A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP Robin Rudowitz, Samantha Artiga, Anthony Damico, and Rachel Garfield 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 up to 138% of the Federal Poverty Level (FPL) 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. Recent analysis shows that 27% or 8.8 million of the 32.3 million non-elderly uninsured are eligible for Medicaid coverage. This issue brief provides a closer look at key characteristics of the uninsured who are eligible for Medicaid and where they live. Analysis is based on state Medicaid expansion decisions as of January 2016 which includes Louisiana's decision to adopt the expansion. These data may help inform outreach and enrollment efforts to increase coverage gains among the eligible but uninsured population. Of the total 32.3 million nonelderly people who remained uninsured as of 2015, an estimated 27% (8.8 million) are eligible for Medicaid or the Children's Health Insurance Program (CHIP). This 27% (8.8. million) includes 18% (5.7 million) who are Medicaid-eligible adults and 10% (3.2 million) who are Medicaid or CHIP-eligible children (Figure 1). The uninsured and eligible for Medicaid and CHIP (referred to as the uninsured and eligible for the rest of Figure 1 this brief) include both adults made newly 8.8 million or 27% of the uninsured are eligible for Medicaid or eligible for the program by the expansion and CHIP. individuals who were already eligible under pre- ACA rules but had not enrolled. Among the Ineligible for Financial remaining uninsured, 9% fall into the "coverage Assistance 42% Medicaid Eligible Adult gap" because they live in one of the 19 states that 18% Eligible for have not adopted the Medicaid expansion and Medicaid/CHIP Medicaid 27% Eligible Child the ACA does not provide financial assistance to Tax Credit Eligible 10% In the people below poverty for other coverage options. 22% Coverage Gap Another 22% of the uninsured may be eligible 9% for tax credits. This group includes individuals Total = 32.3 Million Nonelderly Uninsured with incomes between 100 and 138% FPL in NOTES: Numbers may not sum to subtotals or 100% due to rounding. Tax Credit Eligible share includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. SOURCE: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of states that have not adopted the Medicaid January 2016 and 2015 Current Population Survey data. expansion. Most of the 8.8 million uninsured and eligible (77%, or 6.8 million people) reside in states that are expanding their Medicaid programs for adults, as these states have higher income eligibility for adults than non-expansion states (Figure 2). The other quarter (23%, or 2.0 million people) are in states that have not expanded Medicaid, but are eligible for Medicaid or CHIP under pathways in place before the ACA. Figure 2 More than 3 out of 4 of the uninsured and eligible for Medicaid or CHIP live in states moving forward with the expansion. Includes those States Adopting eligible pre-ACA the Expansion States Not Includes and those newly 77% Adopting the eligible for those eligible Expansion pre-ACA but Medicaid or CHIP (6.8 Million) 23% not enrolled (2.0 Million) Total: 8.8 Million Uninsured Eligible for Medicaid or CHIP 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. Patterns of eligibility for Medicaid among the uninsured differ between states that have and have not expanded Medicaid. Overall, about two-thirds of the uninsured and eligible are adults and one- third are children. However, in expansion states, most (5.2 million or 76%) of the uninsured and eligible are adults and over half (3.8 million or 55%) are non-parent adults. These non-parent adults were the primary group affected by the Medicaid expansion. In non-expansion states, three out of four of the uninsured and eligible are children and a very small share (0.1 million or 3%) are non-parent adults (Figure 3). Figure 3 In expansion states, most of the uninsured and eligible for Medicaid or CHIP are non-parent adults. Number in millions: Child Parent Non-Parent Adult 8.8 Million 6.8 Million 3.8 3.8 1.9 2.0 Million 1.4 0.1 3.2 0.5 1.7 1.5 All Expansion States Non Expansion States NOTES: Numbers may not sum to subtotals or 100% 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. A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP 2 The share eligible for Medicaid varies across states. A greater share of the nonelderly uninsured is eligible for Medicaid in states that have expanded their programs under the ACA. In these states, 41% of the uninsured are eligible, versus just 13% in non-expansion states. Overall, the share of uninsured and eligible ranges from a high of 53% in Louisiana to a low of 9% in Nebraska (Figure 4). The share of uninsured and eligible is high in Louisiana relative to other states because the state has adopted the Medicaid expansion but not yet implemented it; coverage is set to begin in July 2016. Among non-expansion states, Wisconsin has the highest share of uninsured eligible at 32%. Although not an