The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid Rachel Garfield and Anthony Damico While millions of people have gained coverage through the expansion of Medicaid under the Affordable Care Act (ACA), state decisions not to implement the expansion leave many without an affordable coverage option. Under the ACA, Medicaid eligibility is extended to nearly all low-income individuals with incomes at or below 138 percent of poverty ($28,180 for a family of three in 20171). This expansion fills in historical gaps in Medicaid eligibility for adults and was envisioned as the vehicle for extending insurance coverage to low- income individuals, with premium tax credits for Marketplace coverage serving as the vehicle for covering people with moderate incomes. While the Medicaid expansion was intended to be national, the June 2012 Supreme Court ruling essentially made it optional for states. As of October 2017, 19 states had not expanded their programs. Medicaid eligibility for adults in states that did Figure 1 not expand their programs is quite limited: the Gap in Coverage for Adults in States that Do Not Expand median income limit for parents in these states is Medicaid under the ACA just 44% of poverty, or an annual income of $8,985 a year for a family of three in 2017, and in nearly all states not expanding, childless adults remain ineligible.2 Further, because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other 44% FPL coverage options. As a result, in states that do $8,985 for parents in a family of three $12,060 for an individual $48,240 for an individual not expand Medicaid, many adults fall into a as of October2017 as of January 2014 “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits (Figure 1). This brief presents estimates of the number of people in non-expansion states who could have been reached by Medicaid but instead fall into the coverage gap, describes who they are, and discusses the implications of them being left out of ACA coverage expansions. An overview of the methodology underlying the analysis can be found in the Methods box at the end of the report, and more detail is available in the Technical Appendices available here. Nationally, nearly two and a half million3 poor uninsured adults fall into the “coverage gap” that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits. These individuals would be eligible for Medicaid had their state chosen to expand coverage. Adults left in the coverage gap are spread across Figure 2 the states not expanding their Medicaid Distribution of Adults in the Coverage Gap, by State and programs but are concentrated in states with the Region Distribution By State: Distribution By Geographic Region: largest uninsured populations. More than a quarter of people in the coverage gap reside in Texas, which has both a large uninsured Other States that TX 27% population and very limited Medicaid eligibility Have Not Expanded South Medicaid 89% (Figure 2). Sixteen percent live in Florida, ten 38% FL Midwest 7% percent in Georgia, and nine percent in North NC 16% GA 9% 10% Northeast Carolina. There are no uninsured adults in the <1% West 3% coverage gap in Wisconsin because the state is Total = 2.4 Million in the Coverage Gap providing Medicaid eligibility to adults up to the poverty level under a Medicaid waiver. Note: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey. The geographic distribution of the population in the coverage gap reflects both population distribution and regional variation in state take-up of the ACA Medicaid expansion. The South has relatively higher numbers of poor uninsured adults than in other regions, has higher uninsured rates and more limited Medicaid eligibility than other regions, and accounts for the majority (10 out of 19) of states that opted not to expand Medicaid.4 As a result, nearly nine in ten people in the coverage gap reside in the South (Figure 2). The characteristics of the population that falls into the coverage gap largely mirror those of poor uninsured adults. For example, because racial/ethnic minorities are more likely than White non-Hispanics to lack insurance coverage and are more likely to live in families with low incomes, they are disproportionately represented among poor uninsured adults and among people in the coverage gap. Nationally, 48% of uninsured adults in the coverage gap are White non-Hispanics, 24% are Hispanic, and 24% are Black (Figure 3). However, the race and ethnicity of people in the coverage gap also reflects differences in the racial/ethnic composition between states that have and have not expanded Medicaid. Several states that have large Black populations (e.g., Florida, Georgia, and Texas) have not expanded Medicaid under the ACA. As a result, Blacks account for a slightly higher share of people in the coverage gap compared to the total poor adult uninsured The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 2 population. The racial/ethnic characteristics of the population in the coverage gap vary