New Estimates of Eligibility for ACA Coverage among the Uninsured

by Rachel Garfield, Anthony Damico, Cynthia Cox , Gary Claxton, and Larry Levitt  of KFF.org

The Affordable Care Act (ACA) extends health insurance coverage to people who lack access to an affordable coverage option. Under the ACA, as of 2014, Medicaid coverage is extended to low-income adults in states that have opted to expand eligibility, and tax credits are available for middle-income people who purchase coverage through a health insurance Marketplace. Millions of people have enrolled in these new coverage options, but millions of others are still uninsured. Some remain ineligible for coverage, and others may be unaware of the availability of new coverage options or still find coverage unaffordable even with financial assistance.

This analysis provides national and state-by-state estimates of eligibility for ACA coverage options among those who remained uninsured. It is based on Kaiser Family Foundation analysis of the 2015 Current Population Survey, combined with other data sources. We estimate coverage and eligibility as of early 2015, which is prior to the end of the 2015 Marketplace open enrollment period, but have updated this brief to reflect state Medicaid expansion decisions as of January 2016. An overview of the methodology underlying the analysis can be found in the Methods box at the end of the data note, and more detail is available in the Technical Appendices available here.

Background: How Does the ACA Expand Health Coverage?

The ACA fills historical gaps in Medicaid eligibility by extending Medicaid to nearly all nonelderly adults with incomes at or below 138% of the federal poverty level (FPL) ($27,724 for a family of three in 20151). With the June 2012 Supreme Court ruling, the Medicaid expansion essentially became optional for states, and as of January 2016, 31 states and DC had expanded Medicaid eligibility under the ACA. Under rules in place before the ACA, all states already extended public coverage to poor and low-income children, with a median income eligibility level of 255% of poverty in 2016.2 The ACA also established Health Insurance Marketplaces where individuals can purchase insurance and allows for federal tax credits for such coverage for people with incomes from 100% to 400% FPL ($19,790 to $79,160 for a family of three in 2015).3,4 Tax credits are generally only available to people who are not eligible for other coverage.

Because the ACA envisioned low-income people receiving coverage through Medicaid, people with incomes below poverty are not eligible for Marketplace subsidies. Thus, in the 19 states not implementing the Medicaid expansion, some adults fall into a “coverage gap” of earning too much to qualify for Medicaid but not enough to qualify for premium tax credits. In addition, undocumented immigrants are ineligible for Medicaid coverage and barred from purchasing coverage through a Marketplace. In most cases, lawfully present immigrants are subject to a five-year waiting period before they may enroll in Medicaid, though they can purchase coverage through a Marketplace and may receive tax credits for such coverage.

How Many Uninsured Are Eligible for Assistance under the ACA?

As of the beginning of 2015, 32.3 million nonelderly people lacked health coverage in the U.S. Nationally, we estimate that nearly half (15.9 million, or 49%) of this population is eligible for financial assistance to gain coverage through either Medicaid or subsidized Marketplace coverage (Figure 1 and Tables 1 and 2). More than a quarter are either adults eligible for Medicaid (5.7 million, or 18%) or children eligible for Medicaid or the Children’s Health Insurance Program (CHIP) (3.2 million, or 10%). Those who are Medicaid eligible include people who were previously eligible as well as those newly eligible under the ACA. About one in five (7.0 million, or 22%) of the nonelderly uninsured are eligible for premium tax credits to purchase coverage through the Marketplace.5

Figure 1: Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2015

Nearly one in ten uninsured people (2.9 million) fall into the coverage gap due to their state’s decision not to expand Medicaid, and 15% of the uninsured (4.9 million) are undocumented immigrants who are ineligible for ACA coverage under federal law.

The remainder of the uninsured either has an offer of ESI (4.9 million, or 15%) or has an income above the limit for premium tax credits but could purchase unsubsidized Marketplace coverage (3.7 million, or 12%). We cannot determine from available survey data if the offer of ESI would be considered affordable under the law, which would make the individual ineligible for a Marketplace premium subsidy.

