Senate Finance Committee Issues Testimony From Families USA Executive Director Isasi

WASHINGTON, Oct. 26 -- The Senate Finance Committee issued the following testimony by Frederick Isasi, executive director at the Families USA, at an Oct. 20, 2021, hearing entitled "Health Insurance Coverage in America: Current and Future Role of Federal Programs":

* * *

Introduction

Chairman Wyden, Ranking Member Crapo, members of the Committee, thank you for the opportunity to testify today. My name is Frederick Isasi, and I am the executive director of Families USA, a leading national, non-partisan voice for health care consumers. For more than 40 years, Families USA has been dedicated to achieving high-quality, affordable health care and improved health for all.

It is an honor to be with you this morning. Thanks to extraordinary leadership by members of this Committee, as well as your colleagues elsewhere in government, American families have experienced major gains in health coverage during the past decade. But as we all know, our work is not yet done. On behalf of Families USA, I urge you to seize every opportunity to legislate and continue our work to finally make sure that everyone in America can get the affordable health care they need to thrive.

Recent History of Health Insurance in America

As the 21st century dawned, the state of American health insurance was increasingly grim, with the number of people who had no health coverage steadily rising, year after year./1

America's leaders finally turned the tide in 2010 by passing the Affordable Care Act. From 2010 through 2016, 20 million people gained health insurance,/2 many for the first time in their lives.

To be sure, the individual market still had problems after passage of the ACA, with too many people charged premiums and deductibles they couldn't afford. But the ACA took a terrible individual market and made it much, much better. For example, national surveys taken both before and after the law took full effect showed that people buying their own insurance experienced dramatic overall improvements:/3

* Before the ACA, 60% of consumers trying to buy insurance in the individual market reported that it was "very difficult or impossible to find affordable insurance." The ACA cut that proportion to 34%.

* More than two out of five (43%) consumers trying to buy individual insurance before the ACA said that it was "very difficult or impossible to find the coverage they needed." After the ACA, just one in four (25%) experienced this problem.

* Altogether, just 46% of those who tried to buy individual coverage before the ACA wound up actually purchasing insurance. By contrast, two-thirds (66%) of people exploring the ACA's individual market bought coverage.

The ACA also prohibited insurance companies from discriminating against people with preexisting conditions; guaranteed essential preventive care, free from copayments and deductibles, to hundreds of millions of Americans who get health care on the job; and slashed prescription drug costs for millions of senior citizens as the infamous Medicare "prescription drug donut hole" shrank, then closed. Put simply, the Affordable Care Act provided the greatest advance in American health coverage since President Johnson signed Medicare and Medicaid into law in July 1965.

Starting in 2017, however, health coverage in America changed course. Trump Administration policies led to reduced enrollment in Medicaid and marketplace coverage as federal officials decimated funding for outreach and enrollment assistance and

promoted the sale of so-called "junk" insurance plans that let insurance companies discriminate against people with preexisting conditions. The number of people without health insurance once again began rising, growing from 27 million in 2016 to nearly 30 million in 2019./4

In a particularly shocking development, the number of children without any health insurance whatsoever rose for the first time since Congress, on a bipartisan basis, passed the Children's Health Insurance Program in 1997, two decades earlier./5

These insurance losses proved still more tragic in 2020, when the worst pandemic of deadly disease in more than a century and the steepest economic drop since the 1929 stock market crash devastated our country. As millions of workers lost their jobs, the number of people receiving health coverage from their employers fell by nearly 6 million -- one of the largest losses in history./6

The fallout would have been far worse, but thanks to Medicaid and health insurance marketplaces, 70% of people who lost employer-sponsored insurance were able to obtain other forms of coverage./7

All told, the number of uninsured still rose by 1.8 million people in 2020. Notably, the only statistically significant increases in the number of uninsured people reported by the Census Bureau took place in states that had not extended Medicaid coverage as Congress authorized in 2010/8--a problem Congress can and should fix, as I'll explain in a few moments.

Many of us weathered the storm, but many did not; this signals that our work to secure affordable and equitable health care is far from complete. Earlier this year, the members of this Committee and other national leaders once again stepped forward to protect the American people. By passing the American Rescue Plan, you made health care substantially more affordable for people who buy their own insurance. You guaranteed that, through the end of 2022, no one in America will be forced to pay more than 8.5% of their income for benchmark private insurance./9

At the same time, you dramatically lowered premiums charged to millions of hard-working families who buy their own insurance, unable to get health care on the job.

