Exchange-Insured: Who And How Many?

Health insurance exchanges, also known as health insurance marketplaces, are organisations in each US state that allow people to purchase health insurance. Exchanges are not insurers themselves, but they determine which insurance companies can participate. The Patient Protection and Affordable Care Act (ACA), also known as Obamacare, requires that health insurance exchanges be operational in every state.

ACA health exchanges were fully certified and operational by January 1, 2014, under federal law. As of April 14, 2020, 11.41 million people had signed up through the health insurance marketplaces. Private non-ACA health care exchanges also exist in many states and are responsible for enrolling 3 million people.

According to preliminary data from 2014, a majority of the 2.2 million who enrolled in the federal health care exchange were previously insured. Estimates based on data from consultants, insurers, and insurance brokers show that between 11 and 35% of those enrolled in the Affordable Care Act were previously uninsured.

The number of insured people increased from 2021 to 2022

The number of insured people in the United States increased from 2021 to 2022. In 2022, 92.1% of people, or 304 million, had health insurance at some point during the year, representing an increase from 2021, where 91.7% or 300.9 million people were insured. This increase in the number of insured people can be attributed to a variety of factors, including an increase in Medicare coverage and a decrease in uninsured rates among working-age adults.

In 2022, private health insurance coverage was more common than public coverage, with 65.6% and 36.1% of people insured through these plans, respectively. Employment-based insurance was the most prevalent type of health insurance, covering 54.5% of the population for some or all of the calendar year. This was followed by Medicaid (18.8%), Medicare (18.7%), direct-purchase coverage (9.9%), TRICARE (2.4%), and VA and CHAMPVA coverage (1.0%).

The rate of Medicare coverage increased by 0.3% from 2021 to 2022, covering 18.7% of people in 2022. During the same period, the uninsured rate among working-age adults aged 19-64 decreased by 0.8% to 10.8%. This decrease in the uninsured rate was driven in part by a decline in uninsured rates for workers.

The increase in the number of insured people from 2021 to 2022 can also be attributed to policies implemented during the COVID-19 pandemic. Enrollment in public health insurance programs such as Medicaid and the Children's Health Insurance Program (CHIP) increased due to lay-offs and provisions in the Families First Coronavirus Response Act, which required states to ensure continuous enrollment. The overall increase in insured individuals reflects improved access to healthcare for Americans during the pandemic.

People can purchase health insurance that complies with the Patient Protection and Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act (ACA) was enacted on March 23, 2010, and amended by the Health Care and Education Reconciliation Act on March 30, 2010. The law aimed to make affordable health insurance available to more people, expand Medicaid, and support innovative medical care delivery methods to reduce healthcare costs.

The ACA established state health insurance exchanges, or marketplaces, where individuals and small businesses can compare and purchase health plans, and determine and receive premium subsidies for which they are eligible. These exchanges are accessible through websites, call centres, and in-person assistance.

The ACA provides numerous rights and protections that make health coverage fairer and easier to understand, along with subsidies to make it more affordable. These include tax credits to lower monthly insurance payments and cost-sharing reductions, which are discounts that lower the amount paid for deductibles, copayments, and coinsurance.

The law also expands insurance coverage for low-income people, including families, children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels.

To purchase health insurance that complies with the ACA, individuals can access their state's health insurance exchange or marketplace. These exchanges allow for the comparison of health plans and costs, and individuals can determine their eligibility for premium subsidies and enrol in a plan.

The ACA has made significant strides towards achieving near-universal health coverage in the United States, reducing the number of uninsured Americans by more than half.

Private non-ACA health care exchanges exist in many states

Private non-Affordable Care Act (ACA) health care exchanges exist in many states and are responsible for enrolling around 3 million people. These private exchanges are not to be confused with the public health insurance exchanges developed by the government due to the ACA, which are what people generally refer to when they say "health insurance exchange".

Private health insurance exchanges are typically used by employers who buy health coverage for their employees. They are run by private sector companies or non-profits, and health plans and insurance carriers must meet certain criteria defined by the exchange management. Private exchanges combine technology and human advocacy, including online eligibility verification and mechanisms that allow employers to offer subsidies to employees.

Private health insurance exchanges predate the ACA, with the first emerging in the early 1980s. They used computer networking to integrate claims management, eligibility verification, and inter-carrier payments. They became popular in some regions as a way for small and medium-sized businesses to pool their purchasing power, reducing costs. They also allowed small businesses to offer a range of plans to employees, helping them to compete with larger corporations. The largest and most successful private health care exchange is CaliforniaChoice, established in 1996. By 2000, CaliforniaChoice's membership included 140,000 individuals from 9000 business groups.