Patterns of eligibility vary by state (Tables 1 and 2), depending on state decisions about expanding Medicaid, premiums in the exchange, and underlying demographic factors such as poverty rates and access to employer coverage. In states that expanded Medicaid, 41% of the nonelderly uninsured population is eligible for Medicaid, versus just 13% in states that have not expanded Medicaid (Figure 2). No one in Medicaid expansion states falls into a coverage gap; in non-expansion states,  nearly one in five (19%) uninsured people falls into the coverage gap, while about two-thirds as many are eligible for Medicaid under pathways in place before the ACA.  Because adults with incomes from 100% to 138% of poverty in non-expansion states can receive tax credits for Marketplace coverage, a larger share of the uninsured population in those states is eligible for Marketplace tax credits than in expansion states (27% versus 17%).

Figure 2: Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2015, by State Medicaid Expansion Status

Discussion

Though millions of people have gained coverage under the ACA, many remain uninsured. The ACA provides new coverage options across the income spectrum for low and moderate-income people, and nearly half of the uninsured population appear to be eligible for Medicaid or subsidized Marketplace coverage. For these individuals, outreach and education about coverage and financial assistance may be important to continuing coverage gains that were seen in the first two years of full ACA implementation. Data from other sources indicates that misperceptions about cost, lack of awareness of financial assistance, and confusion about eligibility rules were barriers to some eligible uninsured gaining coverage.6 Others report that they found coverage to be too expensive, even with the availability of financial assistance.7

Nearly a quarter of the remaining uninsured population is outside the reach of the ACA due to either their immigration status or their state’s decision not to expand Medicaid. People in the coverage gap would be eligible for Medicaid should their state opt to expand Medicaid but are otherwise likely to remain uninsured, as they have limited incomes, are unlikely to have an affordable offer of coverage from an employer, and do not have access to affordable coverage options under the ACA. Many undocumented immigrants also will likely remain uninsured.8

Approximately a quarter of the uninsured population is not eligible for any assistance under the ACA because they have access to employer coverage that may be considered affordable or have incomes too high to qualify for Medicaid or Marketplace subsidies. Increased penalties under the ACA’s so-called “individual mandate” in 2016 may encourage some of them to obtain coverage.

As of 2016, there are still substantial opportunities to increase coverage by reaching those who are eligible for help under the ACA. However, the breakdown of who the remaining uninsured are suggests that many may be difficult to reach and will still remain uninsured.

Rachel Garfield, Cynthia Cox, Gary Claxton, and Larry Levitt are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation.