Almost before the ink was dry from President Biden's signature on the American Rescue Plan, families all across this nation saw their health care costs dramatically fall and their health security strengthen. During just the six months from February 15 to August 15, 2021, nearly 3 million people signed up for coverage through health insurance marketplaces -- and no wonder!/10

Average premium costs dropped by 50%, as nearly half of families coming to the federal marketplace were charged $10 or less in monthly premiums for health coverage./11

The median deductible for families new to the federal marketplace fell by 90%, from $750 to $50./12

Think about the impact on a family of four making $3,800 a month who, in the past, could afford nothing better than a plan with a $7,000 deductible for each insured family member. Today, by spending $38 on monthly premiums, that same family can buy insurance with a deductible of $800 instead of $7,000./13

That's enormous progress.

And behind every one of these numbers is a real person's story:

* Kristen Black from Lufkin, Texas lost her employer-sponsored health insurance in 2019 when she had to switch from working full time to part time because of a chronic health condition. Kristen worked with a local Insurance Navigator and found a gold plan that allowed her to access the doctors and medication she needs to manage her chronic condition. Two years later with the new American Rescue Plan subsidies, Kristen's plan went from costing her $333.10 per month to $177.10 per month. Saving over $150 every month is a huge help to Kristen. She is finally getting the care she needs at a price she can afford.

* Sheryl Hagen from Missouri couldn't afford the $300 premium her employer charged for health insurance, so she went without. Earlier this year, Sheryl had a health scare that led to a $1,300 bill, so she decided to sign up for insurance. She found a marketplace plan that cost her $73 a month. After President Biden signed the American Rescue Plan into law, Sheryl re-applied, and her monthly premium was cut to $0.

* April Henry, an Oregon-based writer who formerly worked in the health care industry, and her husband began saving $700 a month on premiums after they went back to the marketplace following enactment of the American Rescue Plan. The two of them can now save more for retirement and help their 25-year-old daughter with upcoming dental surgery.

Your hard work earlier this year has already paid off for Kristen and Sheryl and April and millions of other struggling families. In 2010, Congress passed legislation that sought to guarantee all families affordable access to quality health care and protection from costs that deplete the family budget. That promise is closer to fruition than ever before. But all of the extra help hard-working families receive from the American Rescue Plan will come to an end in less than 14 months, unless you once again lead the way on American health care through Build Back Better legislation.

Building Back Better

Build Back Better legislation gives America's leaders an opportunity to finish the job we started in 2010, to finally make sure that everyone in this country is guaranteed access to affordable, high-quality health care. If you act boldly and decisively in the coming weeks, you can provide real relief to so many people in America who are currently forced to choose between feeding their family and filling their prescription.

Families USA supports a network of tightly linked proposals to strengthen American health care. Employer-sponsored insurance, the health insurance marketplace, and public programs like Medicare, Medicaid, and the Children's Health Insurance Program work together to provide a spectrum of coverage for people across the lifespan. We urge you to lower prescription drug costs for people in Medicare and the commercial market, improve coverage for children and postpartum women, help families provide long-term care at home or in the community for seniors and family members with disabilities, enroll the eligible uninsured into coverage, and finally make sure that Medicare beneficiaries who worked hard all their lives receive essential coverage for dental, vision, and hearing care.

But the focus of today's hearing is Medicaid and marketplace coverage. I'm therefore going to center my remaining remarks on two proposals: guaranteeing essential health care to low-income adults who are uninsured because of their states' stubborn refusal to provide Medicaid to their poorest residents; and ensuring that the American Rescue Plan's dramatic improvements to the affordability of private insurance won't be taken away from the millions of families who now rely on them.