widely by state, mirroring the underlying characteristics of the state population (Table 1). Nonelderly adults of all ages fall into the Figure 3 Demographic Characteristics of Adults in the Coverage Gap coverage gap (Figure 3). Notably, over half are middle-aged (age 35 to 54) or near elderly (age Distribution By Distribution By Distribution By 55 to 64). Adults of these ages are likely to have Race/Ethnicity: Age: Health Status: Other increasing health needs, and research has 5% demonstrated that uninsured people in this age 55-64 19-24 Fair or Poor Hispanic years years 20% range may leave health needs untreated until 24% White 18% 17% Excellent or Very 48% 25-34 Good they become eligible for Medicare at age 65.5 Black 35-54 years years 28% Good 47% 32% 24% 37% While half of people in the coverage gap report that their health is excellent or very good, one Total = 2.4 Million in the Coverage Gap fifth (20%) report that they are in fair or poor health (Figure 3). These individuals have known Note: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey. health problems that likely require medical attention. Studies repeatedly demonstrate that Figure 4 uninsured people are less likely than those with Parent Status and Gender of Adults in the Coverage Gap insurance to receive preventive care and services for major health conditions and chronic Parent Status Gender diseases.6 When they do seek care, the uninsured Female often face unaffordable medical bills.7 48% Childless Adult Parent 77% 23% The characteristics of people in the coverage gap Male 52% also reflect Medicaid program rules in states not expanding their programs. Because non-disabled adults without dependent children are ineligible Total = 2.4 Million in the Coverage Gap for Medicaid coverage in most states not expanding Medicaid, regardless of their income, Note: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey. adults without dependent children account for a disproportionate share of people in the coverage gap (77%) (Figure 4). Still, nearly a quarter (23%) of people in the coverage gap are poor parents whose income places them above Medicaid eligibility levels. About 160,000 uninsured children have a parent in the coverage gap (data not shown). Research has found that parent coverage in public programs is associated with higher enrollment of eligible children,8 so these children may be hard to reach if their parents continue to be ineligible for coverage. The share of people in the coverage gap who are adults without dependent children (versus parents) varies by state (see Table 1) due to variation in current state eligibility. For example, Tennessee covers all parents up to at least poverty, so all people in the coverage gap in that state are adults without dependent children. Even though women are more likely than men to qualify for Medicaid in states not expanding their programs, women account for about the same share (48%) of adults in the coverage gap (Figure 4). This pattern occurs because women make up the majority of poor adults in states not expanding their programs. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 3 The work status of people in the coverage gap Figure 5 indicates that there are limited coverage options Work Status of Adults in the Coverage Gap available for people in this situation. Six in ten people in the coverage gap are in a family with a Family work status : Firm size and industry among those working: worker, and half are working themselves (Figure 6% 9% Other Manufacturing /Infrastructure 5). The vast majority of workers in the coverage 100+ employees 44% 16% Education/ Health gap do not have an offer of coverage through Full-time No worker 19% Professional/ worker 50-99 Public Admin their employer (data not shown), and half work 39% 40% employees 6% for small firms (<50 employees) that are not <50 employees Agriculture/ Service Part-time 50% 50% subject to ACA penalties for not offering worker 22% coverage. Further, many firms do not offer coverage to part-time workers. A majority of Total = 2.4 Million in the Coverage Gap Total = 1.2 Million Workers in the Coverage Gap workers in the coverage gap also work in Notes: Industry classifications: Agriculture/Service includes agriculture, construction, leisure and hospitality services, wholesale and retail trade. Education/Health includes education and health services. Professional/Public Admin includes finance, professional and business services, information, and public administration. Manufacturing/Infrastructure includes mining, manufacturing, utilities, and transportation. Totals may not sum to 100% due to rounding. industries with historically low insurance rates, Source: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey. such as the agriculture and service industries. Four in ten adults in the coverage gap are in a family with no workers. Since the Medicaid expansion was designed to reach those left out of the employer-based system, and because people in the coverage gap by