It’s open enrollment time again for Obamacare health plans, a good time to take stock of how New Jersey is doing covering the uninsured. In a previous column, I wrote that quick actions by the New Jersey Legislature and Murphy administration led to savings in premiums for this year’s plan offerings in healthcare.gov. While we are nowhere near declaring the problem of healthcare costs solved, it is nearly unheard of to see premiums actually fall, as they did this year.
For people who are eligible for NJ FamilyCare (New Jersey’s name for Medicaid) or for Affordable Care Act premium subsidies, affordability is mostly not the problem. For a limited time, those subsidies are available. Open enrollment on healthcare.gov started November 1 and runs through December 15, a much shorter enrollment period than in prior years. So, if you know someone who needs insurance, let them know they need to act quickly.
As important as it is, affordability isn’t the only barrier to coverage in the Garden State. Recent federal data show that there are about 665,000 uninsured remaining here. Nearly 9 percent of the nonelderly population lacks coverage. This table paints a picture of who is uninsured. Just over one in ten has income that is too high for some form of subsidy. This group faces the greatest affordability challenge. The remaining uninsured have incomes that would make them eligible for NJ FamilyCare, at no cost to them, or for premium subsidies through healthcare.gov. If affordability isn’t a major barrier for most uninsured, why do so many remain without coverage?
Immigration is a major factor
Forty-six percent of the uninsured in New Jersey are not U.S. citizens. Some immigrants are not eligible for subsidies, no matter how low their incomes. Those not legally present are not eligible for subsidies, period. (No doubt, the undocumented are greatly under-represented in the federal government’s Community Survey data shown in the table.) Those legally present but in the U.S. under five years, about 12 percent of the uninsured, cannot sign up for NJ FamilyCare, although they are eligible for premium subsidies to buy private plans.
That leaves the majority of uninsured immigrants eligible for insurance, often free or subsidized. Why are so many uninsured? It is telling that over a quarter of the uninsured New Jerseyans have limited English proficiency. Not speaking English well can be a major barrier to navigating our complex system of health coverage.
Vitriol directed at immigrants by our national leaders without a doubt is another major barrier to coverage in New Jersey for the non-U.S.-born. They may fear that taking government subsidies could jeopardize their legal status — with good reason because of proposed changes to “public charge” regulations, or could draw attention to relatives not legally present. The roiling debate about whether to include a citizenship question on the upcoming decennial census stokes these fears.
Reaching the uninsured
The composition of the uninsured raises significant challenges to the Murphy administration’s Get Covered New Jersey campaign. It would be an understatement to say that the administration of President Donald Trump is offering no help. In addition to cutting back the ACA open enrollment period, the Trump administration eliminated nearly all federal funding for outreach and help for people to sign up for coverage and has taken numerous other steps that drive up Obamacare premiums — some of which New Jersey regulators have been able to block.
Data on who remains uninsured in New Jersey offers guidance for those trying to reach them during the abbreviated enrollment period. There are uninsured families in every county, but they are concentrated in the northern part of the state. They are also disproportionately Hispanic and young adults, and the majority have jobs.
Reaching out and educating immigrants, especially non-English speakers, is essential. Targeting outreach geographically and crafting messages that resonate with young adults is also key. Partnering with employers is also important. While the data do not tell us why working people are without coverage, it is likely that they are lower-income workers and employees of small businesses that are not required by law to provide coverage. Those workers are eligible for coverage through healthcare.gov.
While public outreach and education are important, policy changes would make a bigger difference. Controlling healthcare costs is vital, although achieving that is a very heavy lift, both politically and practically. Increasing ACA subsidies for those near the income cut-off of 400 percent of the federal poverty level (just over $80,000 for a family of three) and raising the cut-off for who can get financial help, would be very effective in increasing enrollment.
There is no appetite among those who control the policy levers in Washington to put more resources into the ACA subsidies or effectively tackle the drivers of high healthcare costs (except, perhaps, the cost of prescription drugs).
That leaves public outreach and education of the uninsured as the main tools for getting us closer to universal coverage this year. So, for a limited time only, spread the word!