Uninsured by circumstance — or by choice?

I often tell people that I am among the statistic of the uninsured. I’m not covered under traditional health benefits, nor is my family. We use other forms of coverage that provide us with the peace of mind and access to affordable care that we desire.

We’re not alone; the Census Bureau released data last week that showed a marked increase in the number of uninsured across the nation. But are they uninsured by circumstance — or by choice?

Many who support the Affordable Care Act have used this data to claim that President Donald Trump has sabotaged the ACA, and say that many have left the exchanges because of what the administration has done. Opponents of the ACA have used this as an opportunity to blame the health law for driving up the costs of premiums and deductibles, thereby making the exchange plans less attractive to Americans. I would tend to agree with the latter, but a deeper analysis of the data shows something else.

According to the Census Bureau, the most significant changes by income level were among those above 400 percent of the Federal Poverty Limit (about $100,000 for a family of four) and people in Medicaid-expansion states below 100 percent of the FPL.

Since the release of the data, some have claimed the report is somehow evidence that non-expansion states should — and must — expand Medicaid. But the data clearly demonstrates that states that have already expanded it are losing enrollment — beneficiaries are disenrolling from the state benefit. Conversely, there was a significant number of individuals who gained coverage on the Medicaid program in non-expansion states. We can presume that those leaving the Medicaid program in states that expanded the benefit simply did not see the value in continuing their coverage.

One reason for that could be access to care. At the end of 2018, a number of state commissioners raised questions about the adequacy of provider networks and managed care oversight. Expansion continues to strain networks and has led those in expansion states to utilize the emergency department for non-urgent conditions, rather than wait for access to their regular medical professionals.

According to analysis by the Kaiser Family Foundation, only 36 percent of their uninsured count of 27.4 million people in 2017 are ineligible for financial assistance due to income, employer-sponsored insurance offer, or citizenship. Fifteen million people across the nation in 2017, or a whopping 55 percent of the uninsured, were eligible for Medicaid, ACA Tax Credits, or other public programs — and yet did not to utilize such programs. Almost 2.5 million people nationwide fall into the “Medicaid coverage gap” which describes the population who do not bring in enough income to qualify for ACA Tax Credits, but whose situation disqualifies them from Medicaid.

If we naively accept that “uninsured” means “lacking access to health insurance,” we might be quick to assume the uninsured are without options, stuck between a rock and a hard place.

But the numbers disprove this. Many of the uninsured have access to insurance. While 9 percent of Americans are in the Medicaid coverage gap, a much larger percentage of the uninsured have publicly subsidized options. These people, for one reason or another, are not taking advantage of public assistance. They may not be receiving care, or they may be receiving health care without participating in the traditional insurance system.

More comprehensive studies need to be conducted to determine how many of these uninsured are truly priced out of health insurance, lack access to insurance, or simply choose a non-insurance alternative to get coverage.

People make their own choices about their care — and their coverage.

David Balat is the director of the Right on Healthcare initiative at the Texas Public Policy Foundation. Follow him on Twitter @DavidBalatHC.