Private exchanges exist alongside public exchanges, which were established by the ACA to create a competitive private health insurance market. Public exchanges are state-based, competitive marketplaces that provide Americans and small businesses with "one-stop shopping" for affordable coverage. They allow individuals and small businesses to compare and purchase health plans, as well as determine and receive premium subsidies for which they are eligible.

The uninsured rate among working-age adults decreased between 2021 and 2022

The uninsured rate among working-age adults aged 19-64 decreased by 0.8 percentage points between 2021 and 2022, from 11.6% to 10.8%. This decrease was driven in part by a decline in the uninsured rate among workers. In 2022, 9.8% of workers were uninsured, a decrease of 0.9 percentage points from 2021. This decline was observed for both full-time and less-than-full-time workers.

The decrease in the uninsured rate among working-age adults is part of a broader trend of improved insurance coverage in the United States. In 2022, 92.1% of people, or 304 million, had health insurance at some point during the year, representing an increase from 91.7% or 300.9 million in 2021. This increase was driven by gains in employer-sponsored, Medicaid, and non-group coverage among nonelderly adults.

The number of nonelderly uninsured individuals and the uninsured rate among the nonelderly population reached all-time lows in 2022. The number of nonelderly uninsured people was 25.6 million in 2022, over one million fewer than in 2016. The uninsured rate dropped to 9.6% in 2022, continuing a downward trend that started during the pandemic. The decline in the uninsured rate from 2019 to 2022 was driven by coverage protections put in place during the pandemic.

The decrease in the uninsured rate among working-age adults is particularly notable because this group tends to have higher uninsured rates compared to other age groups. In 2022, the uninsured rate for working-age adults was 10.8%, while the rate for children was 5.1% and the rate for adults over 65 was 6.5%. The higher uninsured rate among working-age adults is due in part to higher costs. According to a Kaiser Family Foundation analysis, 74% of uninsured working-age adults in 2019 cited high costs as the reason for lacking coverage. Additionally, in states that have not expanded Medicaid eligibility, many working-age adults fall into a "coverage gap," earning too much to qualify for Medicaid but not enough to qualify for premium tax credits that would make purchasing private insurance affordable.

Despite the overall decrease in the uninsured rate among working-age adults, disparities persist across racial and ethnic groups. In 2022, the uninsured rate for nonelderly Hispanic individuals was 18.0%, and the rate for nonelderly American Indian and Alaska Native people was 19.1%. These rates are more than 2.5 times the uninsured rate for White people (6.6%). However, Asian people have the lowest uninsured rate at 6.0%.

The number of nonelderly uninsured people decreased from 2019 to 2022

The number of nonelderly uninsured people in the US decreased from 2019 to 2022. In 2022, 25.6 million nonelderly individuals were uninsured, a decrease of 3.3 million from 2019. The uninsured rate also decreased from 10.9% in 2019 to 9.6% in 2022. This downward trend continued during the COVID-19 pandemic, with coverage expansions put in place by the Affordable Care Act (ACA) serving as a safety net for those who lost their jobs or faced economic and coverage disruptions.

The decrease in the number of nonelderly uninsured people from 2019 to 2022 was driven by an increase in employer-sponsored, Medicaid, and non-group coverage among nonelderly adults. The share of nonelderly people covered by Medicaid increased by 1.7 percentage points from 2019 to 2022, while the share of those with non-group coverage increased by 0.5 percentage points. During the same period, employer coverage declined by 0.6 percentage points.

The decrease in the number of nonelderly uninsured people was also influenced by coverage protections put in place during the pandemic. Provisions in the Families First Coronavirus Response Act required states to keep people enrolled in Medicaid until the month after the end of the COVID-19 public health emergency. Additionally, enhanced ACA Marketplace subsidies were renewed for another three years in the Inflation Reduction Act of 2022, making coverage more affordable for those transitioning from Medicaid to Marketplace coverage.

The decrease in the number of nonelderly uninsured people from 2019 to 2022 varied across different groups. Coverage gains were largest for American Indian and Alaska Native and Hispanic people, individuals in low-income families, and adults. From 2019 to 2022, the uninsured rate for American Indian and Alaska Native people decreased by 2.4 percentage points, while the uninsured rate for Hispanic people decreased by 2.0 percentage points. The uninsured rate also dropped for people at all income levels, with individuals in low-income families experiencing the largest decline.

While the number of nonelderly uninsured people decreased from 2019 to 2022, it is important to note that racial and ethnic disparities in coverage persist. In 2022, people of color made up 45.7% of the nonelderly US population but accounted for 62.3% of the total nonelderly uninsured population. Hispanic and White people comprised the largest shares of the nonelderly uninsured population, at 40.0% and 37.7%, respectively.

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