would foot the bill for many health-care costs. A lot of them feel  the ACA "got us roughly 40 percent there and established a framework for lawmakers to make that progress going forward," Fiedler said. That's why we're now seeing so many Democratic candidates and lawmakers embracing some iteration of a "Medicare for all" program.  

Republicans still criticize the ACA as vast government overreach and are vowing they will take another stab at repealing it should they maintain the congressional majorities after the November midterms.

“We made an effort to fully repeal and replace ObamaCare and we'll continue," Vice President Pence said while campaigning for Baldwin's opponent, Leah Vukmir, if the GOP performs well in the midterms.


One additional interesting data point from the census is ages at which there was the greatest increases or decreases in the uninsured rate. As highlighted in the chart above, rates of those without insurance rose at ages 18 and 19 -- when children are no longer eligible for the Children's Health Insurance Program; and for those between ages 25 and 26 -- when children no longer qualify for their parents' insurance. The uninsured rate dropped, however, for those aged 64 and 65 -- when adults are eligible for Medicare.

The greatest spike in those without insurance was documented for 26 year olds. That's likely because young adults are typically healthier and feel less urgency to pay for insurance when they lose coverage under their family's plan.

As noted by the New York Times' Margot Sanger Katz on Twitter, these stats show just how crucial government programs and laws have been in providing health coverage to Americans:


AHH: Food and Drug Administration Commissioner Scott Gottlieb announced a major move against retailers for allegedly selling e-cigarettes to minors and threatened a ban of flavored e-cigarette liquids in an effort to stop the “epidemic” of teen vaping.

“The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end,” Gottlieb said in a speech to FDA employees announcing the enforcement action against 1,300 retailers, The Post’s Laurie McGinley reports. She adds officials say it’s the “largest coordinated enforcement action in the agency’s history.”

Preliminary data shows a 75 percent hike in e-cigarette use among high-school students in 2018 compared with last year, Laurie reports. “The FDA declined to publicly release the numbers, but people familiar with them said they were preliminary data from the National Youth Tobacco Survey, on which the agency and the Centers for Disease Control and Prevention collaborate,” she adds.  

OOF: Arkansas officially announced the number of people who were dropped from the Medicaid rolls after failing to meet the state's new work requirements. And as Colby reported in The Health 202 last week, thousands of low-income residents are now ineligible for the program.

Gov. Asa Hutchinson (R) released official numbers Wednesday. As of Sept. 1, 4,353 people were dropped from Medicaid coverage in the state, Amy Goldstein reports. It’s the first state in the nation to implement work requirements for some adults in the health program. There are 26,000 people subject to the work requirements.

“I don’t like that number,” Hutchinson said Wednesday, adding that 1,000 people in the program found employment, and that the work rule is a “proper balance of those values that we hold important,” including work and personal responsibility,” Amy reports.

As Colby noted, the result of in Arkansas will serve as a test for whether work requirements can be effectively applied in other states seeking to do the same thing.

“The concrete reality of more than 4,300 individuals losing insurance — diminishing their access to care — is alarming leaders at medical and mental health clinics and hospitals, as well as legal advocates for the poor,” Amy writes. “They say that logistics of the work rules are ill-suited to the lives of many poor Arkansans, who may not have computer access or may not have even received — or understood — letters the state sent telling them what they need to do to stay on Medicaid.”

In the town of Yabucoa, residents say the Trump administration let them down and their struggle continues. (Video: Whitney Leaming, Jorge Ribas/The Washington Post)

OUCH: People in Puerto Rico say they are still struggling nearly a year after the devastation of Hurricane Maria passed through the U.S. territory, creating an “enduring humanitarian crisis affecting nearly all aspects of life on the island,” our Post colleagues Scott Clement, Emily Guskin and Katie Zezima report.

A new Washington Post-Kaiser Family Foundation poll found 83 percent of people reported “either major damage to their homes, losing power for more than three months, employment setbacks or worsening health problems, among other effects of the storm,” our colleagues report.  Even more specifically, 23 percent said they had a new or worsened health condition and 9 percent said they received mental-health services. The Post and Kaiser survey is a result of a face-to-face survey of 1,500 randomly selected adult residents in Puerto Rico, all of whom lived there when the storm hit.

