ASPE RESEARCH BRIEF ELIGIBLE UNINSURED AFRICAN AMERICANS: 6 IN 10 COULD RECEIVE HEALTH INSURANCE MARKETPLACE TAX CREDITS, MEDICAID OR CHIP December 9, 2013 By Emily R. Gee Under the Affordable Care Act, 6.8 million eligible uninsured African Americans will have access to new options for health care coverage starting January 1, 2014. 1 Six in ten, or 4.2 million, of these eligible uninsured African Americans may qualify either for tax credits to purchase coverage in the Health Insurance Marketplace (2.2 million) or for Medicaid or the Children’s Health Insurance Program (CHIP) (2.0 million). If all states were to expand Medicaid, 95 percent of all eligible uninsured African Americans would be eligible for Marketplace tax credits, Medicaid, or CHIP. Of the 41.3 million uninsured nonelderly U.S. citizens and others lawfully residing in the United States (a group referred to as “eligible uninsured” in this brief), 6.8 million people or one in six (16 percent) are African American. African Americans are uninsured at a higher rate than the U.S. population overall; 16 percent of all nonelderly U.S. citizens and others lawfully residing are uninsured, while the comparable proportion among eligible African Americans is 20 percent. 1 ASPE tabulations from the CY 2011 American Community Survey Public Use Microdata Sample (ACS PUMS) are adjusted to exclude estimated undocumented persons based on ASPE’s TRIM3 microsimulation model. All references to eligible uninsured in this brief use these tabulations. See the methodology section for more information. For more information about eligibility to purchase coverage in the Marketplace, see https://www.healthcare.gov/immigration-status-and-the-marketplace/. The estimates contained in this brief do not take into account certain Marketplace coverage and Medicaid/CHIP eligibility requirements, such as those relating to other minimum essential coverage or tax filing requirements, and thus the populations described in this brief should be construed as “potentially” eligible, subject to these other requirements. Also, the statutory threshold for Medicaid expansion set by the Affordable Care Act is 133 percent of the FPL, not 138 percent of the FPL. This brief refers throughout to 138 percent of the FPL, which is the effective threshold including the 5 percent statutory disregard. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation http://aspe.hhs.gov ASPE Research Brief Page 2 Location — The five states with the greatest number of eligible uninsured African Americans are: • Florida 677,000 (10 percent of all eligible uninsured African Americans), • Georgia 631,000 (9 percent), • Texas 617,000 (9 percent), • North Carolina 380,000 (6 percent), and • New York 354,000 (5 percent). The greater Atlanta, New York, Chicago, Dallas, Houston, and Detroit metropolitan areas are home to one-fifth (21 percent) of eligible uninsured African Americans (see Table 4). Approximately 15 percent of eligible uninsured African Americans live outside a metropolitan area, a lower proportion than among the eligible uninsured population overall (19 percent). Gender — More men than women are uninsured in the United States. This is also the case for African Americans. Among eligible uninsured African Americans, less than half, or 44 percent (3.0 million) are women. Age — Young adults are a disproportionately large share of the uninsured relative to their share of the general population. They are the age group most likely to be without health insurance coverage in the U.S. 2 The same is true among young African Americans: young adults ages 18 to 35 account for nearly half (3.2 million; 47 percent) of the African American eligible uninsured but only 30 percent of the eligible African American population overall. Of the 3.2 million eligible uninsured African Americans ages 18 to 35, 1.3 million (41 percent) are women and 1.9 million (59 percent) are men. Employment — Most (73 percent) of eligible uninsured Americans live in households with at least one full-time worker. Similarly, six in ten (61 percent) eligible uninsured African Americans have at least one full-time worker in the family. Education — About one-fifth (19 percent) of eligible uninsured African Americans did not earn a high school diploma, 71 percent have a high school diploma, and an additional 9 percent hold a college degree. Among all eligible uninsured Americans nationwide (41.3 million), 20 percent do not have a high school diploma, 68 percent have a high school diploma, and 12 percent hold a college degree. Language — Nearly all (97 percent) of eligible uninsured African Americans report that they speak English as a first language or at least “very well” as a second language. Among those who do not, the most common language is French Creole, which is spoken by among 1 percent of eligible uninsured African Americans. 2 For the most up to date information on the demographic characteristics of the uninsured, including by age and gender, see a summary of the Census Bureau’s Current Population Survey released in September 2013 at http://aspe.hhs.gov/health/reports/2013/CPSIssueBrief/ib_cps.cfm. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 3 Income — More than half (3.8 million; 55 percent) of all eligible uninsured African Americans have family incomes 3 below 100 percent of the Federal Poverty Level (FPL), and nearly two- thirds of these people (2.4 million) live in states that are not expanding Medicaid. This means that more than one in three eligible uninsured African Americans may not gain access to affordable coverage through Medicaid in 2014 because their state declined to take the federally funded option to expand Medicaid eligibility. Approximately 4.4 million eligible uninsured African Americans have family incomes at or below 138 percent of the FPL, the threshold for qualifying for Medicaid in expansion states. Of these 4.4 million, 1.5 million live in Medicaid expansion states. 4 Table 1: Distribution of Eligible Uninsured African Americans by Family Income Medicaid Non- Expansion Expansion All States 5 States States Number of States 26 25 51 All Eligible African Americans 6 14,164,000 20,083,000 34,248,000 Eligible Uninsured African Americans 2,372,000 4,448,000 6,820,000 Medicaid Non- By Family Income as Percent of the Expansion Expansion All States Federal Poverty Level (FPL) States States 100% FPL or Less 1,317,000 2,456,000 3,773,000 101% to 138% FPL 205,000 485,000 691,000 139% to 400% FPL 688,000 1,295,000 1,983,000 Above 400% FPL 162,000 212,000 374,000 3 For family income, a “family” is based on the “health insurance unit” (HIU), which includes adults, their spouses, and their dependent children (ages 0-18, plus full-time students under age 23), using ASPE analysis of the ACS PUMS data. 4 Our analysis assumes that the following 25 states plus the District of Columbia expand their Medicaid programs: Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia. 5 The sum of expansion and non-expansion state estimates may not equal the stated total for all states due to rounding. 6 Estimates in this row are for all nonelderly (ages 0 to 64) African American who are U.S. citizens or lawfully residing in the United States. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 4 African Americans and the Marketplace Each state has a Health Insurance Marketplace where consumers can shop for and purchase health insurance coverage. In states that are expanding Medicaid, individuals and families with household incomes from 138 to 400 percent of the FPL may be eligible for tax credits to make health insurance even more affordable. In states that do not expand Medicaid, those with family incomes between 100 and 400 percent of FPL may qualify for tax credits. Of the 2.6 million uninsured African Americans eligible to purchase Marketplace plans, 2.2 million—or nearly 9 in 10 (26 percent)—may qualify for a premium tax credit for Marketplace coverage (see Table 2). 