Although the Affordable Care Act has significantly reduced the percentage of Americans who are uninsured, we have not yet achieved universal coverage. This has become a topic of focused debate amongst Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan, which seems very unlikely in the near future, further gains in insurance coverage will come through means available through the Affordable Care Act.

It's worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policy-makers and advocates to focus their efforts on those populations. A recent report from the Robert Wod Johnson Foundation and the Urban Institute covered just that. This is Healthcare Triage News.

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According to the most recent surveys about 12.2% of the non-elderly, non-military, non-institutionalized population remains uninsured. This is just under 33 million people. About half of those people live in states that have refused the Medicaid expansion. This has certainly made a difference.

The rate of uninsurance in states with the Medicaid expansion is 10.1% compared to 15.4% in states which have refused it. It's clear, therefore, that one way to reduce the number of uninsured at this point would be to increase the number of states participating in the program.

More than a quarter of the uninsured are eligible right now for Medicaid or CHIP. About two-thirds of uninsured children fall into this category, as well. These are all people who could have insurance if they could just overcome the barriers and hurdles necessary to sign up for coverage.

It's also possible this could be an information gap. Many of them may not know they're eligible, and may not have tried to obtain Medicaid or CHIP for themselves or their children. An additional 21% of the uninsured qualify for subsidies on the exchanges, but haven't obtained plans. This, too, could be an information issue, where people do not know that they are eligible for tax credits. It could be that they feel that, even with the tax credits, they still can't afford coverage. It could also be that they simply don't want insurance, and would rather pay the penalty of the individual mandate.

Clearly, however, there's much to be gained from outreach. Efforts to increase enrollment in both Medicaid and CHIP, as well as through the exchanges, could significantly increase the number of people who are already eligible for coverage, but haven't obtained it. More than 80% of the uninsured eligible for Medicaid or CHIP live in metropolitan areas. More than two-thirds of them live in families, in which at least one family member is already receiving an earned income tax credit or some other public benefit. Nearly half have at least one school-aged child in their family. It's possible to locate many of these people, and help them sign up for coverage. 

In addition, furthering the Medicaid expansion is a straight forward way to decreasing uninsurance. That would require more political effort and a different skill set.

Increasing the number of Americans who have health insurance is only one goal of improved access. Making sure the care is still affordable and that under-insurance doesn't become a bigger issue is a whole different ball game. 

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