The size of the uninsured population declined significantly following implementation of the coverage provisions of the ACA in 2014 but has grown in recent years. In 2019, an estimated 28.9 million nonelderly adults and children were uninsured, an increase of 2.2 million since 2016.

The economic downturn caused by the COVID-19 pandemic has resulted in steep increases in unemployment and related losses of employer-sponsored coverage. Although some people losing employer coverage during the pandemic have enrolled in coverage through Medicaid and the ACA marketplaces to avoid becoming uninsured, eroding employer-sponsored coverage rates mean increases in lost coverage are unlikely to reverse, and could accelerate, during the current recession.

Researchers reported these findings:

• Some uninsured adults are unfamiliar with the marketplace and available financial assistance to subsidize purchasing such coverage. In September 2020, only about half of uninsured adults had heard a lot or some about the marketplaces. Just less than two-thirds of uninsured adults had heard nothing or only a little about financial assistance for marketplace coverage.
• Almost half of uninsured adults familiar with marketplace health plans had not looked for information on them, most commonly because of cost concerns.
• Only 29% of uninsured adults had tried to obtain Medicaid/CHIP coverage. Most commonly, those who did not try to obtain Medicaid/CHIP did not think they would qualify. Nearly half of all uninsured adults had neither looked for information on marketplace coverage nor tried to obtain Medicaid/CHIP.
• Of all uninsured adults, only about two in 10 had both sought information about marketplace coverage and tried to obtain Medicaid/CHIP, and about three in 10 uninsured adults had done one or the other.

Policymakers have indicated interest in increasing opportunities to enroll. For example, the Biden Administration has announced a proposal to extend the federal marketplace open enrollment period to ensure more people needing coverage during the public health crisis can obtain it.

If combined with substantial government outreach efforts and the administration's proposal to enhance the generosity of and expand eligibility for premium tax credits during the pandemic, these proposals could make inroads with the largest segment of uninsured adults, those who may qualify for marketplace subsidies but have been dissuaded from seeking information about or enrolling in marketplace coverage over cost concerns.

"Erosion of ESI and declining incomes during the pandemic will likely make millions of people eligible for publicly subsidized coverage," the report said, "but they will need to understand their options and may need help enrolling to avoid becoming uninsured."

Read more: 

• Cost of insurance keeping many Americans from replacing coverage lost in 2020
• HealthCare.gov to reopen for 3-month special enrollment period
• Emergency COVID-19 enrollment period: Just what the doctor ordered?