7 The estimated 2.6 million Marketplace-eligible uninsured include 762,000 eligible uninsured African American adults (ages 19 and older) in Medicaid expansion states with incomes above 138 percent of the FPL, 1.7 million eligible uninsured in the remaining 25 non-expansion states with incomes above 100 percent of the FPL, and 117,000 eligible uninsured African American children from all states with family incomes above 250 percent of the FPL. 8 Table 5 contains examples of premiums before and after tax credits are applied. African Americans and Medicaid Many uninsured African Americans may be eligible for coverage through Medicaid or the Children’s Health Insurance Program (CHIP) at little or no cost. About 1.4 million eligible uninsured African American adults (21 percent of all eligible uninsured African Americans) who reside in states expanding their Medicaid programs may be eligible for Medicaid coverage. Additionally, approximately 615,000 eligible uninsured African American children ages 0 to 18 have family incomes at or below 250 percent of FPL and may be eligible for coverage under Medicaid/CHIP (see Table 2). More than 2.2 million African American adults live in states that are not expanding Medicaid and have family incomes below 100 percent of the FPL. If all states were to expand Medicaid, 95 percent of all eligible uninsured African Americans would be eligible for Marketplace tax credits, Medicaid, or CHIP. 7 We define Marketplace-tax-credit-eligible individuals in this analysis as uninsured U.S. citizens and others lawfully residing in the area served by the Marketplace who are adults (ages 19 to 64) with family incomes above 138 percent to 400 percent of the FPL in Medicaid expansion states and above 100 percent to 400 percent of the FPL in non-expansion states or who are children (ages 0 to18) with incomes 250 percent to 400 percent of the FPL. 8 We make the simplifying assumption in this analysis that all children with incomes below 250 percent of the FPL would be eligible for Medicaid/CHIP rather than the Marketplace. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 5 Table 2: Number and Percentage of Eligible Uninsured African Americans Who May Qualify for Marketplace Tax Credits, Medicaid, or CHIP Medicaid Non- Expansion Expansion All States 9 States States 2,372,000 4,448,000 6,820,000 Eligible uninsured African Americans 34.8% 65.2% 100.0% Uninsured African Americans who may be 801,000 1,795,000 2,596,000 eligible for Marketplace 11.7% 26.3% 38.1% Eligible uninsured African Americans who may 639,000 1,583,000 2,222,000 qualify for Marketplace Premium Tax Credits 9.4% 23.2% 32.6% Eligible uninsured African Americans who may 1,396,000 N/A 10 1,396,000 qualify for Medicaid (age 19 to 64) 20.5% 20.5% Eligible uninsured African Americans who may 175,000 440,000 615,000 qualify for or Medicaid/CHIP (age 0 to 18) 2.6% 6.5% 9.0% African Americans by Location By State — As noted earlier, eligible uninsured African Americans are generally concentrated in Southern states. Nearly two-fifths (38 percent) live in Florida, Georgia, Louisiana, North Carolina, and Texas. Table 3 shows the number of eligible African Americans and those who are uninsured in all 50 states and the District of Columbia. 9 The sum of expansion and non-expansion state estimates may not equal the stated total for all states due to rounding. 10 In non-expansion states, some eligible uninsured may currently qualify for Medicaid and are not enrolled, and such individuals are not included in our analysis. For expansion states, our estimate of the eligible uninsured who may qualify for Medicaid includes both the current and the newly eligible. