Frictional uninsurance — is it possible to get to zero?

Is there such a thing as frictional uninsurance in the United States? Is there a small segment of the population that will not be formally covered in our fragmented, opt-in system that also has numerous explicit and implicit one way coverage options such as the sixty day COBRA retroactive eligibility window?

Massachusetts released their 2019 ACA Open Enrollment report.

overnor Baker announced today that the Massachusetts Health Connector completed Open Enrollment with the highest membership in the 13-year history of the state’s health insurance exchange, covering 282,000 people with health insurance.

“The Health Connector just completed its most successful Open Enrollment since the start of the Affordable Care Act, signing up more than 65,000 new people with health insurance coverage,” said Governor Charlie Baker. “Massachusetts leads the way with the best insured rate in the country, with over 97 percent of our residents covered due in part to the Health Connector’s strong efforts to create a culture of coverage in the Commonwealth.”

This is super impressive. Massachusetts is running near universal coverage even in a national political messaging environment that is anti-coverage. Getting the last three percent of the population covered will be extremely difficult.

That chunk of the population has a variety of quasi-coverage mechanisms without signing up for insurance. There is some uncompensated care. There is Medicaid retroactive coverage if an individual who is uncovered would be Medicaid eligible and has a major medical event. There is the sixty day window after a loss of qualified insurance for an individual to elect COBRA coverage.

At any given point in time, in the US systems of health finance, there will be some people who are uncovered but who have access to an option for coverage. I don’t know if that frictional uninsurance is 3% or 1% or a fraction of 1% but this population is analytically important and odd as they are both covered and uncovered at the same time.

10 replies
  1. 1
    Another Scott says:

    That is good news. But even in Massachusetts, the “population” they’re talking about isn’t every human that lives in the Commonwealth, is it?

    An obvious subset excluded from the “population” is various kinds of immigrants. (Dunno if “green card” holders are required to have insurance, but undocumented people are excluded from the ACA.)

    The exclusions make little sense to me. If someone is living in the US and gets hit by a bus, or develops Denge or measles, or gives birth, they’re going to be in the health care system…



  2. 2
    lahke says:

    Massachusetts is also the home base for the Christian Science Church, which is why the coverage mandate has a religious exemption. Don’t know what proportion of the state population they are, though. Interestingly enough, the CS Church as an employer provides for regular health insurance for their non-CS employees; take that, Hobby Lobby!

  3. 3
    p.a. says:

    @lahke: Is the CS church against traditional general medical treatment, or just psychologic/psychiatric? What about Jehovas and their position on health insurance?

  4. 4
    FlyingToaster says:

    Christian Science generally allows some medical care; vaccinations, setting broken bones, etc. They generally don’t believe in medication, and Christian Scientists are explicitly exempted from being required to have health insurance, as are DutchReformed (who don’t believe in vaccinations).

    Jehovah’s Witnesses don’t accept blood transfusions. Otherwise, they’re fine with medical care.

    The 3% figure is mostly hardcore religous fanatics (remember, Scott Lively is here in Worcester), 27-year-olds just off their parents’ insurance who are working the gig economy, single homeless adults, and libertarian nutcases (though most of them move to NewHampshire).

    Most of our undocumented population is either younger people overstaying their visa to work the gig economy, or long-term folks who are part of the community and have coverage; ICE is hated by nearly everyone here because they keep arresting moms at soccer practice and dads at work.

  5. 5

    @Another Scott: Yes ACA covers permanent residents.

    ETA: Although ACA doesn’t cover them, long term visa holders like student visa holders need to be covered. That insurance also covers a trip home, if necessary.

  6. 6
    Chris Johnson says:


    ICE is hated by nearly everyone here because they keep arresting moms at soccer practice and dads at work.

    Twenty, thirty, forty years ago, would we have guessed we’d be shrugging this off as just the shitty other-side administration?

    I took a Holocaust studies class years ago in high school but now I really viscerally GET how it is a country devolves to ‘the baddies’. I think citizens in Israel also could speak to that. You turn around and things have drifted and now there are mass graves and you’re trying to figure out how to FRAME your reaction knowing the consequences of being a those-people-sympathizer, and there are people too young to know anything else, and people older who ought to know better, and how’d they get so powerful, and meanwhile things sure have drifted.

  7. 7
    Sherparick says:

    On other health related news, as Meaghan McCain, Lynne Cheney, Ronna Romney McDaniel, & Sarah Sanders shout blood libels about Democrats killing mythical babies, Alex Azar is getting grilled about moving funds from programs that save actual lives to support the Administration’s program for kidnapping immigrant kids and letting them die by neglect and abuse.

    New: How Alex Azar plans to pay for surge in unaccompanied kids.

    Among the moves, according to docs provided to POLITICO:

    — Transferring $14 million from CDC
    — Transferring $20 million from National Cancer Institute
    — Transferring $3.5 million from an Alzheimer’s program

    Dan Diamond added,
    Adriel Bettelheim
    Verified account @abettel
    HHS plans to tap $385M from health programs to continue housing unaccompanied migrant kids under the administration’s border policy. … @ddiamond

  8. 8
    Anonymous At Work says:

    I wonder what portion of that 3% are just plain cranks? There isn’t any way to measure it that I can see. Cranks resist the government’s mind-control technology, or the UFO-led fluoridation methods or whatever theories that they believe despite the evidence, and this leads cranks actively to opt-out of insurance methods.
    And since not all of them are living in boxes under freeways, they still count towards that 3%.
    Finally, this being Massachusetts, very few of them are elected to government offices, unlike Texas and Florida.

  9. 9
    MattF says:

    Three percent is ‘in the noise’. Who the hell knows what they think? Three out of a hundred people probably believe they are immortal.

    ETA: Also the error on the ‘3%’ is large– it’s probably 3% +/- 5%.

  10. 10
    FlyingToaster says:


    ETA: Also the error on the ‘3%’ is large– it’s probably 3% +/- 5%.

    Probably a smaller error bar than you think.

    One of the curious things about the Commonwealth (God Save It, because nobody else can be bothered) is the annual census, conducted by each and every municipality. They pass their numbers on to the state, which, by law, doesn’t share diddly squat with the Feds. So we have, for citizens and legal residents, a pretty good idea of how many people we’re supposed to be dealing with. This is our jury pool, voter registration and pet-license database, which is very very important to each of our cities, towns, and villages. Municipalities get allocated local aid from the state taxes per how many bodies they’re having to support.

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