Closing the Medicaid Coverage Gap

The Medicaid program is a cornerstone of American health care. It covers nearly half of all births and, together with the Children's Health Insurance Program, half of all children under age 6./14

It is the country's largest source of funding for substance use treatment and prevention, covering almost 40% of adults suffering from opioid use disorders./15

Medicaid is America's leading source of coverage for long-term services and supports, serving six out of every ten nursing home residents./16

And after controlling for socioeconomic factors, low-income families often have better access to care and more financial protection in Medicaid than in private coverage, at a cost that is 10% lower for children and 25% lower for adults./17

The Affordable Care Act built on that record of accomplishment, extending Medicaid coverage to adults with incomes up to 138% of the federal poverty level, with very generous federal financial support. In more than three out of every four American states, governors and state legislators from both parties have gratefully taken advantage of federal financial incentives to implement this extension--and for good reason. An impressive research base now confirms that Medicaid expansion saves lives, protects people from cancer and other serious diseases, helps combat the scourge of addiction, prevents bankruptcy, saves money for state budgets, boosts employment, and keeps the doors open in rural hospitals./18

And there is no clearer example of the whole community's need for health coverage than the COVID-19 pandemic: newly infected people without insurance delay seeking care because of cost, which lets the virus spread, undetected and untreated. Based on peer-reviewed literature, insurance gaps in Texas, Florida, Oklahoma, Georgia, and Mississippi were linked to more than 40% of those coverage-gap states' COVID-19 deaths./19

Truly, in places where many of us are uninsured, all of us are at risk.

More than two million adults in this country are currently uninsured because they have the misfortune of being poor while living in one of the dozen states that stubbornly refuse to extend Medicaid coverage to their lowest-income residents. In these states, parents cannot get Medicaid unless they have extremely low incomes. In Mississippi, for example, a working mom with two children can't get Medicaid unless she earns $115 a month or less./20

And adults who are neither pregnant nor caring for dependent children are flatly ineligible for health care, no matter how low their income and how severe their need. This cruel exclusion denies health care to desperately poor people who are homeless, who have been diagnosed with a life-threatening illness, or are struggling with severe and untreated mental health or substance use disorders. It makes no sense to say that those who need help the most receive the least, but that is exactly what happens in coverage-gap states.

Many of us believe that public benefits should support rather than undermine work. But if that Mississippi mother sees her pay rise from $115 to $120 a week, she loses her health care. Closing the coverage gap is needed so struggling families can climb the economic ladder without losing their health insurance. If they earn more, they may need to pay more for health care, but never again will moms and dads be penalized with the loss of health insurance if they try to make a better life for their children.

This is not a hypothetical concern. Consider the stories of Della and Wendy.

'Wendy is a restaurant manager from Metairie, Louisiana. Like 70% of all Louisiana businesses that employ fewer than 50 people,/21 her restaurant doesn't provide health insurance. She applied for Medicaid before 2016 and was turned down. She worked so many hours that she made just a little too much money to qualify. When Louisiana became the first state in the Deep South to extend Medicaid to all low-wage workers, Wendy was one of more than 600,000 Louisianans who gained access to health care coverage./22

'That let her go to the doctor, who diagnosed Wendy as having a thyroid condition. The doctor quickly prescribed medication to keep it managed. As a result, she's healthier, feeling better, and losing weight. There is no telling how her health would have degenerated without Medicaid - quality coverage which she never believed was possible for her.

'Just 500 miles away from Wendy, Della is a kidney transplant recipient living in Henry County, Georgia.

'Georgia is one of the twelve states that stubbornly refuse to provide all their low-income residents with health care. As a result, Della earns $100 too much to qualify for Medicaid. Without this coverage, she couldn't afford to take daily immunosuppressant medication. As a result, her new kidney failed. She is now forced to undergo expensive and exhausting dialysis treatments, which limit her ability to work and are sending her deeper and deeper into medical debt.'

In America, your health and financial self-sufficiency should not vary by zip code. Both Della and Wendy should be able to find the quality, affordable coverage they need to remain healthy and thrive, but Della is still stuck in the Medicaid coverage gap.

And make no mistake: people of every race and ethnicity have their lives and economic security endangered by their states' refusal to offer them Medicaid. But families of color are in particular danger. Compared to white adults in non-expansion states, Black adults are 46% more likely and Latinos more than twice as likely to lack insurance because they fall into the coverage gap./23

Put simply, anyone who believes in health equity must also be committed to closing the Medicaid coverage gap.

