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The uninsured rate is rising for these 3 groups

America's uninsured rate has steadily ticked downward ever since the Affordable Care Act became law.

This makes a new Commonwealth Fund study quite surprising: It shows the uninsured rate going up for certain demographics.

"We did see some troubling upticks," says Sara Collins, senior vice president at Commonwealth Fund and lead author of the study.

Collins found the uninsured rate rose among three groups: middle-aged Americans between 35 and 49, middle- and high-income Americans, and those in states that did not expand Medicaid.

Before we dive into details, I think some context is helpful. All available data shows that the country's uninsured rate is at an all-time low. The federal government put out data a few weeks ago showing that more people had insurance in the first three months of 2017 than any other period on record.

All of that is still true. But the Commonwealth Fund report highlights some trouble spots within the overall gains in coverage — demographic groups that have seen their uninsured rates tick upward between 2016 and 2017 after a few years of steady decline.

Why did coverage decline for these particular three groups? For one group, there seems to be a clear explanation — but for two others, it's still a bit of a mystery.

High-income Americans who buy their own coverage saw premiums spike in 2017. Middle- and high-income Americans (defined as those who earn more than 400 percent of the population, which works out to $48,240 for an individual and $96,400 for a family of four) still have especially high rates of coverage. Most of these people get insurance at work. Obamacare didn't change much for this group.

Those who buy their coverage on the individual market, however, had a rough time this year. Premiums spiked on the Obamacare marketplaces in 2017 by an average of 25 percent. Lower-income Americans who receive subsidies to buy coverage were protected from those double-digit increases. But those above 400 percent of poverty do not receive any financial help and were left to manage the higher premiums on their own.

"Last year we saw really big premium increases in states," says Collins. "When we asked people [on the Obamacare marketplaces] whether costs had gone up, people with higher incomes were more likely to say yes."

This is near certainly the explanation for why you see this uptick in uninsured rates among this higher-earning group. It suggests that you could see another increase next year, as many insurance plans are responding to the uncertainty about the health law's future with another round of big rate hikes.

Why did coverage rates decline among middle-aged Americans and those in non-Medicaid expansion states? That's still a bit of a mystery.There is no clear reason why people between 35 and 49 should be faring differently in the marketplaces than those in neighboring age groups.

There has always been a gap between the states that did and didn't expand Medicaid — Medicaid expansion states have seen rapid coverage increases — but why there should be a sudden downturn in the nonexpansion states is not clear at all.

It's possible that the uncertainty about the Affordable Care Act's future played a role. The Commonwealth Fund paper interviewed Americans who remained uninsured this spring. One-third said they didn't look for coverage this year because they "thought the Affordable Care Act was going to be repealed."

Then again, there is no clear reason why this should effect the groups that saw an uptick in uninsured rates anyore than those that didn't. It suggests one possible explanation — but certainly doesn't tell the whole story.

Chart of the Day

Rural areas are losing access to obstetric services

More than 100 rural hospitals have stopped offering obstetric services over the past decade. A new Health Affairs study finds that "fewer than half of all rural counties in the United States had hospital-based obstetric care services as of 2014," raising concern about rural women's access to maternity care. Read more from my colleague Anna North here.

Kliff’s Notes:

With research help from Caitlin Davis

Today's top news

  • “Senate Obamacare fix begins to take shape”: “A handful of governors urged U.S. senators on Thursday to help Obamacare customers by injecting billions of dollars in federal funding into the market, but were divided over the longevity of such support and how much authority states should have in crafting their own healthcare plans.” —Kimberly Leonard, Washington Examiner
  • “Bid to shore up Obamacare faces time crunch, conservative countereffort”: “A bipartisan group of senators has palpable momentum but little time to make good on a bid to shore up Obamacare insurance markets, even as conservative Republicans press a parallel attempt to make good on their promise to repeal the health care law.” —Jennifer Haberkorn, Adam Cancryn, and Rachel Bade, Politico
  • "Advocates call for long-term funding of children's health program": “Children’s health advocates on Thursday called on lawmakers to pass a long-term funding extension for the Children’s Health Insurance Program (CHIP). Federal funding for 9 million low- and middle-income children is set to expire at the end of September, setting up a crucial deadline for a Congress already grappling with other high-stakes battles.” —Nathaniel Weixel, the Hill

Analysis and longer reads

  • “Lawmakers Debate How Much Wiggle Room To Give States In Health Care”: “One of the few things that Republicans and Democrats broadly agree on is that states should have some flexibility to experiment with different ways to pay for and deliver health care. But they disagree — strongly — on how much.” —Julie Rovner, Kaiser Health News
  • "What Older Americans Stand to Lose if ‘Dreamers’ Are Deported”:“Surveys of DACA beneficiaries reveal that roughly one-fifth of them work in the health care and educational sector, suggesting a potential loss of tens of thousands of workers from in-demand job categories like home health aide and nursing assistant. At the same time, projections by the government and advocacy groups show that the economy will need to add hundreds of thousands of workers in these fields over the next five to 10 years simply to keep up with escalating demand, caused primarily by a rapidly aging population.” —Noam Scheiber and Rachel Abrams, the New York Times