expansion state, Wisconsin covers parents and other adults up to 100% FPL largely tied to coverage expansions prior to the ACA. In other non-expansion states, parent eligibility levels generally remain very low and other non-disabled adults without dependent children are not eligible regardless of their income level. For adults, the share of the uninsured who are Medicaid eligible ranges from 50% in Louisiana, 44% in Rhode Island and 42% in West Virginia and DC to only 2% in Texas and 3% in Florida and Georgia; for uninsured children the range eligible is from a high of 17% in Minnesota and Utah to a low of 5% in Mississippi (Table 1). Figure 4 The share of uninsured and eligible for Medicaid or CHIP varies across states, but is generally greater in expansion states. 60% Expansion State (Average = 41%) Non-Expansion State (Average = 13%) 50% 40% 30% 20% 10% 0% OH IA IN IL LA PA OR DE MN MA KS ID MO RI DC MI MT KY MD MS VA NM NY VT OK ME NV NH ND UT AK WA NJ NC HI WV AR CO WY NE AZ CA WI CT TN SC SD AL GA TX FL 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. The uninsured eligible for Medicaid are concentrated in a small number of large states. California, New York, Texas and Pennsylvania account for about one-third of the total non-elderly uninsured who are eligible for Medicaid. Among non-elderly uninsured and eligible adults, five states (California, New York, Pennsylvania, Ohio and Illinois) account for more than four in ten; all of these states have adopted the Medicaid expansion. A combination of expansion and non-expansion states, including Texas, California, Florida and New York, account for 37% of uninsured and eligible children (Table 1). A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP 3 Across all non-elderly uninsured and eligible, half have incomes below poverty, six in ten are people of color and three out of four live in working families (Figure 5). Hispanics account for 31% of those uninsured and eligible, and Blacks account for another 16%. Only one-quarter are in families with no worker. However, there are some key differences between the characteristics of adults who are uninsured and eligible in expansion versus non-expansion states, as discussed below. When examining the characteristics of uninsured and eligible adults it is important to remember that a much higher number of adults (5.2 million) are eligible in expansion states compared to 0.5 million in non-expansion states). Figure 5 The uninsured and eligible for Medicaid or CHIP are likely to be poor, a person of color and working. Distribution By Distribution By Race / Distribution By Family Income: Ethnicity: Worker Status: Other Non- Hispanic 10% 200%+ No FPL Workers 18% Hispanic in Family Black 16% 31% 26% At Least Below one Full- Poverty Time 100 - 51% Only Part- Worker in 199% Time Family FPL White Workers 57% 43% in Family 32% 17% Uninsured and Eligible for Medicaid and CHIP = 8.8 Million NOTES: Numbers may not sum to subtotals or 100% 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. Uninsured and eligible for Medicaid adults in non-expansion states are significantly more likely to have incomes below poverty compared to those in expansion states (85% vs. 54%). This finding reflects the continued limited eligibility limits Figure 6 for adults in non-expansion states (Figure 6). Uninsured and eligible for Medicaid adults are less likely to be Given the historically higher eligibility poor, but more likely to be in a working family and male in expansion states. thresholds for children in Medicaid, the uninsured and eligible children are less likely Expansion States (5.2 Million) Non-Expansion States (0.5 Million) 85% than adults to have incomes below poverty, and 70% there are small differences in income across 54% 53% expansion and non-expansion states for 50% children. Because the Medicaid expansion 30% effectively eliminated categorical eligibility requirements, more than half of the uninsured and eligible adults are male in expansion states, % Below Poverty % with a Worker in the Family % Male compared to non-expansion states where NOTE: Adults are non-elderly. SOURCE: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion uninsured and eligible adults are mostly women decisions as of January 2016 and 2015 Current Population Survey data. due to historic eligibility criteria for Medicaid. A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP 4 Consistent with these income findings, uninsured and eligible adults in expansion states are more likely to live in a family with a worker than those in non-expansion states. In expansion states, 70% of uninsured and eligible adults live in a family with a worker, compared to half of eligible but uninsured adults in non-expansion states (Figure 6). In contrast, the majority of uninsured and eligible children in both expansion and non-expansion states live in a working family, reflecting the more expansive eligibility limits for children across states. Over half of the uninsured and eligible Figure 7 adults in expansion and non-expansion