Making Health Care Affordable for People who buy their Own Insurance

The American Rescue Plan fixed one of the biggest remaining holes in America's health insurance system: unaffordable costs that prevent people from buying insurance when they don't get health benefits on the job. Before that plan took effect, almost 75% of uninsured families said they lacked health care because they could not afford insurance./24

As I noted earlier, the American Rescue Plan cut families' average premium costs by 50% in the health insurance marketplace and lowered median deductibles by 90%./25

The American people showed how much this improved their ability to afford health care for their families: During the COVID-19 special enrollment period that ended on August 15, the number of people insured through health insurance marketplaces shot upward by nearly 3 million, or 35%, in just six short months./26

People of all races and ethnicities need affordable health care, but working-class people in communities of color have a particularly large stake in making sure that American Rescue Plan's affordability assistance remains in place. Based on the most recent available Census Bureau data, Black and Latino adults are 50% more likely than white adults to qualify for financial help buying marketplace coverage and thus to benefit from the American Rescue Plan./27

By keeping affordability assistance in 2023 and beyond, you will be doing more than helping millions of families obtain affordable health care, vital though that goal is. You will also give peace of mind to nearly 170 million people who get health coverage on the job./28

In America, if you lose your job, your family can lose its health insurance. By making it truly affordable for people to buy their own insurance, Build Back Better legislation can guarantee that a pink slip will no longer take away health insurance. As a result, parents will no longer spend sleepless nights worrying that, if they lose their job, they might not be able to take their sick child to the doctor, or may be forced to choose between paying the utility bills and paying for Dad's blood-pressure medicine that he needs to prevent another heart attack.

American entrepreneurship will also receive a much-needed boost. Instead of forcing people to stay in dead-end jobs just to keep their insurance, people can finally start that business they've always dreamed of, knowing that, if they go out on their own, they are guaranteed the ability to buy affordable health care. From 1978 through 2010, new business formation in America plummeted, falling from more than 15% of all companies to just 9%./29

Since 2010 that number has stabilized, but now it's time to reverse the trend and galvanize the creation of new American businesses. One crucial step towards that end is making the American Rescue Plan's affordability improvements permanent. That will help people start their own companies by guaranteeing that, after they go out on their own, entrepreneurs will still able to get affordable health insurance for themselves and their families.

Now is the Time for Action

We face tremendous challenges as a country, but we also have an extraordinary chance to learn from the mistakes of the past and make an historic investment in our collective health and economic recovery. Improving access to affordable health care for every family in America is a cornerstone of that opportunity, and I urge every single member of this Committee, and all of your colleagues in Congress, to put the needs of America's families first by immediately passing a bold and comprehensive Build Back Better Act.

* * *

Footnotes:

1 U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements. "Table HIB-1. Health Insurance Coverage Status and Type of Coverage by Sex, Race and Hispanic Origin: 1999 to 2012." https://www2.census.gov/programs-surveys/demo/tables/health-insurance/time-series/hib/hihistt1b.xls

2 U.S. Census Bureau, 2008 to 2019 American Community Surveys (ACS). "Table HIC-9_ACS. Population Without Health Insurance Coverage by Race and Hispanic Origin: 2008 to 2019." https://www2.census.gov/programssurveys/demo/tables/health-insurance/time-series/acs/hic09_acs.xlsx

3 Sara R. Collins, Munira Z. Gunja, Michelle M. Doty, and Sophie Beutel. "How the Affordable Care Act Has Improved Americans' Ability to Buy Health Insurance on Their Own." (New York, NY; The Commonwealth Fund, February 1, 2017) https://www.commonwealthfund.org/publications/issue-briefs/2017/feb/how-affordable-care-act-has-improvedamericans-ability-buy

4 U.S. Census Bureau, 2008 to 2019 ACS, Table HIC-9_ACS.

5 For estimates from 1997 through 2015, see Brian W. Ward, Tainya C. Clarke, Colleen N. Nugent, and Jeannine S. Schiller. "Early Release of Selected Estimates Based on Data from the 2015 National Health Interview Survey." National Health Interview Survey Early Release Program. National Center for Health Statistics. May 2016. https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201605.pdf. For estimates from 2008 to 2019, see U.S. Census Bureau, 2008 to 2019 American Community Survey (ACS), "Table HIC-5_ACS. Health Insurance Coverage Status and Type of Coverage by State-- Children Under 19: 2008 to 2019." https://www2.census.gov/programssurveys/demo/tables/health-insurance/time-series/acs/hic05_acs.xlsx