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 6 Table 3: Number of Eligible Uninsured African Americans by State Eligible Uninsured Total Eligible Eligible Percent of African African Uninsured Eligible African Americans as American African Americans Who Percent of U.S. State Population Americans Are Uninsured Total Alabama 1,157,000 226,000 19.6% 3.3% Alaska 20,000 3,000 14.9% 0.0% Arizona 229,000 50,000 21.8% 0.7% Arkansas 421,000 84,000 19.9% 1.2% California 1,914,000 335,000 17.5% 4.9% Colorado 176,000 32,000 18.3% 0.5% Connecticut 303,000 32,000 10.5% 0.5% Delaware 171,000 18,000 10.4% 0.3% District of Columbia 260,000 26,000 10.1% 0.4% Florida 2,563,000 677,000 26.4% 9.9% Georgia 2,716,000 631,000 23.2% 9.2% Hawaii 23,000 2,000 6.8% 0.0% Idaho 7,000 1,000 14.2% 0.0% Illinois 1,650,000 339,000 20.6% 5.0% Indiana 529,000 122,000 23.1% 1.8% Iowa 76,000 14,000 17.8% 0.2% Kansas 145,000 28,000 19.4% 0.4% Kentucky 318,000 77,000 24.3% 1.1% Louisiana 1,336,000 340,000 25.4% 5.0% Maine 15,000 1,000 6.5% 0.0% Maryland 1,505,000 183,000 12.2% 2.7% Massachusetts 356,000 25,000 7.0% 0.4% Michigan 1,238,000 241,000 19.5% 3.5% Minnesota 248,000 38,000 15.3% 0.6% Mississippi 1,023,000 241,000 23.6% 3.5% Missouri 612,000 130,000 21.3% 1.9% Montana 3,000 2,000 53.1% 0.0% Nebraska 72,000 15,000 21.3% 0.2% Nevada 189,000 44,000 23.3% 0.6% New Hampshire 11,000 2,000 21.9% 0.0% New Jersey 981,000 161,000 16.4% 2.4% New Mexico 31,000 4,000 12.3% 0.1% New York 2,454,000 354,000 14.4% 5.2% North Carolina 1,856,000 380,000 20.5% 5.6% North Dakota 5,000 1,000 12.3% 0.0% Ohio 1,239,000 233,000 18.8% 3.4% ASPE Office of Health Policy December 2013 ASPE Research Brief Page 7 Eligible Uninsured Total Eligible Eligible Percent of African African Uninsured Eligible African Americans as American African Americans Who Percent of U.S. State Population Americans Are Uninsured Total Oklahoma 252,000 64,000 25.2% 0.9% Oregon 61,000 12,000 19.5% 0.2% Pennsylvania 1,172,000 201,000 17.2% 2.9% Rhode Island 48,000 8,000 16.6% 0.1% South Carolina 1,170,000 263,000 22.4% 3.9% South Dakota 9,000 2,000 27.2% 0.0% Tennessee 981,000 193,000 19.7% 2.8% Texas 2,683,000 617,000 23.0% 9.0% Utah 27,000 5,000 17.0% 0.1% Vermont 4,000 1,000 12.8% 0.0% Virginia 1,394,000 246,000 17.7% 3.6% Washington 212,000 42,000 19.9% 0.6% West Virginia 51,000 16,000 32.4% 0.2% Wisconsin 326,000 58,000 17.7% 0.8% Wyoming 5,000 1,000 19.9% 0.0% United States 34,248,000 6,820,000 19.9% 100.0% By Metropolitan Area — Eligible uninsured African Americans are concentrated in certain metropolitan areas as shown in Table 4, which lists the top 20 metropolitan statistical areas by the number of eligible uninsured African Americans. Four in ten of the nation’s eligible uninsured African Americans live in one of these 20 metropolitan areas. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 8 Table 4: Top 20 Metropolitan Statistical Areas by Number of Eligible Uninsured African Americans MSA MSA Eligible Eligible Uninsured Uninsured Eligible Eligible African African Uninsured Uninsured Americans Americans African African as Percent as Percent Americans Americans of State of U.S. Rank Metropolitan Statistical Area (MSA) in MSA in State Total Total 1 Atlanta, GA 332,000 631,000 52.6% 4.9% 2 New York-Northeastern NJ, NY portion only 276,000 354,000 77.9% 4.0% 3 Chicago, IL 263,000 339,000 77.6% 3.9% 4 Dallas-Fort Worth, TX 198,000 617,000 32.1% 2.9% 5 Houston-Brazoria, TX 196,000 617,000 31.8% 2.9% 6 Detroit, MI 166,000 241,000 68.8% 2.4% 7 Los Angeles-Long Beach, CA 137,000 335,000 41.0% 2.0% 8 Miami-Hialeah, FL 121,000 677,000 17.8% 1.8% 9 Philadelphia, PA portion only 120,000 201,000 59.9% 1.8% 10 Fort Lauderdale-Hollywood-Pompano Beach, FL 111,000 677,000 16.5% 1.6% 11 New York-Northeastern NJ, NJ portion only 100,000 161,000 62.3% 1.5% 12 Memphis, TN/AR/MS 89,000 193,000 46.0% 1.3% 13 Baltimore, MD 86,000 183,000 46.7% 1.3% 14 New Orleans, LA 83,000 340,000 24.6% 1.2% 15 Norfolk-Virginia Beach-Newport News, VA 82,000 246,000 33.2% 1.2% 16 Washington, DC; MD portion only 80,000 183,000 43.7% 1.2% 17 Orlando, FL 80,000 677,000 11.8% 1.2% 18 St. Louis, MO-IL 74,000 130,000 57.2% 1.1% 19 Charlotte-Gastonia-Rock Hill, NC portion only 70,000 380,000 18.3% 1.0% 20 Tampa-St. Petersburg-Clearwater, FL 66,000 677,000 9.8% 1.0% TOTAL Top 20 MSAs (and respective 15 states) 11 2,731,000 5,028,000 54.3% 40.0% 11 The 15-state total is based on the 15 states corresponding to the top 20 MSAs listed in the table, not the 15 states by greatest number of eligible uninsured African Americans. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 9 Table 5: Examples of Marketplace Monthly Premiums after Tax Credit This table includes premiums for two illustrative groups, a single 27-year-old and a family of four, in major metropolitan areas in selected states with large eligible uninsured African American populations. For example, in Jefferson County, Alabama, which includes the city of Birmingham, a 27-year-old with income of $25,000 could purchase a bronze plan for as little as $104 per month after the tax credit. If a city spans more than one county, the premiums below are for the county which covers a larger area of the city. 27-Year-Old with an Income Family of Four with an Income Premium for a 27-Year-Old of $25,000 of $50,000 12 Second Second Second Second Lowest Lowest Lowest Lowest Lowest Lowest Silver Silver Bronze Silver Silver Bronze Before After After Before After After Lowest Lowest Lowest Tax Tax Tax Tax Tax Tax City, State County Bronze Silver Catastrophic Credit Credit Credit Credit Credit Credit 13 Birmingham, AL Jefferson $170 $209 $140 $211 $145 $104 $714 $282 $144 L.A. (north) $153 $182 $122 $207 $145 $92 $698 $282 $102 Los Angeles, CA14 L.A. (south) $172 $198 $148 $212 $145 $105 $717 $282 $147 San Francisco, CA San Francisco $182 $251 $169 $306 $145 $21 $1,033 $282 $0 Washington, DC $124 $178 $72 $181 $145 $88 $711 $282 $60 Fort Lauderdale, FL Broward $128 $174 $86 $199 $145 $74 $674 $282 $41 Jacksonville, FL Duval $137 $186 $92 $210 $145 $72 $709 $282 $36 Miami, FL Miami-Dade $163 $202 $109 $221 $145 $87 $746 $282 $86 Orlando, FL Orange $182 $207 $141 $225 $145 $102 $761 $282 $136 Tampa, FL Hillsborough $167 $189 $129 $199 $145 $113 $673 $282 $173 West Palm Beach, FL Palm Beach $147 $167 $109 $220 $145 $72 $744 $282 $36 12 For the purposes of this analysis, a family of four is defined as two 30-year-old adults and two children. 13 Net of tax credits, bronze premiums for a family of four may be below those for a single individual and may be as low as 0. This occurs because the tax credit is calculated as the difference between the cost of the second lowest cost silver plan premium and the maximum payment amount determined by income. Because premiums for older individuals and families are higher than those for younger individuals, tax credits are larger for older individuals and families. Therefore, using tax credits to purchase a bronze plan may yield lower bronze premiums for older individuals. 14 Los Angeles County is split into two rating areas for Marketplace premiums. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 10 27-Year-Old with an Income Family of Four with an Income Premium for a 27-Year-Old of $25,000 of $50,000 12 Second Second Second Second Lowest Lowest Lowest Lowest Lowest Lowest Silver Silver Bronze Silver Silver Bronze Before After After Before After After Lowest Lowest Lowest Tax Tax Tax Tax Tax Tax City, State County Bronze Silver Catastrophic Credit Credit Credit Credit Credit Credit 13 Atlanta, GA Fulton $166 $188 $127 $205 $145 $105 $694 $282 $148 Chicago, IL Cook $125 $172 $141 $174 $145 $96 $586 $282 $117 Indianapolis, IN Marion $223 $278 $190 $290 $145 $78 $980 $282 $54 New Orleans, LA Orleans $170 $242 $160 $255 $145 $60 $861 $282 $0 Baltimore, MD Baltimore $129 $175 -- 15 $197 $145 $78 $664 $282 $55 Detroit, MI Wayne $138 $156 $105 $184 $145 $99 $621 $282 $126 St. Louis, MO St. Louis $147 $196 $100 $216 $145 $76 $730 $282 $48 Jackson, MS Hinds $199 $226 $150 $336 $145 $8 $1,135 $282 $0 Charlotte, NC Mecklenburg $183 $247 $115 $251 $145 $77 $849 $282 $53 Greensboro, NC Guilford $167 $224 $105 $228 $145 $84 $771 $282 $76 Raleigh, NC Wake $161 $221 $101 $222 $145 $84 $750 $282 $77 Newark, NJ Essex $230 $260 $186 $264 $145 $110 $892 $282 $165 New York, NY New York $308 $359 $184 $390 $145 $63 $1,112 $282 $49 Cleveland, OH Cuyahoga $152 $201 $121 $204 $145 $93 $688 $282 $107 Philadelphia, PA Philadelphia $195 $210 $171 $246 $145 $94 $831 $282 $109 Memphis, TN Shelby $117 $152 $113 $159 $145 $103 $536 $282 $141 Dallas, TX Dallas $153 $217 $196 $223 $145 $74 $754 $282 $44 Houston, TX Houston $133 $189 $172 $195 $145 $83 $658 $282 $74 Norfolk, VA Norfolk $174 $223 $152 $228 $145 $91 $770 $282 $100 Richmond, VA Richmond $173 $227 $151 $229 $145 $89 $775 $282 $93 15 Information on the lowest-price catastrophic plan in the Baltimore metro area was not readily available. ASPE Office of Health Policy December 2013 ASPE Research Brief Page 11 Methodological Overview and Study Limitations This analysis is based on ASPE analysis of the 2011 American Community Survey Public Use Microdata Sample (ACS PUMS), the best source for obtaining information about the current characteristics of the uninsured population at the state level and for smaller demographic groups. ASPE tabulations from the ACS PUMS have been adjusted to exclude estimated undocumented persons based on ASPE’s TRIM3 microsimulation model (http://trim.urban.org). 16 The smallest geographic unit defined in the ACS PUMS is the Census-defined public-use microdata area (PUMA). To obtain metropolitan area estimates, we assigned PUMAs to metropolitan statistical areas based on a crosswalk created from the University of Minnesota’s Integrated Public Use Microdata Series. 17 Our methodology for examples of plan premiums is described in detail in an earlier ASPE brief titled “Health Insurance Marketplace Premiums for 2014.” The full text is available online at http://aspe.hhs.gov/health/reports/2013/MarketplacePremiums/ib_marketplace_premiums.cfm. Complete plan data for some states is available at https://www.healthcare.gov/health-plan- information/, and the remaining premium data was obtained from state Marketplace sources. For family incomes used to estimate Marketplace and Medicaid eligibility, the “family” is defined as the “health insurance unit” (HIU). HIUs include adults plus their spouses and dependent children (ages 0 to 18, plus full-time students under age 23) living in the household, based on ASPE analysis of the ACS PUMS data. The estimate of uninsured Medicaid-eligible adults is the number of adults age 19 older who have family (HIU) incomes below 138 percent of the FPL and live in one of the 25 Medicaid expansion states or the District of Columbia. Although the statutory threshold for Medicaid expansion set by the Affordable Care Act is 133 percent of the FPL, this brief uses 138 percent of the FPL, which is the effective threshold when the 5 percent statutory disregard is included. We made the simplifying assumption that children in families with incomes at or below 250 percent of FPL are eligible for CHIP, and children in families with incomes between 250 percent and 400 percent of the FPL are eligible for Marketplace coverage with premium tax credits. We recognize that states have different maximum income standards for CHIP eligibility. 16 The adjustment methodology is based on imputations of immigrant legal status in ASPE’s TRIM3 microsimulation model (http://trim.urban.org/), according to methods initially developed by Jeffrey Passel and Rebecca Clark. 17 The Integrated Public Use Microdata Series (Version 5.0) was developed by Steven Ruggles, J. Trent Alexander, Katie Genadek, Ronald Goeken, Matthew B. Schroeder, and Matthew Sobek at the University of Minnesota. Available online: https://usa.ipums.org/usa/index.shtml. ASPE Office of Health Policy December 2013