Over half of the uninsured and eligible for Medicaid or CHIP in states are persons of color. Blacks make up a expansion and non-expansion states are persons of color. higher share of the uninsured and eligible adults White Black Hispanic Other Non-Hispanic in non-expansion states compared to expansion states (29% compared to 16%). In both 10% 3% 12% 9% 25% expansion and non-expansion states, uninsured 26% 40% 38% and eligible children are more likely to be 16% 29% 10% 17% Hispanic compared to adults (Figure 7). There 48% 43% 38% are few differences in the health status of 35% uninsured and eligible adults in Medicaid Expansion States Non-Expansion States Expansion States Non-Expansion States 5.2 Million 0.5 Million 1.7 Million 1.5 Million expansion and non-expansion states. However, Adults Children children are more likely than adults to report very NOTES: Numbers may not sum to subtotals or 100% due to rounding. good or excellent health in both expansion and 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. non-expansion states. 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 more than one in four of the uninsured population appears to be eligible for Medicaid. As such, continued coverage gains may be achieved by reaching and enrolling these individuals into coverage. Better understanding who this group is and where they live can help support outreach and enrollment efforts. These findings show that as a result of the increased coverage potential for adults through the ACA, most of the uninsured and eligible live in states that have expanded Medicaid; however, two million (mostly children) reside in non-expansion states. In planning outreach and enrollment efforts, it is also important to recognize some key differences between the eligible but uninsured population in expansion versus non-expansion states:  In non-expansion states, the large majority of uninsured and eligible individuals are children, who are covered up to higher income levels than adults. Roughly four in ten of these children are Hispanic, demonstrating the importance of outreach and enrollment efforts targeted to Hispanics to achieve coverage gains among this group. Just half a million uninsured adults are eligible for Medicaid in non-expansion states since adult eligibility remains limited. The majority of these adults have incomes below poverty and only half live in a family with a worker. Three in ten of these adults are Black, and seven in ten are women. A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP 5  In expansion states, the majority of the uninsured and eligible population is adults, particularly non-parent adults. Moreover, most live in working families and, as such, have higher incomes than adults traditionally covered by Medicaid. Further, over half are men, a group that historically has had limited connections to Medicaid. Given these characteristics, it will be important for states to explore new outreach and enrollment avenues to reach these individuals, who may not be touched through previous outreach and enrollment avenues designed to reach low-income families. States that have achieved significant enrollment success have embraced a full array of outreach and enrollment strategies and approaches. These strategies include implementing broad marketing and outreach campaigns, promoting the expansion through strong leadership and collaboration, establishing a coordinated and diverse network of assisters, developing effective eligibility and enrollment systems that coordinate with Marketplace coverage, and planning ahead to translate coverage gains into improved access to care. While 100% participation in voluntary programs like Medicaid is not likely, sustained efforts over time have resulted in significantly higher rates of coverage for children and low uninsured rates. As many adults are newly eligible for coverage under the ACA, a focus on uninsured adults who are eligible for Medicaid is one of the next challenges in reducing overall uninsured rates. Robin Rudowitz, Samantha Artiga and Rachel Garfield are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation. A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP 6 Alabama 513,000 75,000 15% NR NR 55,000 11% Alaska 100,000 51,000 51% 37,000 37% 14,000 14% Arizona 808,000 368,000 46% 280,000 35% NR NR Arkansas 285,000 127,000 44% 112,000 39% NR NR California 3,845,000 1,428,000 37% 1,060,000 28% 368,000 10% Colorado 593,000 223,000 38% 150,000 25% 73,000 12% Connecticut 247,000 69,000 28% 56,000 22% NR NR Delaware 63,000 22,000 35% 15,000 24% NR NR DC 42,000 20,000 48% 17,000 42% NR NR Florida 2,788,000 306,000 11% 75,000 3% 231,000 8% Georgia 1,524,000 201,000 13% 47,000 3% 154,000 10% Hawaii 70,000 35,000 50% 26,000 37% NR NR Idaho 166,000 21,000 13% NR NR NR NR Illinois 1,122,000 397,000 35% 302,000 27% 95,000 9% Indiana 686,000 310,000 45% 227,000 33% 82,000 12% Iowa 188,000 88,000 47% 53,000 28% NR NR Kansas 302,000 38,000 13% NR NR NR NR Kentucky 285,000 121,000 43% 90,000 32% NR NR Louisiana 582,000 311,000 53% 292,000 