definition are poor, it is not surprising that most are unlikely to have access to health coverage through a job. If states that are currently not expanding their Figure 6 programs adopt the Medicaid expansion, all of Nonelderly Uninsured Adults in Non-Expansion States Who Would be Eligible for Medicaid if Their States Expanded the 2.4 million adults in the coverage gap would Currently Eligible gain Medicaid eligibility. In addition, 1.6 million for Medicaid Total = 4.5 Million Nonelderly Uninsured Adults 0.5 Million (12%) uninsured adults who are currently eligible for Marketplace coverage (those with incomes Currently in the Currently Eligible between 100 and 138% of poverty9) would also Coverage Gap for Marketplace 2.4 Million (52%) 1.6 Million (36%) gain Medicaid eligibility (Figure 6 and Table 2). Though most of these adults are eligible for tax credits to purchase Marketplace coverage,10 Medicaid coverage may provide lower premiums Income below current Medicaid Income between Medicaid eligibility and 100% FPL Income 100-138% FPL or cost-sharing than they would face under eligibility Note: Total may not sum to 100% due to rounding. The "100%-138% FPL" category presented here uses a Marketplace eligibility determination for the lower bound (100% FPL) and a Medicaid eligibility determination for the upper bound (138% FPL) in order to Marketplace coverage. appropriately isolate individuals within the range of potential Medicaid expansions but also with sufficient resources to avoid the coverage gap. Source: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey. A small number (about 538,000) of uninsured adults in non-expansion states are already eligible for Medicaid under eligibility pathways in place before the ACA. If all states expanded Medicaid, those in the coverage gap and those who are instead eligible for Marketplace coverage would bring the number of nonelderly uninsured adults eligible for Medicaid to 4.5 million people in the nineteen current non-expansion states. The potential scope of Medicaid varies by state (Table 2). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 4 The ACA Medicaid expansion was designed to address the high uninsured rates among low-income adults, providing a coverage option for people with limited access to employer coverage and limited income to purchase coverage on their own. In states that expanded Medicaid, millions of people gained coverage, and the uninsured rate dropped significantly as a result of the expansion.11 However, with many states opting not to implement the Medicaid expansion, millions of uninsured adults remain outside the reach of the ACA and continue to have limited options for affordable health coverage. The majority of people in the coverage gap are in poor working families—that is, either they or a family member is employed but still living below the poverty line. Given the characteristics of their employment, it is likely that many will continue to lack access to coverage through their job even with ACA provisions for employer responsibility for coverage.12 Further, even if they do receive an offer from their employer that meets ACA requirements, many will find their share of the cost to be unaffordable. Because this population is generally exempt from the individual mandate, and because firms will not face a penalty for these workers remaining uninsured, they will continue to fall between the cracks in the employer-based system. It is unlikely that people who fall into the coverage gap will be able to afford ACA coverage without financial assistance: in 2017, the national average unsubsidized premium for a 40-year-old non-smoking individual purchasing coverage through the Marketplace was $361 per month for a silver plan and $292 per month for a bronze plan,13 which equates to more than seventy percent of income for those at the lower income range of people in the gap and more than a third of income for those at the higher income range of people in the gap. If they remain uninsured, adults in the coverage gap are likely to face barriers to needed health services or, if they do require medical care, potentially serious financial consequences. Many are in fair or poor health or are in the age range when health problems start to arise but lack of coverage may lead them to postpone needed care due to the cost. While the safety net of clinics and hospitals that has traditionally served the uninsured population will continue to be an important source of care for the remaining uninsured under the ACA, this system has been stretched in recent years due to increasing demand and limited resources. Further, the racial and ethnic composition of the population that falls into the coverage gap indicates that state decisions not to expand their programs disproportionately affect people of color, particularly Black Americans. As a result, state decisions about whether to expand Medicaid have implications for efforts to address disparities in health coverage, access, and outcomes among