Coverage basics

Insurance coverage does not guarantee  access to care. Also important are transportation, available appointments with appropriate providers at convenient hours, culture and language access, and sufficient funds to cover copays, deductibles, and other consumer costs. But having coverage, and the adequacy of that coverage, is critical to staying healthy and being able to access care when needed.

Most state residents are covered with insurance through their own or a family member’s employment. As of the start of 2023, Medicaid covers about a million state residents, but that number will drop as COVID-related provisions end. One in five Connecticut residents are covered by Medicare; that number is growing as our population ages.  The number of state residents in private insurance coverage is slowly declining, while the number on public programs – Medicare and Medicaid – is increasing. One in twenty Connecticut residents has no coverage at all, but that number is dropping.

While the Affordable Care Act (ACA) increased Medicaid enrollment, the recession of 2008 increased enrollment more as workers lost jobs and incomes dropped. The ACA had little impact on employer-sponsored coverage, which has been slowly declining for decades, but did increase Medicaid enrollment and lower the uninsured rate.

Undocumented immigrants are four times more likely to be uninsured. The state now covers children to age 12 regardless of immigration status under Medicaid. In July 2024 that age will rise to 15.

Coverage Deeper Dive

How are Connecticut residents covered?

Most Connecticut residents continue to receive coverage through an employer-based insurance plan, although that proportion has been slowly declining for over a decade. Connecticut residents are slightly more likely to have employer coverage than other Americans (58.7% vs. 54.7%). Medicaid is an important coverage option for children in Connecticut, covering over one in three state residents under age 19.

Source: Health Insurance Coverage in the United States: 2021, US Census, September 13, 2022, https://www.census.gov/library/publications/2022/demo/p60-278.html

A 2022 survey found that one in four working age Americans have inadequate insurance that doesn’t make care affordable. Half of American adults would be unable to pay an unexpected $1,000 medical bill within 30 days.

One in eight state residents buy private insurance directly – either through AccessHealthCT, Connecticut’s health insurance exchange or independently through a broker or insurer. That number has grown since passage of the Affordable Care Act, as AccessHealth CT offers federal subsidies on coverage for people with incomes that qualify.

Three in ten Connecticut residents are covered by HUSKY, Connecticut’s Medicaid program. There has been significant growth in Medicaid enrollment for decades, because of recessions, Connecticut’s Affordable Care Act expansion, and the COVID pandemic.

Almost one in five state residents are covered by the federal Medicare program. That number is slowly growing, mainly because of the rising number of aged Americans.

Uninsured

One in twenty (5.2%) of Connecticut residents has no coverage. Connecticut has the fourteenth lowest uninsured rate in the US. Historically, Connecticut’s uninsured rate has been lower than the US rate.

While Connecticut’s uninsured rate at 5.2% is lower than the US rate at 8.6%, it represented 184,000 state residents in 2021. That’s greater than the population of any Connecticut city or town. Connecticut’s uninsured are more likely to have low family incomes, be middle-aged, Hispanic, and not a US citizen.

Impact of uninsurance on people and the system

Uninsured American adults are three times less likely to have had a medical visit in the last year and are less likely to get regular, preventive health screenings. Because they miss preventive care and screenings, the uninsured are more likely to be diagnosed at later stages of disease when problems are harder and more costly to treat. One in four has postponed needed care due to cost in the last year, compared with 3% of privately insured Americans and 8% with government plans such as Medicare and Medicaid. One in five didn’t get needed care and 19% postponed or didn’t get a needed prescription drug in the last year due to cost.

When they access healthcare, uninsured patients get less care than other patients. A study of severe auto accident victims in Wisconsin found that patients without health insurance or Medicaid had 20% shorter hospital stays, received fewer services in the hospital, and were 37% more likely to die of their injuries. The researchers controlled for crash severity, vehicle type, injury, and personal characteristics.