6 From 2019 to 2020, the number of people with employer-sponsored insurance fell by 5.8 million, according to Census Bureau estimates based on the Current Population Survey (CPS). Katherine Keisler-Starkey and Lisa N. Bunch. "Health Insurance Coverage in the United States: 2020." Current Population Reports, P60-274. U.S. Census Bureau, September 2021. https://www.census.gov/library/publications/2021/demo/p60-274.html

7 The Census Bureau's CPS estimates also showed that the number of uninsured increased by 1.8 million from 2019 to 2020, even as employer-based insurance covered nearly 6 million fewer people. Keisler-Starkey and Bunch. Health Insurance Coverage in the United States: 2020.

8 Keisler-Starkey and Bunch. Health Insurance Coverage in the United States: 2020, Table A-1.

9 American Rescue Plan Act of 2021, P.L. 117-2, March 11, 2021, Section 9661. https://www.congress.gov/117/plaws/publ2/PLAW-117publ2.pdf

10 Centers for Medicare & Medicaid Services (CMS). 2021 Final Marketplace Special Enrollment Period Report. September 15, 2021. https://www.hhs.gov/sites/default/files/2021-sep-final-enrollment-report.pdf

11 CMS. 2021 Final Marketplace Special Enrollment Period Report.

12 CMS. 2021 Final Marketplace Special Enrollment Period Report.

13 Before the ARP, a family of four at 175% of the federal poverty level (FPL) purchasing coverage with premiums at national average levels would have had to pay $12 for bronze coverage and $204 for silver coverage. After the ARP, the cost of silver has declined to $38. Kaiser Family Foundation. Health Insurance Marketplace Calculator. (Undated) https://www.kff.org/interactive/subsidy-calculator/. In healthcare.gov, the average combined deductible for a single individual is $6,921 for a bronze plan and $800 for an 87%-actuarial value silver plan, which would be available to a family with income at 175% of FPL. Kaiser Family Foundation. Cost-Sharing for Plans Offered in Federal Marketplace for 2021. January 14, 2021. https://files.kff.org/attachment/Cost-Sharing-for-Marketplace-for-2021.pptx

14 Manatt, Phelps & Phillips, LLP. Medicaid's Role in Children's Health. Robert Wood Johnson Foundation, Feb. 1, 2019, https://www.rwjf.org/en/library/research/2019/02/medicaid-s-role-in-children-s-health.html. From July 2019 to April 2021, the number of children covered through Medicaid and CHIP rose from 35.2 million to 38.9 million. Center for Medicaid and CHIP Services (CMCS), Medicaid and CHIP Enrollment Trends Snapshot through June 2020 (undated), https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/june-medicaid-chipenrollment-trend-snapshot.pdf; CMCS, Medicaid and CHIP Enrollment Trends Snapshot through April 2021 (undated), https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/downloads/april-2021-medicaidchip-enrollment-trend-snapshot.pdf.

15 Manatt, Phelps & Phillips, LLP. Medicaid's Role in Fighting the Opioid Epidemic. Robert Wood Johnson Foundation, Feb. 1, 2019, https://www.manatt.com/Manatt/media/Media/Images/White%20Papers/Issue-6-Medicaid-s-Role-inFighting-the-Opioid-Epidemic.pdf.

16 Kaiser Family foundation. Medicaid's Role in Nursing Home Care. June 2017. https://www.kff.org/infographic/medicaids-role-in-nursing-home-care/

17 Julia Paradise and Rachel Garfield. What is Medicaid's Impact on Access to Care, Health Outcomes, and Quality of Care? Kaiser Family Foundation, August 2, 2013. https://www.kff.org/report-section/what-is-medicaids-impact-onaccess-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence-issue-brief/; John Holahan and Sharon K. Long. Costs, Access, and Utilization under Medicaid: A Review of the Evidence. Urban Institute, June 30, 2006. https://www.urban.org/sites/default/files/publication/50326/1001002-Costs-Access-and-UtilizationUnder-Medicaid-A-Review-of-the-Evidence.PDF; Teresa A. Coughlin, Sharon K. Long, Lisa Clemans-Cope and Dean Resnick. What Difference Does Medicaid Make? Assessing Cost Effectiveness, Access, and Financial Protection under Medicaid for Low-Income Adults. Urban Institute, May 2013, https://www.kff.org/wp-content/uploads/2013/05/8440what-difference-does-medicaid-make2.pdf.