Just this week, Trump touted the administration’s response following the catastrophic storm, saying it was an “incredible, unsung success.”

“It’s amazing that he really believes that,” 55-year-old diabetes educator Jorge Antonio Rodriguez Zayas told The Post. He said residents are “living day by day, and we’re living with hope that things might get better, but they have not.”


 — The Centers for Medicare and Medicaid Services yesterday announced it has doled out $10 million in grants for grassroots groups that aim to help Americans sign up for insurance under the ACA.

Our colleague Amy previously reported the Trump administration was set to slash most of the funding for the navigator groups, dropping the funding from $36.8 million to $10 million for the enrollment period starting in November.

“The grants announced today mark a new direction for the Navigator program aimed at providing a more cost-effective approach that takes better advantage of volunteers and other community partners,” CMS Administrator Seema Verma said in a statement. “This new direction will increase accountability and ensure the grants are effective in helping consumers find health coverage that meets their needs. We will continue to monitor the impact of these changes with the primary goal of ensuring consumers have the resources to select a health plan that best fits their needs.” 


— Planned Parenthood announced it has tapped Baltimore health commissioner Leana Wen to be its new president, succeeding Cecile Richards, who ran the organization for a dozen years. Wen is the first physician to lead the women's health group in nearly half a century.

Wen is an emergency room doctor who has been an “outspoken critic of President Trump,” our Post colleague Lenny Bernstein reports.

“The decision to appoint her to lead one of the country’s most visible women’s health organizations signals, as Wen said in a video for the group, Planned Parenthood’s desire to emphasize the basic health-care services it provides beyond abortions,” Lenny writes. “Wen has been appointed in an era when Planned Parenthood has fought administration attempts to cut off its taxpayer funding and faces deep concerns about the U.S. Supreme Court’s tilting increasingly against abortion rights.”

Wen, 35, “immigrated from China with her family as a child. Her family relied on Medicaid, food stamps and Planned Parenthood for health care as she grew up in California,” Lenny writes. “In recent years, Wen has been one of the more outspoken and progressive advocates of a public health approach to the opioid epidemic in a city that has long been plagued by heroin. She was an early proponent of widespread distribution of naloxone, the fast-acting antidote to opioid overdoses, making it available over the counter to anyone who wanted it.”

Rep. Elijah Cumming (D-Md.) told the New York Times’s Kate Zernike “anyone who has worked with Dr. Wen knows that when it comes to protecting her patients, she doesn’t back down from a fight.” “In Baltimore, she has expanded care, found solutions around obstacles, and, most important of all, saved lives. While Baltimore is losing its ‘Doctor for the City,’ Planned Parenthood is gaining a powerful new advocate,” he added.


— The Health 202 reported yesterday that an opioids package would pass the Senate this week, but the vote has been postponed until Monday night. The Senate adjourned early to allow lawmakers to make it home before Hurricane Florence hit. 

"The pain that opioid addiction and drug abuse has inflicted on families across America is almost unfathomable," Senate Majority Leader Mitch McConnell said on the floor. "And I’ll be proud to vote to pass this legislation soon.”

— New research found nearly 600 Twitter accounts linked to the Internet Research Agency, a Russian-linked company, tweeted mostly about health policy and the ACA.  

The Wall Street Journal’s Stephanie Armour and Paul Overberg report that while Russian Twitter accounts “often focus on such hot-button issues as Hillary Clinton’s email or athletes kneeling during the national anthem, they also target substantive and divisive policy areas like health care.”

“Researchers at Clemson University provided The Wall Street Journal with the set of about 9,800 tweets involving health policy and the ACA that the IRA posted over that period,” Stephanie and Paul write. “An analysis by the Journal found that 80% of the tweets had conservative-leaning political messages, often disparaging the health law.”

— The Democratic Congressional Campaign Committee launched a series of television ads featuring a fictional smart speaker “Audrey” to target the health-care record of Rep. John Abney Culberson (R-Texas), who represents Texas' 7th Congressional District.