Table 1: Number of Nonelderly People Eligible for ACA Coverage Among those Remaining Uninsured as of 2015
State Total Uninsured Medicaid Eligible Tax Credit Eligible Ineligible for Financial Assistance due to Income, ESI Offer, or Citizenship In Medicaid Coverage Gap
US Total 32,339,000 8,850,000 7,022,000 13,572,000 2,895,000
Alabama 513,000  75,000 160,000 139,000 139,000
Alaska 100,000  51,000 20,000 29,000                    –
Arizona 808,000  368,000 100,000 341,000                    –
Arkansas 285,000  127,000 60,000 98,000                    –
California 3,845,000  1,428,000 623,000 1,795,000                    –
Colorado 593,000  223,000 104,000 266,000                    –
Connecticut 247,000  69,000 62,000 116,000                    –
Delaware 63,000  22,000 15,000 25,000                    –
DC 42,000  20,000 N/A 19,000                    –
Florida 2,788,000  306,000 825,000 1,091,000 567,000
Georgia 1,524,000  201,000 406,000 612,000 305,000
Hawaii 70,000  35,000 N/A 28,000                    –
Idaho 166,000  21,000 43,000 72,000 30,000
Illinois 1,122,000  397,000 166,000 559,000                    –
Indiana 686,000  310,000 128,000 248,000                    –
Iowa 188,000  88,000 30,000 71,000                    –
Kansas 302,000  38,000 83,000 131,000 49,000
Kentucky 285,000  121,000 N/A 119,000                    –
Louisiana* 582,000 311,000 117,000 154,000
Maine 121,000  18,000 40,000 39,000 24,000
Maryland 336,000  133,000 43,000 160,000                    –
Massachusetts 288,000  93,000 N/A 147,000                    –
Michigan 685,000  320,000 147,000 218,000                    –
Minnesota 364,000  126,000 45,000^ 193,000                    –
Mississippi 359,000  42,000 104,000 106,000 108,000
Missouri 516,000  52,000 156,000 198,000 109,000
Montana 126,000  59,000 27,000 40,000                    –
Nebraska 178,000  16,000 46,000 90,000 27,000
Nevada 350,000  147,000 61,000 143,000                    –
New Hampshire 94,000  37,000 17,000 41,000                    –
New Jersey 940,000  335,000 131,000 473,000                    –
New Mexico 233,000  109,000 31,000 94,000                    –
New York 1,476,000  548,000 317,000^ 611,000                    –
North Carolina 1,138,000  152,000 289,000 452,000 244,000
North Dakota 64,000  24,000 16,000 24,000                    –
Ohio 834,000  404,000 165,000 264,000                    –
Oklahoma 581,000  109,000 144,000 236,000 91,000
Oregon 307,000  122,000 N/A 150,000                    –
Pennsylvania 994,000  477,000 180,000 338,000                    –
Rhode Island 55,000  27,000 13,000 15,000                    –
South Carolina 604,000  100,000 186,000 195,000 123,000
South Dakota 77,000  12,000 22,000 30,000 13,000
Tennessee 605,000  104,000 127,000 257,000 118,000
Texas 4,425,000  493,000 1,035,000 2,132,000 766,000
Utah 337,000  66,000 92,000 138,000 41,000
Vermont 34,000  8,000 11,000 15,000                    –
Virginia 804,000  77,000 235,000 361,000 131,000
Washington 621,000  238,000 116,000 267,000                    –
West Virginia 116,000  56,000 31,000 29,000                    –
Wisconsin 410,000  129,000 100,000 181,000
Wyoming 56,000  6,000 19,000 20,000 11,000
NOTES: Numbers may not sum to totals due to rounding. * LA’s Governor signed an Executive Order to adopt the Medicaid expansion on 1/12/16, but coverage under the expansion is not yet in effect. For purposes of this analysis, LA is considered an expansion state. ^ Tax credit-eligible population in Minnesota and New York include uninsured adults who are eligible for coverage through the Basic Health Plan. † Wisconsin covers adults up to 100% FPL in Medicaid under a waiver but did not adopt the ACA expansion. Estimates of subsidy eligibility of uninsured nonelderly in DC, HI, KY, MA, and OR are “N/A” because point estimates do not meet minimum standards for statistical reliability.
SOURCE:  Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data.
Table 2: Distribution of Nonelderly Eligibility for ACA Coverage Among those Remaining Uninsured as of 2015
State Total Uninsured Medicaid Eligible Tax Credit Eligible Ineligible for Financial Assistance due to Income, ESI Offer, or Citizenship In Medicaid Coverage Gap
US Total 32,339,000 27% 22% 42% 9%
Alabama 513,000 15% 31% 27% 27%
Alaska 100,000 51% 20% 29%
Arizona 808,000 46% 12% 42%
Arkansas 285,000 44% 21% 34%
California 3,845,000 37% 16% 47%
Colorado 593,000 38% 18% 45%
Connecticut 247,000 28% 25% 47%
Delaware 63,000 35% 24% 40%
DC 42,000 48% N/A 45%
Florida 2,788,000 11% 30% 39% 20%
Georgia 1,524,000 13% 27% 40% 20%
Hawaii 70,000 50% N/A 39%
Idaho 166,000 13% 26% 44% 18%
Illinois 1,122,000 35% 15% 50%
Indiana 686,000 45% 19% 36%
Iowa 188,000 47% 16% 38%
Kansas 302,000 13% 28% 43% 16%
Kentucky 285,000 43% N/A 42%
Louisiana* 582,000 53% 20% 26%
Maine 121,000 15% 33% 32% 20%
Maryland 336,000 40% 13% 48%
Massachusetts 288,000 32% N/A 51%