18 Madeline Guth and Meghana Ammula. Building on the Evidence Base: Studies on the Effects of Medicaid Expansion, February 2020 to March 2021. Kaiser Family Foundation, May 6, 2021, https://www.kff.org/medicaid/report/buildingon-the-evidence-base-studies-on-the-effects-of-medicaid-expansion-february-2020-to-march-2021/; Madeline Guth, Rachel Garfield, and Robin Rudowitz. The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020. Kaiser Family Foundation, March 17, 2020. https://www.kff.org/medicaid/report/the-effects-ofmedicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/

19 Stan Dorn. The Catastrophic Cost of Uninsurance: COVID-19 Cases and Deaths Closely Tied to America's Health Coverage Gaps. Families USA, March 2021. https://familiesusa.org/wp-content/uploads/2021/03/COV-2021-64_Lossof-Lives-Report_Report_v2_4-20-21.pdf

20 Kaiser Family Foundation. "Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty, as of January 1, 2021." State Health Facts. https://www.kff.org/health-reform/state-indicator/medicaid-income-eligibilitylimits-for-adults-as-a-percent-of-the-federal-povertylevel/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. HHS Poverty Guidelines for 2021. https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-povertyguidelines-federal-register-references/2021-poverty-guidelines.

21 Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. "Table II.A.2 Percent of private-sector establishments that offer health insurance by firm size and State: United States, 2020." 2020 Medical Expenditure Panel Survey-Insurance Component. https://meps.ahrq.gov/data_stats/summ_tables/insr/state/series_2/2020/tiia2.htm

22 Office of the Governor of Louisiana. Gov. Edwards Celebrates the 5-year Anniversary of Medicaid Expansion That Continues to Save Lives, Jobs, Rural Hospitals and Reduce the Number of Uninsured Louisianans. July 1, 2021. https://gov.louisiana.gov/index.cfm/newsroom/detail/3253

23 Analysis of Figure 3, results for adults ages 19-64, in Samantha Artiga, Latoya Hill, Kendal Orgera, and Anthony Damico. Health Coverage by Race and Ethnicity, 2010-2019. Kaiser Family Foundation, July 16, 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/

24 The second most common reason given in response to the survey, ineligibility for coverage, was cited by only 25% of uninsured families. Survey respondents could give more than one explanation for lacking insurance. Jennifer Tolbert, Kendal Orgera, and Anthony Damico. Key Facts about the Uninsured Population. Kaiser Family Foundation, November 6, 2020. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ 25 CMS. 2021 Final Marketplace Special Enrollment Period Report.

26 By the end of the Special Enrollment period, 8.0 million people previously receiving marketplace coverage were joined by an additional 2.8 million new members, representing a 35% increase. CMS. 2021 Final Marketplace Special Enrollment Period Report.

27 In 2019, the most recent year for which data are available, among citizens and lawfully present immigrants age 19-64, 10.0% of whites qualified for premium tax credits, including both those who enrolled in individual-market coverage and those who were uninsured despite qualifying for assistance. Among adults of color, 14.5% were eligible for premium tax credits and either uninsured or enrolled in individual-market plans, including 16.4% of Indigenous adults, 15.4% of African-American adults, 15.2% of Latino adults, and 11.4% of Asian-American/Pacific-Islander adults. Unpublished analysis of 2019 ACS data by the National Center for Coverage Innovation at Families USA, accessed through IPUMS USA, University of Minnesota, www.ipums.org.

28 Kaiser Family Foundation. "Health Insurance Coverage of the Total Population (CPS): 2020." State Health Facts. https://www.kff.org/other/state-indicator/health-insurance-coverage-of-the-total-populationcps/?dataView=1&currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

29 U.S. Census Bureau, Business Dynamics Statistics, "Rate of establishments born during the last 12 months," Business Dynamics Statistics: Establishment Age: 1978-2019, downloaded on October 10, 2021, from https://data.census.gov/cedsci/table?q=BDSTIMESERIES.BDSEAGE&tid=BDSTIMESERIES.BDSEAGE&hidePreview= true.