In one version of the ad, a woman asks why “prescriptions are so expensive." “Audrey” explains the role of Congress, adding Culberson “voted with the drug companies” and “received over $115,000 in contributions from the drug industry and also voted to give drug companies a billion dollar tax break.”

“Oh really? Well bless his heart,” a woman responds to her speaker.


— Throughout the Carolinas, many nursing homes and elderly care institutions were shutting their doors and preparing to evacuate residents, “worried about a repeat of last year’s deaths of elderly residents after Hurricane Irma struck Florida,” The Post’s Kristine Phillips and Patricia Sullivan report.

“While officials at many senior-care facilities in Myrtle Beach and Wilmington, N.C., had boarded up their facilities by Wednesday after a week of preparation, others said they were confident that their planning was adequate to keep their facilities in operation, saying they have taken every precaution to safeguard residents, employees and, often, their families,” Kristine and Patricia write.

“North and South Carolina’s state governments said it is up to individually operated nursing homes outside of mandatory evacuation zones to decide whether to move their medically fragile patients,” they add.

Lee Young, vice president of operations for Holiday Retirement said some facilities along the southeastern coast, from Savannah, Ga., to the Chesapeake Bay, have been in the path of previous storms before and were ready with supplies.

“Let’s face it — this can be a fragile population. They’re our responsibility,” Young said. “As they move in with us and seek to experience a better life, we want to make sure that when things are at their worst, that they’re taken care of.”


— It’s not just you. New research from Gallup based on the emotional lives of more than 154,000 people in 145 countries found more people reported “negative experiences, defined as worry, stress, physical pain, anger or sadness, than at any point since 2005,” the New York Times’s Niraj Chokshi reports.

The negativity was mostly prompted by a rise in worry and stress, according to the report. Physical pain and sadness also increased by 1 percent, while there was no change in reports of anger, Niraj notes. “In all, well over a third of respondents told Gallup in 2017 that they had experienced a lot of worry or stress the day before taking the survey,” he reports. “Just under a third reported experiencing a lot of physical pain, while about a fifth said they had felt a lot of sadness or anger the day before.”

Meanwhile, positive experiences fell only slightly to 2011 and 2012 levels, and at least 70 percent of the people surveyed reported “feeling a lot of joy, feeling well rested, feeling treated with respect, and smiling or laughing a lot the day before being interviewed.”

— And here are a few more good reads: 

Arrests of migrant families rose 38 percent in August in what Trump officials call a ‘crisis’ at the border (Nick Miroff)

Settlement reached in family separation cases: More than 1,000 rejected asylum seekers to get second chance if court approves (Fred Barbash and Allyson Chiu)

Senate passes bipartisan spending package as lawmakers eye shutdown deadline (Erica Werner)

Pramila Jayapal Is Starting The First Medicare For All PAC (HuffPost)

Paul Ryan Says “Entitlement Reform” Will Continue in 2019 (Roll Call)


Kavanaugh says 'abortion-inducing drugs' quote was summarizing plaintiffs in case (CNN)

Activists raised $1 million to defeat Susan Collins if she votes for Kavanaugh. She says it’s bribery. (Eli Rosenberg)

A prototype of how to fight the next pandemic: A vaccine without the shot (Carolyn Johnson)

Interior law enforcement officers seize 17 pounds of heroin on reservation (The Hill )

Study cracks open the secrets of the cancer-causing BRCA1 gene (Stat)



  • The House Veterans Affairs Subcommittee on Health holds a legislative hearing.
  • The House Energy and Commerce Subcommittee on Health holds a hearing on “Examining Barriers to Expanding Innovative, Value-Based Care in Medicine."
  • AHIP holds a webinar “Redesign your Payment Integrity Model to Achieve Savings."

Coming Up

  • The National Committee on Vital and Health Statistics holds a committee meeting on Thursday and Friday.

From the Fact Checker: Unraveling President Trump's top 5 claims

The Fact Checker is keeping a running list of the false or misleading claims Trump says most regularly. Here’s what you need to know. (Video: The Washington Post)

McConnell: Close Senate races are 'knife fights' to retain majority

Senate Majority Leader Mitch McConnell (R-Ky.) said on Sept. 11 that he's gearing up for a "very challenging election," with "dead-even" races in nine states. (Video: Reuters)