Michigan 685,000 47% 21% 32%
Minnesota 364,000 35% 12%^ 53%
Mississippi 359,000 12% 29% 29% 30%
Missouri 516,000 10% 30% 38% 21%
Montana 126,000 47% 22% 32%
Nebraska 178,000 9% 26% 50% 15%
Nevada 350,000 42% 17% 41%
New Hampshire 94,000 39% 18% 43%
New Jersey 940,000 36% 14% 50%
New Mexico 233,000 47% 13% 40%
New York 1,476,000 37% 21%^ 41%
North Carolina 1,138,000 13% 25% 40% 21%
North Dakota 64,000 37% 25% 38%
Ohio 834,000 48% 20% 32%
Oklahoma 581,000 19% 25% 41% 16%
Oregon 307,000 40% N/A 49%
Pennsylvania 994,000 48% 18% 34%
Rhode Island 55,000 49% 23% 27%
South Carolina 604,000 17% 31% 32% 20%
South Dakota 77,000 16% 29% 39% 17%
Tennessee 605,000 17% 21% 42% 19%
Texas 4,425,000 11% 23% 48% 17%
Utah 337,000 20% 27% 41% 12%
Vermont 34,000 24% 33% 43%
Virginia 804,000 10% 29% 45% 16%
Washington 621,000 38% 19% 43%
West Virginia 116,000 48% 27% 25%
Wisconsin 410,000 32% 24% 44%
Wyoming 56,000 11% 34% 36% 19%
NOTES: Numbers may not sum to 100% due to rounding. *LA’s Governor signed an Executive Order to adopt the Medicaid expansion on 1/12/16, but coverage under the expansion is not yet in effect. For purposes of this analysis, LA is considered an expansion state. ^ Tax credit-eligible population in Minnesota and New York include uninsured adults who are eligible for coverage through the Basic Health Plan. † Wisconsin covers adults up to 100% FPL in Medicaid under a waiver but did not adopt the ACA expansion. Estimates of subsidy eligibility of uninsured nonelderly in DC, HI, KY, MA, and OR are “N/A” because point estimates do not meet minimum standards for statistical reliability.
SOURCE:  Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data.
Table 3: Number and Distribution of Nonelderly People Ineligible for Financial Assistance due to
Income, Offers of Employer Coverage, or Citizenship Status as of 2015, in States with Sufficient Sample Size
State Number of Nonelderly People Ineligible due to: % of Nonelderly Uninsured Ineligible due to:
Total Ineligible Due to Income, ESI Offer, or Citizenship Income Employer Offer Citizenship Total Ineligible Due to Income, ESI Offer, or Citizenship Income Employer Offer Citizenship
US Total 13,572,000 3,720,000 4,916,000 4,936,000 42% 12% 15% 15%
Arizona 341,000 113,000 100,000 127,000 42% 14% 12% 16%
Arkansas 98,000 25,000 45,000 28,000 34% 9% 16% 10%
California 1,795,000 396,000  476,000 922,000 47% 10% 12% 24%
Colorado 266,000 72,000  95,000 99,000 45% 12% 16% 17%
Florida 1,091,000 290,000 417,000 384,000 39% 10% 15% 14%
Georgia 612,000 187,000  233,000 192,000 40% 12% 15% 13%
Illinois 559,000 173,000 151,000 235,000 50% 15% 13% 21%
Minnesota 193,000 66,000 73,000 55,000 53% 18% 20% 15%
Nebraska 90,000 31,000 33,000 26,000 50% 17% 18% 15%
Nevada 143,000 31,000 50,000 62,000 41% 9% 14% 18%
New Jersey 473,000 91,000 118,000 264,000 50% 10% 13% 28%
New Mexico 94,000 34,000 25,000 35,000 40% 14% 11% 15%
New York 611,000 150,000  242,000 220,000 41% 10% 16% 15%
North Carolina 452,000 119,000 190,000 143,000 40% 10% 17% 13%
Oklahoma 236,000 68,000 114,000 54,000 41% 12% 20% 9%
Oregon 150,000 45,000 50,000 56,000 49% 15% 16% 18%
Pennsylvania 338,000 123,000 149,000 66,000 34% 12% 15% 7%
Tennessee 257,000 88,000 99,000  69,000 42% 15% 16% 11%
Texas 2,132,000 416,000 652,000 1,064,000 48% 9% 15% 24%
Virginia 361,000 122,000 140,000 99,000 45% 15% 17% 12%
Washington 267,000 72,000 96,000 99,000 43% 12% 15% 16%
NOTES: States not included above do not have sufficient sample size to show distribution of uninsured nonelderly ineligible for financial assistance in at least one of the three categories (income, ESI, and/or citizenship). Numbers may not sum to totals due to rounding.
SOURCE: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data.
Methods
This analysis uses data from the 2015 Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC). The CPS ASEC provides socioeconomic and demographic information for the United Sates population and specific subpopulations. Importantly, the CPS ASEC provides detailed data on families and households, which we use to determine income for ACA eligibility purposes.The CPS asks respondents about coverage at the time of the interview (for the 2015 CPS, February, March, or April 2015) as well as throughout the preceding calendar year. People who report any type of coverage throughout the preceding calendar year are counted as “insured.” Thus, the calendar year measure of the uninsured population captures people who lacked coverage for the entirety of 2014 (and thus were uninsured at the start of 2015). We use this measure of insurance coverage, rather than the measure of coverage at the time of interview, because the latter lacks detail about coverage type that is used in our model. Based on other survey data, as well as administrative data on ACA enrollment, it is likely that a small number of people included in this analysis gained coverage in 2015.