50% NR NR Maine 121,000 18,000 15% NR NR NR NR Maryland 336,000 133,000 40% 107,000 32% NR NR Massachusetts 288,000 93,000 32% 57,000 20% 36,000 13% Michigan 685,000 320,000 47% 279,000 41% NR NR Minnesota 364,000 126,000 35% 65,000 18% 61,000 17% Mississippi 359,000 42,000 12% 24,000 7% 18,000 5% Missouri 516,000 52,000 10% NR NR 47,000 9% Montana 126,000 59,000 47% 43,000 34% 15,000 12% Nebraska 178,000 16,000 9% NR NR NR NR Nevada 350,000 147,000 42% 110,000 31% 37,000 10% New Hampshire 94,000 37,000 39% 30,000 32% NR NR New Jersey 940,000 335,000 36% 264,000 28% 71,000 8% New Mexico 233,000 109,000 47% 80,000 34% 29,000 12% New York 1,476,000 548,000 37% 376,000 25% 172,000 12% North Carolina 1,138,000 152,000 13% NR NR 120,000 11% North Dakota 64,000 24,000 37% 15,000 23% NR NR Ohio 834,000 404,000 48% 313,000 38% 91,000 11% Oklahoma 581,000 109,000 19% 22,000 4% 87,000 15% Oregon 307,000 122,000 40% 96,000 31% 26,000 9% Pennsylvania 994,000 477,000 48% 357,000 36% 120,000 12% Rhode Island 55,000 27,000 49% 24,000 44% NR NR South Carolina 604,000 100,000 17% 36,000 6% 65,000 11% South Dakota 77,000 12,000 16% NR NR NR NR Tennessee 605,000 104,000 17% NR NR 71,000 12% Texas 4,425,000 493,000 11% 80,000 2% 413,000 9% Utah 337,000 66,000 20% NR NR 56,000 17% Vermont 34,000 8,000 24% 7,000 21% NR NR Virginia 804,000 77,000 10% NR NR 61,000 8% Washington 621,000 238,000 38% 171,000 28% 67,000 11% West Virginia 116,000 56,000 48% 49,000 42% NR NR Wisconsin 410,000 129,000 32% 86,000 21% 43,000 10% Wyoming 56,000 6,000 11% NR NR 5,000 9% NOTES: Numbers may not sum to totals due to rounding. NR = 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. A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP 7 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.1,2 This 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 implementation of the Medicaid expansion as of January 2016 and 2015 Federal Poverty Levels.3 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.4 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. A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP 8 1State Health Access Data Assistance Center. 2013. "State Estimates of the Low-income Uninsured Not Eligible for the ACA Medicaid Expansion." Issue Brief #35. Minneapolis, MN: University of Minnesota. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404825 2 Van Hook, J., Bachmeier, J., Coffman, D., and Harel, O. "Can We Spin Straw into Gold? An Evaluation of Immigrant Legal Status Imputation Approaches" Demography. Forthcoming. 3Based on state-reported eligibility levels as of January 1, 2015. Eligibility levels are updated to reflect state implementation of the Medicaid expansion as of January 2016 and 2015 Federal Poverty Levels, but may not reflect other eligibility policy changes since January 2015. The Kaiser Family Foundation State Health Facts. Data Source: Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families: Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015, Kaiser Family Foundation, January 20, 2015. 4 Non-MAGI pathways for nonelderly adults include disability-related pathways, such as SSI beneficiary; Qualified Severely Impaired Individuals; Working Disabled; and Medically Needy. We are unable to assess disability status in the CPS sufficiently to model eligibility under these pathways. However, previous research indicates high current participation rates among individuals with disabilities (largely due to the automatic link between SSI and Medicaid in most states, see Kenney GM, V Lynch, J Haley, and M Huntress. "Variation in Medicaid Eligibility and Participation among Adults: Implications for the Affordable Care Act." Inquiry. 49:231-53 (Fall 2012)), indicating that there may be a small number of eligible uninsured individuals in this group. Further, many of these pathways (with the exception of SSI, which automatically links an individual to Medicaid in most states) are optional for states, and eligibility in states not implementing the ACA expansion is limited. For example, the median income eligibility level for coverage through the Medically Needy pathway is 15% of poverty in states that are not expanding Medicaid, and most states not expanding Medicaid do not provide coverage above SSI levels for individuals with disabilities. (See: O'Mally-Watts, M and K Young. The Medicaid Medically Needy Program: Spending and Enrollment Update. (Washington, DC: Kaiser Family Foundation), December 2012. Available at: http://www.kff.org/medicaid/issue-brief/the-medicaid-medically-needy-program-spending-and/. And Kaiser Commission on Medicaid and the Uninsured, "Medicaid Financial Eligibility: Primary Pathways for the Elderly and People with Disabilities," February 2010. Available at: http://www.kff.org/medicaid/issue-brief/medicaid-financial-eligibility-primary-pathways-for-the-elderly-and- people-with-disabilities/. The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400 Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270 www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.