ObamaCare faces a tougher path ahead in enrolling the roughly 30 million people who remain uninsured, despite the record gains already made.
The administration signed up 12.7 million people for coverage in 2016, a significant number, but only a small bump from the 11.7 million enrolled last year.
Officials warned from the start that this year would be the hardest yet, because the people most eager to sign up already had.
But the 30 million people uninsured are a stark problem for a law that was intended to fulfill the decades-old Democratic dream of providing universal coverage.
Larry Levitt, an expert on the health law at the Kaiser Family Foundation, said that there is likely to be “slow and steady progress” going forward, but “we’re unlikely to see the kind of tremendous reductions in the uninsured that happened in 2014."
“The [Affordable Care Act] has reduced the share of people uninsured to the lowest levels ever recorded, but we are still well short of universal coverage,” he added.
Sen. Bernie Sanders (I-Vt.), a Democratic presidential contender, has drawn attention to the remaining uninsured. He argues that ObamaCare can't get it done and that his single-payer "Medicare for all" plan is the only way to get everyone insured.
“I voted for [the Affordable Care Act],” Sanders said at a recent debate. “But right now, what we have to deal with is the fact that 29 million people still have no health insurance.”
The people who remain uninsured fall into three main groups, according to the Kaiser Family Foundation.
About 10 percent are ineligible for coverage because they live in a state that declined to expand Medicaid under ObamaCare. Another 15 percent are ineligible because of their immigration status. And about half are eligible for coverage, but have not signed up.
Within that last group are the 10.5 million uninsured people eligible for ObamaCare’s marketplaces that the administration is targeting. About 4 million new people signed up for ObamaCare this year, which could be a sign that uninsured number is coming down. It remains to be seen, though, how many of the 4 million were previously uninsured.
Asked about further reducing the uninsured rate, Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services, noted those 4 million new sign-ups, as well as the obstacles from immigration status and Medicaid expansion that limit the ability to sign up more people.
“If you'd asked me a few months ago if we'd be happy where we are relative to our ability to cover more people, we feel very good,” he said, noting gains made in previous years.
Secretary of Health and Human Services Sylvia Burwell told reporters Friday that growth in the marketplaces and getting more states to expand Medicaid are points of emphasis, but that full universal coverage is difficult without immigration reform.
“The third change in terms of things that would contribute to a large number [of enrollees] is actually changes in the immigration laws,” Burwell said.
Under current law, people in the country illegally are barred from Medicaid or ObamaCare marketplace coverage.
However, even among the 10.5 million uninsured people who are eligible for the ObamaCare marketplaces, there are barriers to signing more up.
Caroline Pearson, senior vice president at Avalere Health, a consulting firm, noted that the marketplaces have struggled to sign up middle-class people, with most enrollees so far being low-income people.
“The challenge is really middle-income people,” she said. “They feel like the coverage is too expensive and they just can't afford it.”
Financial assistance under the law is heavier for low-income people, but phases out as income goes up.
A study from Avalere last year found that less than 30 percent of people with incomes above 200 percent of the poverty line had signed up for ObamaCare, compared to 76 percent of people with incomes between 100 and 150 percent of the poverty line.
“The big challenge is that health insurance still may not be sufficiently affordable for many people,” Levitt said.
A solution could be to increase the level of financial assistance for middle-income people, but that option is politically impossible at the moment.
A more feasible option for chipping away at the uninsured rate is getting more states to expand Medicaid, though that would only bring in about 3 million more people.
Thirty-one states have expanded it so far, including a number of Republican-led states that negotiated with the Obama administration to put a conservative twist, like making enrollees pay premiums, on the program.
Burwell said she saw “energy” for Medicaid expansion in many places, particularly because it has been shown to help state economies and keep hospitals from closing down. But she acknowledged that “whether that energy will come to fruition while I sit in this chair” is an open question.
She said she believes that all states would eventually get there.
“What I do think is the fact that one sees so much energy [for] this across the country is a reflection that in truth, this is a question of ‘When?’ ”