PAP 2025: Understanding the Uninsured Landscape

Image Credit: Nicholas Saraceno

Day 2 of Informa’s Access USA conference represented the start of its track-based sessions. In terms of the patient assistance & access program (PAP) focus of the conference, Aaron Winn, associate professor at the University of Illinois Chicago, led off the morning with a presentation centered around “Understanding the Uninsured Landscape.”¹

The session’s objectives were to gain a comprehensive overview of the uninsured population, including demographics, geographic distribution, and common health conditions; discuss the multitude of obstacles faced by patients in accessing PAPs, such as language barriers, transportation issues and lack of awareness; and dig further into the role of programs when it comes to accessing PAPs versus accessing the healthcare system as a whole.

Winn began the presentation by sharing the history behind the Affordable Care Act (ACA)’s origins, which was ultimately passed in 2010 after a failed Clinton health plan in 1993-1994 and reform initiative by the state of Massachusetts in 2006. The latter model was able to combine Medicaid expansion, subsidized private health insurance, an exchange of health insurance, and insurance market reforms, along with mandates. It even grew coverage by expounding on existing insurance arrangements.

Following lessons learned from the Clinton administration and Massachusetts, the ACA was built on the concept that single-payer insurance was not practical from a political perspective; rather, reform should be centered around private insurance and Medicaid. Its intention was to not reinvent the private insurance wheel, but to instead limit disruption.

Over the years, Republican lawmakers have aimed to repeal and replace the ACA, even decreasing funding for various ACA programs. And more recently, the Trump Administration sought out policies that would lower enrollment in its marketplaces, while also pursuing waivers that would reverse increases in enrollment when it comes to Medicaid.

The ACA expanded its Medicaid coverage to low-income adults, which grew eligibility to nearly all adults with incomes at or below 138% of the federal poverty level. This was adopted by 41 states—and DC—which provided coverage to over 12 million people. Meanwhile, it also expanded dependent coverage, allowing an adult to stay on their parents’ plan until the age of 26 (was previously 18). Pre-existing conditions and essential health benefits would also be covered (via a minimum package), and there are no annual or lifetime limits.

Despite some states not adopting Medicaid, the ACA featured nationwide insurance regulations that not only boosted access, but set forth new requirements for benefits and cost-sharing. It also prevents insurers from denying coverage or even charging higher to those who are sick, which could be done in the past via non-group market premiums.

Even with this, 6.24% of individuals under the age of 20, 16.67% between 20-45, and 10.26% between 46-64 remain uninsured. Data show that males are more likely to be uninsured versus females, as they represent 13.01% and 10.08% respectively.

And across race and education level, 31.38% of the American Indian/Alaska Native population with a high school education is uninsured, with Black individuals with a high school education being the second highest 22.52%.

Following these statistics, Winn concluded that although the ACA did in fact reduce the size of the uninsured, there still continue to be individuals who are still uninsured.

“There's still a lot to go—there's a lot of improvements that can still be made. So that's kind of the punchline,” he said.

Reference

1. Winn A. Understanding the Uninsured Landscape. March 19, 2025. PAP 2025. Philadelphia.