people of color. There is no deadline for states to opt to expand Medicaid under the ACA, and debate continues in some states about whether to expand. In addition, the administration has indicated to states that it is open to state Medicaid waiver proposals, which may lead some states that have not yet expanded Medicaid under the ACA to develop Medicaid expansion waivers and further extend coverage. However, several non-expansion states have reported that consideration of the Medicaid expansion is on hold due to uncertainty about the future of the ACA.14 Thus, it is uncertain what insurance options, if any, adults in the coverage gap may have in the future, and these adults are likely to remain uninsured without policy action to develop affordable coverage options. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 5 Rachel Garfield is with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 6 Alabama 75,000 49% 79% 57% 50% Florida 384,000 47% 87% 49% 48% Georgia 240,000 60% 78% 54% 62% Idaho 22,000 N/A 80% 51% 69% Kansas 48,000 42% 84% 36% 46% Maine N/A N/A N/A N/A N/A Mississippi 99,000 54% 79% 44% 59% Missouri 87,000 N/A 63% 44% 82% Nebraska 16,000 N/A 77% 40% 52% North Carolina 208,000 36% 79% 43% 60% Oklahoma 84,000 51% 76% 42% 53% South Carolina 92,000 47% 91% 51% 54% South Dakota 15,000 51% 67% N/A 76% Tennessee 163,000 31% 100% 39% 41% Texas 638,000 74% 63% 53% 74% Utah 46,000 N/A 77% 39% 77% Virginia 138,000 50% 85% 45% 55% Wisconsin* 0 - - - - Wyoming 6,000 N/A 93% 59% 48% NOTES: * Wisconsin provides Medicaid eligibility to adults up to the poverty level under a Medicaid waiver. As a result, there is no one in the coverage gap in Wisconsin. Totals may not sum due to rounding. N/A: Sample size too small for reliable estimate. SOURCE: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 7 Alabama 153,000 N/A 75,000 59,000 Florida 702,000 40,000 384,000 278,000 Georgia 463,000 75,000 240,000 148,000 Idaho 43,000 N/A 22,000 19,000 Kansas 79,000 N/A 48,000 26,000 Maine 29,000 N/A N/A N/A Mississippi 167,000 N/A 99,000 57,000 Missouri 199,000 N/A 87,000 86,000 Nebraska 34,000 N/A 16,000 15,000 North Carolina 339,000 46,000 208,000 85,000 Oklahoma 142,000 N/A 84,000 40,000 South Carolina 170,000 N/A 92,000 61,000 South Dakota 29,000 N/A 15,000 12,000 Tennessee 332,000 61,000 163,000 108,000 Texas 1,178,000 101,000 638,000 439,000 Utah 91,000 N/A 46,000 31,000 Virginia 272,000 N/A 138,000 113,000 Wisconsin* 97,000 65,000 0 32,000 Wyoming 15,000 N/A 6,000 6,000 NOTES: * Wisconsin provides Medicaid eligibility to adults up to the poverty level under a Medicaid waiver. As a result, there is no one in the coverage gap in Wisconsin. ^ The "100%-138% FPL" category presented here uses a Marketplace eligibility determination for the lower bound (100% FPL) and a Medicaid eligibility determination for the upper bound (138% FPL) in order to appropriately isolate individuals within the range of potential Medicaid expansions but also with sufficient resources to avoid the coverage gap. Totals may not sum due to rounding. N/A: Sample size too small for reliable estimate. SOURCE: Kaiser Family Foundation analysis based on 2017 Medicaid eligibility levels and 2017 Current Population Survey. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 8 This analysis uses data from the 2017 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 and household composition for ACA eligibility purposes. 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 federally-funded 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.15,16 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 Pew Research Center. 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 indicate whether a worker held an offer of ESI at the time of interview (for the 2017 CPS, February, March, or April 2017) but not during the prior year (which serves as our basis for type of insurance coverage), we developed a model that predicts offer of ESI for any individuals with a change in employment status across the period. Additionally, for families with a Marketplace eligibility level below 250% FPL, we assume any reported worker offer does not meet affordability requirements and therefore does not disqualify the family from Tax Credit eligibility on the Exchanges. For more detail on the offer imputation used in this analysis, see the technical Appendix C available here. The CPS asks respondents about coverage at the time of the interview 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 2016 (and thus were uninsured at the start of 2017). We use this measure of insurance coverage in 2016, 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. 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, 2017, updated to reflect state Medicaid expansion decisions as of October 2017 and 2016 Federal Poverty Levels.17 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.18 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. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 9 1 U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2017 Poverty Guidelines. Available at: https://aspe.hhs.gov/poverty-guidelines 2 Of the states not moving forward with the expansion, only Wisconsin provides full Medicaid coverage to adults without dependent children as of 2014. For state-by-state information on Medicaid eligibility, see The Kaiser Family Foundation State Health Facts. “Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level.” Data Source: Based on state-reported eligibility levels as of January 1, 2017, collected through a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families. Accessed on October 18, 2017. Available at: http://kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/ 3 National and state-by-state estimates of the number of people in the coverage gap may change from year to year due to several factors, including differences in the underlying data, small changes in state Medicaid eligibility, and declines in the number of uninsured people by state as economic conditions improve. 4 Stephens, J., S. Artiga, and J. Paradise. Health Coverage and Care in the South in 2014 and Beyond. (Washington, DC: The Kaiser Commission on Medicaid and the Uninsured), April 2014, available at: http://kff.org/report-section/health-coverage-and-care-in-the- south-in-2014-and-beyond-health-coverage-and-care-in-the-south-today/ 5 McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. “Use of Health Services by Previously Uninsured Medicare Beneficiaries.” New England Journal of Medicine. 2007 July 12, 357(2): 143-53. 6 For a review of findings on access to care for the uninsured, see: Kaiser Commission on Medicaid and the Uninsured. The Uninsured: A Primer. (Washington, DC: Kaiser Family Foundation. Available at: http://kff.org/uninsured/report/the-uninsured-a-primer/ 7 Ibid. 8 Sommers BD. “Insuring children or insuring families: do parental and sibling coverage lead to improved retention of children in Medicaid and CHIP?” J Health Econ. 2006 Nov;25(6):1154-69. Epub 2006 Jun 5. 9 The "100%-138% FPL" category presented here uses a Marketplace eligibility determination for the lower bound (100% FPL) and a Medicaid eligibility determination for the upper bound (138% FPL) in order to appropriately isolate individuals within the range of potential Medicaid expansions but also with sufficient resources to avoid the coverage gap. 10 The vast majority of these people are eligible for tax credits to subsidize the cost of coverage in the Marketplace, though some (e.g., people with an offer of employer coverage) may not qualify for tax credits. 11 Antonisse, L., Garfield R., Rudowitz R. and Artiga S. 2017 The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. (Washington, DC: Kaiser Family Foundation), available at: https://www.kff.org/medicaid/issue-brief/the-effects- of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/ 12 See http://www.kff.org/infographic/employer-responsibility-under-the-affordable-care-act/ for a review of these requirements. 13 The methods for arriving at this estimate can be found on the Kaiser Family Foundation Subsidy Calculator, available here: http://www.kff.org/interactive/subsidy-calculator/ 14 Gifford, K., Ellis, E., Edwards, B.C., et al. 2017. Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018.(Washington, DC: Kaiser Family Foundation), available at: https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey- for-state-fiscal-years-2017-and-2018/ 15 State 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 16 Van Hook, J., Bachmeier, J., Coffman, D., and Harel, O. 2015. “Can We Spin Straw into Gold? An Evaluation of Immigrant Legal Status Imputation Approaches.” Demography. 52(1):329-54. 17 Based on state-reported eligibility levels as of January 1, 2017. Eligibility levels are updated to reflect state implementation of the Medicaid expansion as of October 2017 and 2016 Federal Poverty Levels but may not reflect other eligibility policy changes since January 2017. The Kaiser Family Foundation State Health Facts. Data Source: Kaiser Family Foundation with the Georgetown University Center for Children and Families. Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2017: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, January 12, 2017), Available at: https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2017- findings-from-a-50-state-survey 18 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 The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid 10 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 18% of poverty in states that are not expanding Medicaid. (See: MACPAC, Medicaid Income Eligibility Levels as a Percentage of the FPL for Individuals Age 65 and Older and Persons with Disabilities by State, 2016. Available at: https://www.macpac.gov/wp-content/uploads/2015/01/EXHIBIT-36.-Medicaid-Income-Eligibility-Levels-as-a-Percentage-of-the- FPL-for-Individuals-Age-65-and-Older-and-Persons-with-Disabilities-by-State-2016.pdf 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.