There is a persistent myth that healthcare is free for uninsured Connecticut residents through emergency rooms, community health centers, and hospital clinics. This is untrue. Uninsured patients are charged for their care. Sometimes fees are discounted by income, but often uninsured patients are charged higher rates, as much as 50% higher, than insurers or government plans pay. Two thirds of bankruptcy filers cite medical problems as a cause. In a 2019 survey, 74% of uninsured American adults cite the high cost of coverage as the reason they are uninsured.

As uninsured patients tend to have lower incomes, very often they cannot pay for the care they need. Under-insured patients also experience trouble paying their medical bills. In 2020, Connecticut hospitals provided $255 million in uncompensated care, or 2% of expenses. Uncompensated care is about evenly split between debts hospitals could not collect, and charity care they never intended to bill for. However, hospitals do receive partial reimbursement for these costs through Medicaid and other grants. Independent practices may also incur uncompensated care, but the amount is unknown.

Impact of the Affordable Care Act

The Affordable Care Act (ACA) coverage expansions implemented in 2014 have reduced Connecticut’s uninsured rate significantly and changed sources of coverage in our state. Connecticut chose both the ACA options to expand Medicaid to low-income childless adults and to operate a state-based health insurance exchange, Access Health CT. Both these decisions lowered our uninsured rate. But, thankfully, expected reductions in employer-sponsored coverage haven’t happened. Medicare continued it’s slow increase and employer-sponsored coverage continued its slow decline, both of which pre-dated the ACA.

Economic forces can have a much larger impact on coverage than changes in healthcare policy. While the ACA had a large impact on Connecticut healthcare coverage, the impact of the preceding 2008 recession was even larger. As large numbers of Connecticut residents lost their jobs, they also lost their employer-sponsored coverage. Many bought individual insurance directly and many now qualified for Medicaid because their incomes dropped. Some became uninsured.

The percent of uninsured Connecticut residents dropped from 9.1% in 2012 to 5.9% by 2016 due to Connecticut’s decisions to expand Medicaid under the ACA and to develop a state-based health insurance exchange, Access Health CT.

There were concerns when the ACA passed that expanded public options for coverage, including Medicaid and federally subsidized health insurance for lower income households, that employers would stop offering coverage to employees. However, employer-sponsored coverage for Connecticut residents had been declining before the ACA expansions were implemented. The ACA had little impact on employer-sponsored coverage for Connecticut residents but did increase Medicaid enrollment while uninsurance declined.

Connecticut Medicaid enrollment grew substantially when the state expanded Medicaid under the Affordable Care Act, and again during the COVID pandemic. During the pandemic many people qualified when they lost their jobs and their incomes dropped. In addition, the federal government increased funding to the state with the condition that states not remove anyone from the program during the pandemic. As the pandemic wanes, the Department of Social Services is reassessing Medicaid recipients’ eligibility starting in early 2023 and the numbers are expected to go down.

Undocumented immigrants

The uninsured rate among Connecticut non-citizens is four-fold higher than for citizens. Immigrants without legal status in the United States are barred from enrolling in AccessHealthCT coverage and Medicare. Because the state cannot get federal matching funds for undocumented immigrants in Medicaid, Connecticut like most states, did not cover immigrants without legal status. In 2021, the state changed the law to cover children to age 8 that are income eligible, regardless of immigration status under Medicaid starting in 2023. In 2022, that eligibility was increased to age 12, and children initially covered will continue with coverage through age 19. In the budget passed in 2023 legislative session, that age will rise to 15 as of July 2024. The state will pay the full costs of coverage for these children.

Trends

• Public coverage program enrollment will grow – Medicare will grow as Connecticut’s population ages and, after COVID ends and the rolls drop, Medicaid will grow again as fewer employers offer health coverage.
• Employer-sponsored coverage will continue to decline as premiums, and the underlying prices of healthcare services, continue to increase making coverage unaffordable for more employers
• Enrollment in AccessHealthCT will grow as employer-sponsored coverage declines

Updated November 2, 2023