Medicaid and Marketplaces have different rules about household composition and income for eligibility. For this analysis, we calculate household membership and income for both Medicaid and Marketplace premium tax credits for each person individually, using the rules for each program.  For more detail on how we construct Medicaid and Marketplace households and count income, see the detailed technical Appendix A available here.

Undocumented immigrants are ineligible for Medicaid and Marketplace coverage. Since CPS data do not directly indicate whether an immigrant is lawfully present, we draw on the methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. al.9,10This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to CPS, controlling to state-level estimates of total undocumented population from Department of Homeland Security. For more detail on the immigration imputation used in this analysis, see the technical Appendix B available here.

Individuals in tax-filing units with access to an affordable offer of Employer-Sponsored Insurance are still potentially MAGI-eligible for Medicaid coverage, but they are ineligible for advance premium tax credits in the Health Insurance Exchanges. Since CPS data do not directly indicate whether workers have access to ESI, we draw on the methods comparable to our imputation of authorization status and use SIPP to develop a model that predicts offer of ESI, then apply the model to CPS. For more detail on the offer imputation used in this analysis, see the technical Appendix C available here.

As of January 2014, Medicaid financial eligibility for most nonelderly adults is based on modified adjusted gross income (MAGI). To determine whether each individual is eligible for Medicaid, we use each state’s reported eligibility levels as of January 1, 2015, updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Federal Poverty Levels.11 Some nonelderly adults with incomes above MAGI levels may be eligible for Medicaid through other pathways; however, we only assess eligibility through the MAGI pathway.12

An individual’s income is likely to fluctuate throughout the year, impacting his or her eligibility for Medicaid. Our estimates are based on annual income and thus represent a snapshot of the number of people in the coverage gap at a given point in time. Over the course of the year, a larger number of people are likely to move and out of the coverage gap as their income fluctuates.

 

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